대한흉부영상의학회 Korean Society of Thoracic Radiology

Discussion

Diagnosis With Brief Discussion

Diagnosis

Bronchial Anthracofibrosis (Inflammatory Bronchial Stenosis with Anthracotic Pigmentation)

Radiologic Findings

PA and lateral chest radiographs show air-space consolidation in right middle lobe. Contrast-enhanced CT scans show luminal narrowing of right upper lobar bronchus, bronchus intermedius and obstruction of right middle lobar bronchus with collapse of right middle lobe. Enlarged lymph node anterior to right upper lobar bronchus is also noted. Thickening and calcification along the bronchial wall are also seen.

On Fiberoptic bronchoscopy, smooth multifocal luminal narrowing of bronchi and black anthracotic pigmentation in bronchial mucosa were found (A-view from right upper lobar bronchus; B-view from bronchus intermedius; C-obstructed right middle lobar bronchus with mucosal thickening). This patient had a history of pulmonary tuberculosis in his young age.

Brief Review

Anthracofibrosis is a bronchoscopic finding showing dark anthracotic pigmentation on the bronchial mucosa in conjunction with bronchial narrowing or obliteration (1). Most patients are elderly women who usually present with cough, sputum, and dyspnea. Because of their age and segmental or lobar atelectasis on chest radiographs, bronchoscopy and chest CT are usually performed to exclude bronchogenic carcinoma. On CT, a segmental collapse distal to involved bronchi is the most common finding. The right middle lobe is the most frequently involved lobe. Bronchial narrowing is commonly accompanied by thickening of the wall. Enlarged or calcified mediastinal and hilar lymph nodes adjacent to the involved bronchi are frequently noted (2).
Establishing the origin of anthracotic pigments and the cause for bronchial stenosis is difficult. Previously, dark anthracotic pigmentation in the bronchial mucosa has been regarded as bronchoscopic findings of pneumoconiosis or evidence of heavy exposure to atmospheric soot particles (3). Recent investigators propose that bronchial tuberculosis is one of the most likely causes for the development of bronchial anthracofibrosis. Several evidences supporting this opinion are the association of either active or old pulmonary tuberculosis with anthracofibrosis, the reported cases with development of the anthracotic pigmentation during the course of antituberculous chemotherapy, and similar CT findings between bronchial tuberculosis and anthracofibrosis (1,2,4).
The hypothesis about the development of bronchial anthracofibrosis is as follows. Perforation of a tuberculous lymph node into the bronchus may develop insidiously, and the healing process may appear without apparent clinical symptoms in the aged population. The black pigments in the bronchial wall might be derived from anthracotic material in the adjacent lymph nodes, which might subsequently be incorporated into the scarred area of the bronchus. The involved lymph nodes, however, may perforate into the adjacent bronchi, and carbon particles in the lymph nodes may penetrate through the bronchial wall as deep as the mucosa, resulting in coloring of the bronchial mucosa. Subsequently, healing with fibrotic response may occur in the bronchi, resulting in bronchial narrowing or obstruction with anthracitic pigmentation (1).

References

1. Chung MP, Lee KS, Han J, Kim H, Rhee CH, Han YC, Kwon OJ. Bronchial stenosis due to anthracofibrosis. Chest. 1998; 113:344-350.
2. Kim HY, Im JG, Goo JM, Kim JY, Han SK, Lee JK, Song JW. Bronchial anthracofibrosis (inflammatory bronchial stenosis with anthracotic pigmentation): CT findings. AJR Am J Roentgenol. 2000; 174:523-527.
3. Stradling P. Diagnostic bronchoscopy. 5th ed. New York: Churchill Livingstone, 1986; 157.
4. Kim JY, Park JS, Kang MJ, et al. Endobronchial anthracofibrosis is causally associated with tuberculosis. Korean J Intern Med 1996; 51:351-357.

Keywords

Airway, Non-infectious inflammation, Bronchial Anthracofibrosis (Inflammatory Bronchial Stenosis with Anthracotic Pigmentation)