A 31-year-old man from Western Maryland presented with recurrent hemoptysis of a 2-month duration.
Prepared by Robert D. Pugatch, MD and Stuart E. Mirvis, MD,
FACR, Department of Radiology, University of Maryland School of
Medicine, Baltimore, MD.
A 31-year-old man from Western Maryland presented with recurrent
hemoptysis of a 2-month duration.
Histoplasmosis with broncholithiasis
The frontal and lateral chest radiographs show a few scattered
nodules with focal calcification in the right hilar area (figure
1). There is fullness of the hila on the lateral view. There is no
evidence of lung consolidation or pleural effusion. The CT image
viewed in lung windows shows scattered calcified nodules
bilaterally with slight hypodensity in the right middle lobe
(figure 2A). The CT image in soft-tissue windows (figure 2B)
demonstrates a soft-tissue mass with dense central calcification
located in the middle mediastinum, anterior to the vertebral body
and surrounding the right intermediate bronchus. This finding is
consistent with calcified and enlarged hilar and mediastinal lymph
nodes. The enlarged lymph nodes are restricting the right
intermediate bronchus with possible erosion into the airway by
calcification. The pericardium is normal.
Histoplasmosis is caused by the organism Histoplasma capsulatum,
which is endemic in the central United States and is found in soil
excrement of birds (especially pigeons) and bats. Within endemic
areas, 80% of the population test positive for histoplasmosis, but
most remain asymptomatic.
Inhalation of spores results in a localized infection of the lung
that will migrate to involve the hilar and mediastinal lymph nodes,
and eventually to the liver and spleen.
Usually the organism is destroyed with no residual infection, but a
scar or focal calcification may remain.
There are a wide variety of radiologic manifestations of
histoplasmosis. The acute phase is characterized by single or
multiple areas of consolidation and, possibly, associated hilar or
mediastinal adenopathy. This usually resolves without treatment
within weeks to months. Radiographically, there may be complete
clearing, or a focus of calcification may persist. The epidemic
form shows multiple discrete nodules throughout both lungs and may
be associated with hilar adenopathy. When the nodules and lymph
nodes begin to heal, they become calcified. A third radiographic
pattern consists of a histoplasmoma (solitary granuloma), which is
a well-defined necrotic focus of infection surrounded by an
inflammatory reaction usually found in the lower lobes.
Complications from calcified lymph nodes include fibrosing
mediastinitis and broncholithiasis.
Fibrosing mediastinitis is due to the effects of large calcified
lymph nodes and a surrounding fibrotic reaction that constrict and
encase important mediastinal structures.
Broncholithiasis occurs when calcified nodes erode into a bronchus,
which can lead to unexplained chronic cough, hemoptysis, distal
atelectasis, and distal lung parenchymal infection.
A differential diagnosis for broncholithiasis includes
tuberculosis, actinomycosis, coccidiodomycosis, crytococcosis, and
In the present case, the patient underwent an emergent right
pneumonectomy for an episode of uncontrollable life-threatening