A 68-year-old woman presented to the emergency department with a 3-day history of worsening shortness of breath, wheezing, dry cough, fevers, and chills. Her oxygen saturation was 96% while she was breathing ambient air. Pulmonary examination revealed crackles in the left lower lobe. Computed tomography of the chest showed an obstructing broncholith in the bronchus of the left lower lobe (arrow in Panel A, bone-window setting) with peribronchial ground-glass and patchy consolidation (Panel B, lung-window setting). Flexible bronchoscopy revealed a loose broncholith that was obstructing the proximal bronchus of the left lower lobe (Panel C). The broncholith, which measured 1.00 by 1.45 cm (Panel D), was grasped and gently retracted. Broncholiths are most commonly formed by peribronchial lymph nodes that calcify and migrate into the lumen of the bronchus. Lymphatic calcification can develop after chronic granulomatous infection, such as histoplasmosis or tuberculosis. Cultures of bronchoalveolar-lavage fluid were negative for mycobacterial, bacterial, and fungal organisms. An interferon-gamma release assay to test for evidence of previous tuberculosis exposure was negative, and serologic testing for histoplasmosis was negative. The patient was treated with antibiotics for postobstructive pneumonia, and her symptoms resolved. Source
