DOI: 10.1097/LBR.0b013e31828244d8
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PMID: 23328156
Issn Print: 1944-6586
Publication Date: 2013/01/01
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Excerpt
In general, a large lung mass seen on a computed tomography (CT) scan of the chest is considered malignant until proven otherwise, especially in those with high risk. Differential diagnosis of a lung mass includes neoplastic (malignant or benign) and non-neoplastic causes. Infections such as tuberculosis, fungal, or parasitic infections are considered in the endemic areas once neoplasm is excluded. Here, we report a case of bronchial anthracofibrosis (BAF) that presented with a large lung mass. BAF is not routinely included in the differential diagnosis of a lung mass, at least in the United States. Although imaging studies and bronchoscopic airway examination provide clues toward the diagnosis, a definitive diagnosis is made by bronchoscopic biopsies. A thorough search for malignancy and underlying tuberculosis infection is necessary.
A 66-year-old man was referred for evaluation of a right parahilar mass that was found incidentally when he presented to the emergency department with neck pain after a physical work in his yard. Imaging studies revealed multiple focal lucencies in cervical vertebral bodies on a cervical CT scan, reported as suggestive for bony metastases, and a large parahilar mass measuring 5.4×5.3 cm in diameter, obstructing the right middle lobe (RML) bronchus, distal to the bifurcation of the bronchus intermedius and extending superiorly involving the apical and anterior segmental right upper lobe (RUL) bronchi. There was also an atelectatic collapse of the RML and innumerable pulmonary nodules in the right lung, raising the possibility of metastatic disease on CT chest (Fig. 1). The patient was diagnosed with chronic obstructive pulmonary disease several years ago and underwent a bronchoscopy with biopsies for a lung lesion in 2010 in Pakistan. He was told that he did not have malignancy and was treated with several inhalers for his chronic obstructive pulmonary disease. He also remembered having several bouts of pneumonia that were treated as outpatient during past 2 years. He also complained of long-standing cough with dark colored phlegm production and dyspnea on exertion. He had a history of chewing tobacco and working as a truck driver. He denied weight loss, fever, or tuberculosis exposure, but he had never been tested for the latter condition. The only abnormal laboratory studies were mildly elevated C-reactive protein and positive QuantiFERON-TB Gold test. The patient underwent flexible bronchoscopy and endobronchial ultrasound-guided biopsies with high clinical suspicion of primary lung cancer. Airway examination revealed areas of discoloration in the right main bronchus and 90% obstruction of RML bronchus without an endobronchial mass and black discoloration on the bronchial mucosa (Fig. 2). Needle aspirations and endobronchial biopsies revealed necrotizing granulomatous inflammation with negative staining for fungi and mycobacteria. Seven days later, flexible bronchoscopy was repeated to obtain more biopsies for pathologic and microbiological evaluation. Biopsies from the mucosal discoloration and lung parenchyma confirmed anthracotic pigmentations and chronic inflammatory changes confirming diagnosis of BAF. Transbronchial biopsies from the RML and RUL and bronchioalveolar lavage (BAL) from RML were sent for microbiological staining and cultures. BAL fluid cultures came back positive for Mycobacterium tuberculosis complex by DNA probe, and the patient was started on 4-drug regimen treatment. Magnetic resonance imaging of the spine with contrast showed hemangiomas as explanation of lucencies seen on the CT scan.
BAF usually presents as bronchial narrowing or obliteration caused by a mass with black (anthracotic) pigmentation of the overlying mucosa.1 BAF is not an uncommon condition and is well described in Asia where air pollution is prevalent. It is very rare in developed countries.2–4 The majority of the patients are female.5 As in our patient, the patients may have cough, dyspnea, or chest pain.
