Images in Pulmonary, Critical Care, Sleep Medicine and the Sciences Tophus Causing Bronchial Obstruction Rosemary Adamson1, J. Matthew Lacy2, Aaron M. Cheng3, and David R. Park1 1 Division of Pulmonary & Critical Care Medicine, 2Department of Pathology, and 3Division of Cardiothoracic Surgery, University of Washington, Seattle, WA
Figure 1. Coronal cut of chest computed tomography demonstrating multifocal consolidation, most dense in the right lower lobe, with foreign body visible in right lower lobe bronchus.
Figure 2. Photograph taken during flexible bronchoscopy demonstrating foreign body in right lower lobe bronchus distal to takeoff of superior and medial basal segmental bronchi.
A 56-year-old man with a history of chronic obstructive pulmonary disease and alcohol abuse was admitted to the medical ICU with septic shock and hypoxic respiratory failure requiring intubation. Imaging demonstrated multifocal consolidation including complete consolidation of the right lower lobe (Figure 1) and blood cultures grew Streptococcus pneumoniae. He was treated with appropriate antibiotics and improved after 6 days but developed recurrent fevers and purulent airway secretions on Day 9. We performed bronchoscopy to evaluate for ventilator-associated pneumonia. A foreign body was found in the right lower lobe bronchus (Figure 2). It could not be removed using flexible bronchoscopy techniques and was later extracted using rigid bronchoscopy. Histopathologic examination revealed an acellular material (Figure 3) with crystalline structure which demonstrated strong negative birefringence under polarized light (Figure 4) consistent with urate crystals. There have been a number of case reports of gout affecting the larynx but to our knowledge this is the first report of a tophus in the lower airways (1, 2). The patient had no known history of gout or any signs of arthritis or external tophi on physical examination. No laryngeal abnormalities were noted during intubation. Author disclosures are available with the text of this article at www.atsjournals.org.
References 1. Tsikoudas A, Coatesworth AP, Martin-Hirsch DP. Laryngeal gout. J Laryngol Otol 2002;116:140–142.
Author Contributions: R.A. is the pulmonary and critical care fellow who cared for the patient, performed bronchoscopy, took the bronchoscopic image, wrote and submitted the manuscript. J.M.L. is the pathologist who examined the bronchial foreign body, determined that it was urate crystal and took the photomicrographs for this article. A.M.C. is the cardiothoracic surgeon who extracted the foreign body from the bronchus. D.R.P. is the pulmonary and critical care attending who cared for the patient, supervised bronchoscopy and oversaw the writing of the manuscript and selection of images. Am J Respir Crit Care Med Vol 188, Iss. 12, pp e72–e73, Dec 15, 2013 Copyright ª 2013 by the American Thoracic Society DOI: 10.1164/rccm.201301-0097IM Internet address: www.atsjournals.org
2. Habermann W, Kiesler K, Eherer A, Beham A, Friedrich G. Laryngeal manifestation of gout: a case report of a subglottic gout tophus. Auris Nasus Larynx 2001;28:265–267.
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Figure 3. Photomicrograph of the touch preparation of the foreign body showing acellular crystalline material (310 magnification).
Figure 4. Photomicrograph of the crystals under polarized light demonstrating negative birefringence (340 magnification).
Figure 1. Coronal cut of chest computed tomography demonstrating multifocal consolidation, most dense in the right lower lobe, with foreign body visible in right lower lobe bronchus.
Figure 2. Photograph taken during flexible bronchoscopy demonstrating foreign body in right lower lobe bronchus distal to takeoff of superior and medial basal segmental bronchi.
A 56-year-old man with a history of chronic obstructive pulmonary disease and alcohol abuse was admitted to the medical ICU with septic shock and hypoxic respiratory failure requiring intubation. Imaging demonstrated multifocal consolidation including complete consolidation of the right lower lobe (Figure 1) and blood cultures grew Streptococcus pneumoniae. He was treated with appropriate antibiotics and improved after 6 days but developed recurrent fevers and purulent airway secretions on Day 9. We performed bronchoscopy to evaluate for ventilator-associated pneumonia. A foreign body was found in the right lower lobe bronchus (Figure 2). It could not be removed using flexible bronchoscopy techniques and was later extracted using rigid bronchoscopy. Histopathologic examination revealed an acellular material (Figure 3) with crystalline structure which demonstrated strong negative birefringence under polarized light (Figure 4) consistent with urate crystals. There have been a number of case reports of gout affecting the larynx but to our knowledge this is the first report of a tophus in the lower airways (1, 2). The patient had no known history of gout or any signs of arthritis or external tophi on physical examination. No laryngeal abnormalities were noted during intubation. Author disclosures are available with the text of this article at www.atsjournals.org.
References 1. Tsikoudas A, Coatesworth AP, Martin-Hirsch DP. Laryngeal gout. J Laryngol Otol 2002;116:140–142.
Author Contributions: R.A. is the pulmonary and critical care fellow who cared for the patient, performed bronchoscopy, took the bronchoscopic image, wrote and submitted the manuscript. J.M.L. is the pathologist who examined the bronchial foreign body, determined that it was urate crystal and took the photomicrographs for this article. A.M.C. is the cardiothoracic surgeon who extracted the foreign body from the bronchus. D.R.P. is the pulmonary and critical care attending who cared for the patient, supervised bronchoscopy and oversaw the writing of the manuscript and selection of images. Am J Respir Crit Care Med Vol 188, Iss. 12, pp e72–e73, Dec 15, 2013 Copyright ª 2013 by the American Thoracic Society DOI: 10.1164/rccm.201301-0097IM Internet address: www.atsjournals.org
2. Habermann W, Kiesler K, Eherer A, Beham A, Friedrich G. Laryngeal manifestation of gout: a case report of a subglottic gout tophus. Auris Nasus Larynx 2001;28:265–267.
Images in Pulmonary, Critical Care, Sleep Medicine and the Sciences
e73
Figure 3. Photomicrograph of the touch preparation of the foreign body showing acellular crystalline material (310 magnification).
Figure 4. Photomicrograph of the crystals under polarized light demonstrating negative birefringence (340 magnification).
