Clinical Images
Do You Know This Uncommon Cause of Chronic Cough?
Authors: Ahsan Wahab MD, Ahad Ayaz MD, Susan Smith MD.
A 46-year-old Caucasian female presented with non-productive cough, exertional dyspnea and wheezing for two months. She complained of fatigue and malaise but denied fever, night sweats, weight loss or history of bird exposure. Her history was negative for asthma, COPD, foreign body aspiration, tuberculosis and fungal infections. She had received oral antibiotics, steroids and bronchodilators without relief. On examination, vitals were normal with 97% oxygen saturation on room air; she was not in acute distress. Lungs were clear with good air entry throughout and lymph nodes were non-palpable. She was treated for post-infectious cough with oral antitussives. One month later she returned with resolution of cough and significant symptom improvement after having expectorated five irregularly-shaped stones with streaky hemoptysis. Her chest-x ray showed mild right hilar calcification. CT chest showed a partially-calcified subcarinal lymph node eroding the right bronchus intermedius (Figure 1 and 2). Quantiferon-TB Gold and histoplasma antibody tests were negative.
Fiberoptic bronchoscopy showed a spur protruding from the right bronchus intermedius without obstruction. There was no endobronchial mass lesion and hence no biopsy. Thoracic surgery recommended against intervention since symptoms had resolved and there was no airway compromise. She remained asymptomatic and serial chest CT was recommended for follow-up.
MCQ: What is the most likely diagnosis?
- Broncholithiasis
- Chronic bronchitis
- Aspiration of a bone fragment
- Calcification of aspirated foreign material
- Calcified endobronchial tumor
Click here for MCQ Answer and Discussion
Brief Bio:
Dr. Ahsan Wahab is currently working as a PGY-3 Internal Medicine resident in McLaren Flint –Michigan State University Residency Program in Flint, Michigan. Upon completing residency, he anticipates joining a fellowship for subspecialty training.
Dr. Ahad Ayaz recently graduated, but served as an academic chief for the McLaren Flint-Michigan State University Residency Program. He now lives near Fort Wayne, Indiana, where he has joined other McLaren Flint graduates in an inpatient-outpatient internal medicine practice.
Dr. Susan J Smith has served as Program Director at McLaren Flint –Michigan State University Internal Medicine residency program for the last 27 years. She is a general internist with subspecialization in Geriatrics and Hospice and Palliative Medicine.