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JAMA Clinical Challenge
May 22/29, 2018

A Young Woman With Cough and Lithoptysis

Author Affiliations
  • 1Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
  • 2Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, Massachusetts
JAMA. 2018;319(20):2129-2130. doi:10.1001/jama.2018.5101

A 28-year-old healthy woman presented with a 2-week history of dyspnea, cough, wheezing, and lithoptysis (expectoration of calcific material). She had no significant past medical history. She did not smoke, drink alcohol, or use illicit drugs. The patient was living in New England but had previously lived in Nebraska, Colorado, Mississippi, and Florida. Recent travel included visits to Uganda, Afghanistan, Albania, and Croatia and frequent hiking and camping trips. She received initial therapy with inhaled albuterol and oral azithromycin, but symptoms did not improve. A chest radiograph was unremarkable. Subsequent computed tomography (CT) of the chest revealed a mediastinal and endobronchial broncholith compromising the left main-stem bronchus lumen (Figure 1). Extensive testing for Mycobacterium tuberculosis and fungal and bacterial infectious agents were within normal limits, with the exception of a borderline urine Histoplasma antigen level (<0.5 ng/dL).