Chest
Volume 144, Issue 5, November 2013, Pages 1696-1706
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Special Features
Black Bronchoscopy

https://doi.org/10.1378/chest.13-0981Get rights and content

A presence of black pigmentation involving the endobronchial tree is not uncommon. It was first described in the literature in association with occupational exposure in the early 1940s. However, in 2003, Packham and Yeow formally used the term black bronchoscopy to describe endobronchial metastasis from a malignant melanoma. Hyperpigmentation of the airway, however, is associated with multiple etiologies such as congenital disease, inborn errors of metabolism, infections, environmental exposures, neoplasm, and iatrogenic causes. Although the majority of these conditions are benign, a proper diagnosis is important for optimal management. In this article, we review the etiology of black bronchoscopy and discuss its presentations and current management guidelines.

Section snippets

Melanosis

Tracheobronchial melanosis (TBM) is an uncommon finding reported in the literature. Previous series have quoted a prevalence of one in every 52 bronchoscopies performed.2 The common sites affected are the secondary and the tertiary carina. Men and women are equally affected.2 Single or multiple areas of dark pigmentation are encountered incidentally on bronchoscopy performed for unrelated indications. No other mucosal abnormalities or distortions of the airways are noted (Fig 1D). Melanosis of

Alkaptonuria (Ochronosis)

Alkaptonuria is a rare inborn error of metabolism involving the degradation of the amino acids phenylalanine and tyrosine. It is a genetic disorder with an autosomal-recessive mode of inheritance.4 It is caused by a deficiency of the genes encoding for the homogentisate-1, 2-dioxygenase, which is an important liver enzyme that degrades homogentisic acid (HGA), a metabolite in the phenylalanine and tyrosine degradation pathway. The term ochronosis describes the accumulation of homogentisic acid

Aspergillus niger

Tracheobronchial aspergillosis can present in various clinical forms, such as invasive, ulcerative, or pseudomembranous tracheobronchitis.7 It predominantly affects the immunocompromised population. Endoscopic findings vary depending on the Aspergillus species involved. One percent of all Aspergillus airway infections following lung transplantation are from the niger species. It is usually encountered in the nosocomial environment and in patients who are suffering from hypogammaglobulinemia and

Anthracosis and Anthracofibrosis

Anthracosis refers to the deposition of carbon particles in the airways and the lung parenchyma. It is found among those who smoke cigarettes or reside or work in areas heavily polluted with atmospheric soot. The deposition of carbon within the bronchial mucosa or lung parenchyma does not induce inflammation or fibrosis. Most anthracotic particles are usually removed by mucociliary clearance; however, a small amount of carbon particles, phagocytosed by macrophages, remain within the bronchioles.

Endobronchial Melanoma

Several endobronchial neoplasms exhibit dark pigments. Primary melanoma of the lung is a rare tumor involving 0.01% of all lung tumors.47 Metastatic melanoma is the more common endobronchial lesion than its primary counterpart. Endobronchial melanomas, when metastatic, usually present after the onset of the primary tumors. It is vital to rule out an occult primary tumor if melanoma of the lung is suspected on bronchoscopy. The pathogenesis of endobronchial melanomas has been revised by Kiryu et

Charcoal Aspiration

Activated charcoal is considered an effective GI decontaminant for acute intoxication with select drugs. Charcoal prevents absorption by binding directly to the toxic drug and creating a passive diffusion gradient from the bloodstream, across the GI lumen (GI dialysis).55 Patients with an altered mental status are at high risk of aspiration of activated charcoal into the lungs, especially if the airway is not adequately protected. Aspiration is reported in 1.7% of patients who receive charcoal

Conclusion

The presence of black pigmentation involving the bronchial mucosa is a relatively uncommon and, hence, underrecognized condition. In this article, we provide a comprehensive review on the etiology of black bronchoscopy. In most of the cases, diagnosis can be made by reviewing the history of exposure to hazardous substance and by performing endobronchial biopsies and cultures. In case these basic diagnostic tests are unable to reveal the etiology, special diagnostic tests may be needed such as

Acknowledgments

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

References (75)

  • GR Bond

    The role of activated charcoal and gastric emptying in gastrointestinal decontamination: a state-of-the-art review

    Ann Emerg Med

    (2002)
  • FR Justiniani et al.

