B47-12 Chronic Cough Unveiling Broncholith-Induced Bronchoesophageal Fistula

Abstract Introduction Broncholithiasis is a rare condition in which calcifications deposit in the tracheoendobronchial tree risking airway inflammation, obstruction, or erosion. Causes of broncholithiasis include malignancy, primary ciliary dyskinesia, fungal infection, tuberculosis, and silicosis. More than half of patients with this condition present with a cough.1 Chronic cough significantly affects quality of life and serves as a leading referral to pulmonary clinics. Case Description A 75-year-old female with a history of obstructive sleep apnea, atrial fibrillation, deep vein thrombosis/pulmonary embolism on apixaban, former tobacco use, and right renal cell carcinoma status-post nephrectomy presented to pulmonology clinic with a chronic cough. She had partial response to treatments for reactive airway disease, upper airway cough syndrome, and silent laryngopharyngeal reflux. Otolaryngology, allergy, and neurology guided these therapies. A computed tomography chest demonstrated atelectasis and a granulomatous calcification in the right lower lobe. Initially, the patient elected surveillance imaging rather than bronchoscopic evaluation. Over the following year she reported worsening cough, lithoptysis, and intermittent aspiration of solids and liquids. A modified barium swallow revealed gastroesophageal reflux, and repeat imaging showed ongoing right lower lobe granulomatous calcification with concern for a broncholith. This prompted a bronchoscopy with interventional pulmonology which showed no stones, although the right lower lobe couldn’t be visualized due to tissue bleeding and friability. Since the patient’s symptoms persisted and often involved cough with food intake, a second esophagram was performed and noted a bronchoesophageal fistula between the right lower lobe and esophagus. Thoracic surgery completed a right thoracotomy with takedown of the bronchoesophageal fistula and closure using a muscle flap. A likely contributory broncholith was removed. The patient’s recovery was complicated by subsequent admissions for a surgical site hematoma and wound dehiscence. While the patient’s cough has shown significant improvement, she has ongoing multidisciplinary follow-up for residual symptoms along with persistent GERD and post-operative pain. Discussion This case features a unique cause of a common respiratory complaint. Although cough commonly occurs in patients with broncholithiasis, lithoptysis is infrequent and bronchoesophageal fistula formation is rare.1 Serial diagnostic testing for progressive or persistent symptoms was critical as the patient’s broncholiths and fistula were only seen on repeat imaging. Our patient’s case serves as a reminder to maintain broad differentials for cough and that complications can still arise despite thorough clinical investigation. References 1. Alshabani, K., Ghosh, S., Arrossi, A. V., & Mehta, A. C. (2019). Broncholithiasis. Chest, 156(3), 445–455. https://doi.org/10.1016/j.chest.2019.05.012 This abstract is funded by: None