CTICasesBroncholithiasis with Post-Obstructive Atelectasis
Imaging findings
Radiograph shows a calcified pulmonary granuloma with calcified regional hilar and perihilar lymph nodes typical of prior granulomatous disease. There is left upper lobe opacity and subtle volume loss. CT demonstrates calcifications in an atelectatic left upper lobe lying in close relationship to the airways, with post-obstructive changes including dilated anterior segment bronchi containing endoluminal material. Bronchoscopy confirms a calcified endobronchial lesion compromising the lumen, and lobectomy pathology shows necrotizing granulomatous inflammation, calcifications, and fungal hyphal forms on GMS stain within a granuloma.
Key takeaways
Calcified granulomas from prior granulomatous infection (presumed histoplasmosis) can erode over time into the bronchial lumen, producing a broncholith that causes obstructive atelectasis and post-obstructive bronchiectasis. The close spatial relationship between calcified nodal or parenchymal material and an adjacent airway on CT should prompt consideration of broncholithiasis, and bronchoscopy can directly demonstrate the calcified endobronchial lesion. The finding of fungal hyphal forms within the granuloma is notable, as histoplasma typically appears as a yeast in tissue.
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