A RARE CASE OF PROGRESSIVE PULMONARY CAVITARY LESIONS

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Recurrent respiratory papillomatosis (RRP) is a rare and often benign condition caused by a human papilloma virus (HPV) infection that results in papilloma growth throughout the respiratory tract. It is placed into 2 categories: juvenile (<18 years) and adult (>18 years) onset. The incidence of juvenile onset RRP (JORRP) is estimated to be 2 cases per 100,000 children. Here, we discuss a case of JORRP in a middle-aged male presenting with recurrent dyspnea and cough. CASE PRESENTATION: A 37-year-old male with a history of JORRP, diagnosed at age 2 with over 50 debulking procedures by the age of 28, presented to the pulmonary clinic with progressive dyspnea and cough. He was noted to be tachycardic with bilateral rales, room air oxygen saturation of 90% and other vital signs stable. Chest radiography revealed patchy ground-glass nodules, cavities and a mass-like opacification in the right lower lobe with air fluid levels. Flexible bronchoscopy revealed diffuse papillomas involving the laryngeal vestibule, glottis, subglottis and trachea down to carina as well as evidence of pus in his left mainstem bronchus. Treatment with antibiotics for post obstructive pneumonia resulted in symptomatic improvement. Weeks later, he represented with similar symptoms and was retreated for post obstructive pneumonia. Computed tomography (CT) chest revealed multiple bilateral peribronchovascular cavitary lesions, scattered solid nodules, dense airspace consolidation in the bilateral lower lobes and bulky bilateral subcarinal lymphadenopathy. Imaging was consistent with RRP but also concerning for infection or malignant transformation to squamous cell carcinoma (SCC). CT-guided lung biopsy showed squamous papilloma with areas of necrosis and rare foci suspicious for invasion. Given concern for malignant transformation, repeat biopsy revealed mild to moderate dysplasia but no evidence of invasion. PET-CT to evaluate for malignancy was recommended following completion of antibiotics. DISCUSSION: JORRP is an acquired infection that occurs during vaginal delivery with symptoms of respiratory obstruction starting in childhood. Dysphonia is commonly noted due to papilloma growth on the vocal cords disrupting normal vibration. It is primarily managed by surgical resection including micro-debridement and laser resection. Adjuvant therapies include interferon alpha, antivirals and bevacizumab. Malignant transformation of RRP into invasive SCC is reported to be 3-7% in adults and thought to be from a mutation in the HPV viral genome. CONCLUSIONS: JORRP is the most aggressive form of RRP with no curative therapy. Diagnosis is established by laryngoscopy and first seen in the vocal folds. Post-obstructive pneumonia and malignant transformation to SCC should always be considered given the nature of RRP. REFERENCE #1: Fortes, H. R et al.(2017).Recurrent respiratory papillomatosis:A state-of-the-art review. Resp. Medicine,126,116-121. REFERENCE #2: Ivancic, R. et al. (2018). Current and future management of recurrent respiratory papillomatosis. Laryngoscope Investigative Otolaryngology, 3(1), 22-34. REFERENCE #3: Karatayli-Ozgursoy, S. et al. (2015). Risk factors for dysplasia in recurrent respiratory papillomatosis in an adult and pediatric population. Annals of Otology, Rhinology & Laryngology, 125(3), 235-241. DISCLOSURES: No relevant relationships by Kathy Chan, source=Web Response No relevant relationships by George Moran, source=Web Response No relevant relationships by Sudhir Rajan, source=Web Response No relevant relationships by Eduardo Solbes, source=Web Response