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A6739 - Unusual Cause of Chronic Cough in a Patient with Hepatocellular Carcinoma
Author Block: M. Kwon1, B. Colaco2, D. Sella3, K. Mody4, J. P. Leventhal1, V. Arunthari2; 1Pulmonary and Critical Care Medicine, Mayo Clinic Florida, Jacksonville, FL, United States, 2Pulmonary and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL, United States, 3Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL, United States, 4Hematology and Oncology, Mayo Clinic Florida, Jacksonville, FL, United States.
We present a very interesting case of chronic cough in a patient with hepatocellular carcinoma (HCC). A 64-year-old male presented with chronic cough for one year. He had alcoholic liver cirrhosis and emphysema. He was diagnosed of HCC 4 years prior to his presentation. The tumor was initially within the right lobe of the liver and he received a course of radioembolization. HCC progressed over time to involve right adrenal gland and inferior vena cava. He subsequently received drug-eluting bead transarterial chemoembolization (TACE) in liver segments II, III, VII, VIII, and the right phrenic artery supplying the right lobe, utilizing Oncozene™ labeled with doxorubicin, sequentially 3 times. The last TACE was 18 month prior to his presentation. On physical exam, he had decreased breath sound in the right lower lung field. Vital signs were normal. Laboratory testing showed mild anemia, elevated bilirubin and alpha-fetoprotein level. Pulmonary function test revealed moderate obstruction. CT of the chest revealed tree-in-bud nodularity and focal consolidation in the right lower lobe, abutting the diaphragm and costophrenic angle. MRI of the abdomen raised a concern for a fistulous connection between peripheral intrahepatic bile duct in segment VII, where the main tumor was present, and the right lung bronchi. Swallow evaluation did not show aspiration. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a stenotic biliary duct. Finally, bronchoscopy revealed copious greenish-yellow secretion from right distal bronchial trees, and bile was present in the bronchial washing. Bronchobiliary fistula is a connection between the biliary tree and pulmonary bronchi. Key clinical symptoms are chronic cough and bile in the sputum. Described cases have been associated with liver abscess, trauma, or hepatectomy. Possible mechanism of fistula formation is an ischemic peripheral bile duct injury from the repeated TACE with subsequent peripheral bile duct sequestration, leading to bile leakage into the necrotized hepatic parenchyma with subsequent erosion of the diaphragm. ERCP or percutaneous transhepatic cholangiogram are used for diagnosis. Initial therapy can be medical (drainage of subphrenic abscesses, antibiotic therapy, and resolution of biliary stenosis), but surgical treatment may be necessary if severe. We emphasize the role of the pulmonologist in detecting a bronchobiliary fistula in chronic cough patients with known risk factors, and the utility of bronchoscopy in diagnosis. To our knowledge, this is the first bronchobiliary fistula case after TACE, reported in the US.