    Charcoal-containing empyema complicating treatment for overdose

    Chest

    (1985)
  • E Küpeli et al.

    “Pills” and air passages

    Chest

    (2013)
  • MC Ott et al.

    Pulmonary toxicity in patients receiving low-dose amiodarone

    Chest

    (2003)
  • WJ Martin

    Mechanisms of amiodarone pulmonary toxicity

    Clin Chest Med

    (1990)
  • A Brinker et al.

    Acute pulmonary injury in association with amiodarone

    Chest

    (2004)
  • S Krawtz et al.

    Nd-YAG laser-induced endobronchial burn. Management and long-term follow-up

    Chest

    (1989)
  • S Packham et al.

    Black bronchoscopy

    Respiration

    (2003)
  • L Pagliaccio et al.

    Endobronchial melanosis: occurrence and possible significance.[abstract]

    Chest

    (1989)
  • RW Babin et al.

    Oral hyperpigmentation and occult malignancy—report of a case

    J Otolaryngol

    (1978)
  • C Phornphutkul et al.

    Natural history of alkaptonuria

    N Engl J Med

    (2002)
  • D Karnak et al.

    Endobronchial fungal disease: an under-recognized entity

    Respiration

    (2007)
  • N Singh et al.

    Infections due to dematiaceous fungi in organ transplant recipients: case report and review

    Clin Infect Dis

    (1997)
  • ZA Qureshi et al.

    Ochroconis gallopava: a dematiaceous mold causing infections in transplant recipients

    Clin Transplant

    (2012)
  • S Shoham et al.

    Transplant-associated Ochroconis gallopava infections

    Transpl Infect Dis

    (2008)
  • R Long et al.

    Bronchial anthracofibrosis and tuberculosis: CT features before and after treatment

    AJR Am J Roentgenol

    (2005)
  • HY Kim et al.

    Bronchial anthracofibrosis (inflammatory bronchial stenosis with anthracotic pigmentation): CT findings

    AJR Am J Roentgenol

    (2000)
  • AJ Reginato et al.

    Ochronotic arthropathy with calcium pyrophosphate crystal deposition. A light and electron microscopic study

    Arthritis Rheum

    (1973)
  • AP Chua et al.

    New disease—new terminology

    Chest

    (2010)
  • E Mireles-Cabodevila et al.

    Anthracostenosis

    J Bronchol

    (2006)
  • V Boonsarngsuk et al.

    Bronchial anthracostenosis with mediastinal fibrosis associated with long-term wood-smoke exposure

    Respirology

    (2009)
  • JM Naccache et al.

    Anthracofibrosis attributed to mixed mineral dust exposure: report of three cases

    Thorax

    (2008)
  • P Dumortier et al.

    Comparative analysis of inhaled particles contained in human bronchoalveolar lavage fluids, lung parenchyma and lymph nodes

    Environ Health Perspect

    (1994)
  • K Amoli

    Bronchopulmonary disease in Iranian housewives chronically exposed to indoor smoke

    Eur Respir J

    (1998)
  • QH Liao

    A clinicopathological study of 16 autopsy cases of anthracosilicosis with lung cancer [in Chinese]

    Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi

    (2005)
  • D Wang et al.

    The implication of background anthracosis in the development and progression of pulmonary adenocarcinoma

    Cancer Sci

    (2003)
  • SD Meredith et al.

    Cervical manifestations of fibrosing mediastinitis: a diagnostic and therapeutic dilemma

    Head Neck

    (1993)
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