Endobronchial actinomycosis associated with broncholithiasis: CT findings for nine patients

Stepwise diagnostic algorithm for high-attenuation pulmonary abnormalities on CT

High-attenuation pulmonary abnormalities are commonly seen on CT. These findings are increasingly encountered with the growing number of CT examinations and the wide availability of thin-slice images. The abnormalities include benign lesions, such as infectious granulomatous diseases and metabolic diseases, and malignant tumors, such as lung cancers and metastatic tumors. Due to the wide spectrum of diseases, the proper diagnosis of high-attenuation abnormalities can be challenging. The assessment of these abnormal findings requires scrutiny, and the treatment is imperative. Our proposed stepwise diagnostic algorithm consists of five steps. Step 1: Establish the presence or absence of metallic artifacts. Step 2: Identify associated nodular or mass-like soft tissue components. Step 3: Establish the presence of solitary or multiple lesions if identified in Step 2. Step 4: Ascertain the predominant distribution in the upper or lower lungs if not identified in Step 2. Step 5: Identify the morphological pattern, such as linear, consolidation, nodular, or micronodular if not identified in Step 4. These five steps to diagnosing high-attenuation abnormalities subdivide the lesions into nine categories. This stepwise radiologic diagnostic approach could help to narrow the differential diagnosis for various pulmonary high-attenuation abnormalities and to achieve a precise diagnosis.Critical relevance statement Our proposed stepwise diagnostic algorithm for high-attenuation pulmonary abnormalities may help to recognize a variety of those high-attenuation findings, to determine whether the associated diseases require further investigation, and to guide appropriate patient management. Key points • To provide a stepwise diagnostic approach to high-attenuation pulmonary abnormalities.• To familiarize radiologists with the varying cause of high-attenuation pulmonary abnormalities.• To recognize which high-attenuation abnormalities require scrutiny and prompt treatment.

A 51-Year-Old Woman With Pellets in the Sputum

CASE PRESENTATION

A 51-year-old woman with no comorbidities presented with a 3-month history of cough with mucopurulent expectoration and intermittent fever. Over the past 1 month, she complained of streaky hemoptysis and gave history of expectorating "whitish pellets" in the sputum on two occasions. She had developed progressive breathlessness for a week prior to presentation to our hospital. There was no history of chest pain or loss of weight or appetite. She was a nonsmoker and did not consume alcohol. She had received multiple courses of antibiotics at another center with no relief of symptoms.

Broncholithiasis: A Review

The term "broncholithiasis" is defined as the presence of calcified or ossified materials within the tracheobronchial tree. The report of the condition dates back to 300 bc when Aristotle first described a symptom of "spitting of stones." The process of calcification usually starts within either the mediastinal, hilar, or peribronchial lymph nodes. The impetus is typically initiated by a granulomatous process such as TB or histoplasmosis; however, it can also been seen following exposure to other fungal or occupational elements. The exact mechanism of the calcified material (broncholith) entering the endobronchial tree remains unknown. It is hypothesized, however, that the calcified tissues gradually erodes and/or breaks loose in the airways as a result of repetitive movements of respiration or cardiac pulsations. The broncholiths are often found in the airways without any signs of erosion, however. The most common symptoms of broncholithiasis include cough, hemoptysis, and wheezing as a result of irritation of the airways and the surrounding tissues. The diagnosis is typically suspected on chest radiographs and confirmed by using bronchoscopy. Depending on the severity of the disease, management options range from simple observation to surgical resection. Despite the potential for major complications, the overall disease prognosis is good if timely and appropriate management is provided.

Management of broncholithiasis

Broncholithiasis is a condition in which calcified material has entered the tracheobronchial tree, at times causing airway obstruction and inflammation. Broncholiths generally originate as calcified material in mediastinal lymph nodes that subsequently erode into adjacent airways, often as a result of prior granulomatous infection. Disease manifestations range from asymptomatic stones in the airway to life-threatening complications, including massive hemoptysis and post-obstructive pneumonia. Radiographic imaging, particularly computed tomography scanning of the chest, is integral in the evaluation of suspected broncholithiasis and can be helpful to assess involvement of adjacent structures, including vasculature, prior to any planned intervention. Management strategies largely depend on the severity of disease. Observation is warranted in asymptomatic cases, while therapeutic bronchoscopy and surgical interventions may be necessary for cases involving complications. Bronchoscopic extraction is often feasible in cases in which the broncholith is freely mobile within the airway, whereas partially-embedded broncholiths represent additional challenges. Surgical intervention is indicated for advanced cases deemed not amenable to endoscopic management. Complex cases involving complications such as massive hemoptysis and/or bronchomediastinal fistula formation are best managed with a multidisciplinary approach, utilizing expertise from fields such as pulmonology, radiology, and thoracic surgery.

