A 69-year-old woman was admitted to hospital in November 9, 2007 with acute exacerbation of chronic cough and dysphagia with solids and liquids for 2 weeks. She did not have hemoptysis, fever, chills, chest pain, or weight loss. When she was 9 years old, she had worked as a stone crusher for 3 years and was exposed to a large amount of quartz dust for not using any respiratory protective equipment. In 1969, she was diagnosed with silicosis and tuberculosis. She was treated for tuberculosis and was stable. She had no further exposure to dust or other toxic substances, thereafter. On follow-up, her condition had no change. The patient was a life-long nonsmoker and consumed no alcohol. Nor did she receive any medications. 
 On physical examination, the patient looked well, with no palpable peripheral lymph nodes. Occasional wheezing was heard on both lung fields. Laboratory data, including blood tests and serum electrolytes, liver enzymes, and bilirubin, as well as renal function were normal. Skin test for tuberculosis was negative. Three consecutive samples of sputum were negative for acid-fast bacilli by staining and culture. Chest x-ray and computed tomography (CT) of the chest demonstrated eggshell calcification of the hilar and mediastinal lymph nodes in the paratracheal, subcarinal, and aorticopulmonary window regions. Bilateral multiple pulmonary nodules were also visible. The lower lobe of the left lung showed a ground-glass, dense shadow. Barium esophagography revealed two fistulas between the middle esophagus and the left main bronchus, immediately tracking into the left bronchial tree (Fig 1). The diagnosis was silicosis with esophagobronchial fistula and aspiration pneumonitis. The patient received antibiotics. An esophageal stent was placed on December 14, 2007. The symptoms improved. 
 The symptoms however recurred within three days. Gastroesophageal endoscopy demonstrated a small ulcerated lesion above the metallic stent, with a small diverticulum 18 cm from the upper incisor; the esophageal mucosa was inflamed and friable. Biopsy revealed chronic inflammation and an ulcer without granulomas, malignancy, or organisms (Fig 2). Another esophageal stent was placed on December 20, 2007. The symptoms improved and the patient was discharged from hospital. 
 After two months, the patient was admitted to another hospital because of severe cough exacerbated by swallowing liquids and solid foods. Gastroesophageal endoscopy revealed a new small mid-esophageal ulcer. Other examinations, including tests for tumor markers, were normal. A tuberculin skin test gave negative results. Over the next few days, the patient reported expectoration of small grayish coral-like calculi with a stony consistency, measuring 5-10 mm in diameter, as well as episodes of coughing. Bronchoscopic examination showed a free broncholithiasis in the left main bronchus, mucosal thickening, and stenosis with no significant airway obstruction of the main bronchus. The broncholithiasis was extracted with no bleeding. Biopsy of the bronchus revealed chronic inflammation, with no evidence of malignant tumor cells or granulomas. Sputum and bronchoalveolar lavage analyses did not reveal Mycobacterium tuberculosis, fungi, or malignant cells. The diagnosis was silicosis with broncholithiasis and esophagobronchial fistula. 
 The patient continued to have frequent complications and persistent fistula probably related to stasis in the esophagus. Because of her frail condition, we decided to initiate a conservative operative approach and inserted a gastrostomy tube. 
 Two samples of the expectorated materials were analyzed by electron microscopy and energy-dispersive spectrometry (EDS), with a Phenom ProX system (Phenom-world Co, the Netherlands), operating at 15 kV. Without any coating on the sample, with SDD high resolution and a high-sensitivity EDS detector, semiquantitative chemical analyses were performed. Mineralogy analysis revealed the broncholithiasis was composed of calcium and phosphate, with no crystals of silica or silicate (Fig 3). 
 After 16 months, in June 2009, the patient was readmitted because of cough, sputum, dyspnea, fever, and night sweating for 10 days. The admission laboratory data included a white blood cell count of 6.65x103/muL (reference range 4.0-10.0x103/muL), hemoglobin level of 11.4 g/dL (11.0-15.0 g/dL), high-sensitivity C-reactive protein level of 26.38 mg/L (0-3 mg/L), serum albumin level of 4.32 g/dL (35-55 g/dL), serum protein level 7.0 g/dL, erythrocyte sedimentation rate 34.9 mm/h (0-20 mm/h). A skin test for purified protein derivative (5 TU) was strongly positive, with an induration of 25 mm with ulceration. The concentrated sputum test result was positive. The diagnosis was silicotuberculosis relapse. CT revealed an esophageal stent shadow, esophageal wall thickening, multiple small nodule spots, patchy shadows, and mediastinal and lung door multiple calcified lymph nodes (Fig 4). Antituberculous treatment with 450 mg rifapentine, twice a week, 300 mg inhaled isoniazid, once a day, and 750 mg pyrazinamide, once a day, was started. After nine months of antituberculous treatment, the patient did well. We continued to follow the patient until the time we wrote this report; she had no change (Fig 4).