Pulmonary actinomycosis associated with endobronchial vegetable foreign body

A 51-year-old woman visited our hospital with massive hemoptysis. She had suffered from recurrent hemoptysis for five years and had undergone bronchial artery embolization many times. The patient had a history of pulmonary tuberculosis and bronchiectasis. Chest radiography showed consolidation around the nodule in the lateral basal segment of the right lower lobe. We successfully performed a right lower lobectomy. The histological study of the resected specimen showed a vegetable foreign body and clumps of Actinomyces, indicating actinomycosis, which was suggested to be the cause of the hemoptysis. This was a very rare case of hemoptysis caused by a vegetable foreign body and actinomycosis.

Endobronchial hamartoma as a cause of pneumonia

Patient: Male, 66

Final Diagnosis: Endobronchial hamartoma

Symptoms: Fever

Medication: —

Clinical Procedure: Flexible bronchoscopy • surgical resection

Specialty: Pulmonology

A Case of Endobronchial Actinomycosis with a Broncholith cured by Cryotherapy through a Flexible Bronchoscope

<p>We report the case of a 53-year-old man who presented with obstructive pneumonitis and broncholithiasis. We attempted to remove the broncholith with forceps through a flexible endoscope, but the potential for bleeding due to partial synechia did not allow this. We succeeded in removing it with cryotherapy. The histopathological diagnosis was thoracic actinomycosis associated with broncholithiasis. Endobronchial actinomycosis with a broncholith is very rare. We successfully treated a patient with endobronchial actinomycosis with a broncholith by administering short-term antibiotics after broncholithectomy via cryotherapy through a flexible bronchoscope.</p>

Endobronchial actinomycosis after airway stenting

Actinomycosis is a chronic suppurative infection with filamentous, gram-positive, nonspore forming anaerobic bacteria of the genus Actinomyces. Actinomyces species are commensals of the human oropharynx, gastrointestinal tract, and female genitalia. Involvement of the thorax accounts for 15% to 20% of actinomycosis cases. Thoracic actinomycosis classically presents as an intrapulmonary infection of the alveoli, peribronchial tissue, and/or bronchioles. Endobronchial actinomycosis is a rare condition that has been reported in association with aspiration of a foreign body or broncholithiasis. A critical component in the pathogenesis is disruption of the mucosal barrier, thereby allowing invasion of the microorganisms from aspirated oropharyngeal secretions. Even with a high clinical suspicion, actinomycosis is a diagnostic challenge. The most common symptoms of endobronchial actinomycosis include cough, sputum production, and fever. The disease is often confused with lung cancer, tuberculosis, fungal infections, nocardiosis, and poorly responding pneumonia. The present case highlights the first reported case of endobronchial actinomycosis associated with a covered nitinol endobronchial stent.

An overview of thoracic actinomycosis: CT features

Background

Thoracic actinomycosis is an uncommon, chronic suppurative bacterial infection caused by actinomyces species, especially Actinomyces israelii.

Methods

It is usually seen in immunocompetent patients with respiratory disorders, poor oral hygiene, alcoholism and chronic debilitating diseases.

Results

We illustrate the radiological manifestations of thoracic actinomycoses in various involved areas in the thorax.

Conclusion

Thoracic actinomycosis can be radiologically divided into the parenchymal type, the airway type including bronchiectasis, the endobronchial form, and the mediastinum or chest wall involvement type.

Teaching Points

Important risk factors for thoracic actinomycosis are underlying respiratory disorders such as emphysema and chronic bronchitis.

Different CT patterns can be distinguished in thoracic actinomycosis: parenchymal, bronchiectatic, endobronchial and extrapulmonary.

Typical CT findings in the parenchymal pattern are a central low density within the parenchymal consolidation and adjacent pleural thickening.

Thoracic Actinomycosis: CT Features with Histopathologic Correlation

OBJECTIVE

Thoracic actinomycosis is a chronic suppurative pulmonary or endobronchial infection caused by Actinomyces israelii, a gram-positive anaerobic organism. We present the CT features of thoracic actinomycosis with histopathologic correlation.

CONCLUSION

The typical CT feature of parenchymal actinomycosis is a chronic segmental air-space consolidation containing necrotic low-attenuation areas with frequent cavity formation. A broncholith can be secondarily infected with Actinomyces organisms, resulting in endobronchial actinomycosis. It usually manifests as a proximal endobronchial calcification associated with distal obstructive pneumonia.