AN UNUSUAL PRESENTATION OF CHRONIC COUGH: PLASTIC BRONCHITIS AND CHYLOPTYSIS

Abstract

SESSION TITLE: Fellows Cardiothoracic Surgery Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Plastic bronchitis and chyloptysis are rare medical conditions characterized by expectoration of bronchial cast and production of white milky sputum rich in chyle, respectively. Plastic bronchitis is associated with congenital heart disease in children and lymphatic system disease in adults. CASE PRESENTATION: A 49-year-old Hispanic female with no past medical history presented with dyspnea and right-sided pleuritic chest pain during her first pregnancy 27 years ago. Initial evaluation, work up and imaging studies revealed right-sided chylothorax requiring chest tube placement, thoracotomy with decortication, and thoracic duct ligation. One month later, cisterna chyli ligation and right lower lobe wedge resection were performed. Right lower lobe biopsy results disclosed chronic interstitial pneumonitis and focal foreign body reaction. During follow up patient reported resolution of symptoms. In May 2019, the patient presented to our institution with four-month history of dyspnea, dry cough, and expectoration episodes of a thick, white-red, cord-like material accompanied by viscous milky white sputum. The patient’s symptoms progressively worsened where she developed a choking sensation at night and in supine position. Chest CT scan show small areas of ground glass airspace opacity in the dependent portions of bilateral lungs with concentric thickening of the right pleura. Bronchoscopy was performed and was notable for milky-white secretions with abundant pale and slightly red, stranded bronchial casts lodged within the left lower lobe anterior segment. Bronchial lavage and aspiration specimen sent for oil red stain showed macrophages with lipid droplets. These findings were consistent with the clinical impression of chyloptysis producing subsequent plastic bronchitis. Cytology was negative for malignancy. Patient completed course of broad spectrum antibiotics and steroids with partial improvement in her condition. She currently is under evaluation for embolization and/or invasive approach. DISCUSSION: This case addresses a 49-year-old female who presented with milky-white sputum and cough. Bronchoscopy showed milky-white secretions and bronchial cast, bronchial lavage was positive for oil red stain which confirms chyloptysis causing plastic bronchitis. She completed a course of antibiotics and steroids with partial improvement in her condition. Now is under evaluation for embolization and/or invasive approach. CONCLUSIONS: This case illustrates an unusual presentation of chronic cough and chyloptysis, confirmed by bronchoscopy. Plastic bronchitis and chyloptysis rare medical conditions that should be suspected after obtaining thorough history and physical exam, high index of suspicion is fundamental for the recognition and treatment of this rare entity. Reference #1: Itkin M, Mccormack FX, Dori Y. Diagnosis and Treatment of Lymphatic Plastic Bronchitis in Adults Using Advanced Lymphatic Imaging and Percutaneous Embolization. Annals of the American Thoracic Society. 2016;13(10):1689-1696. Reference #2: Lim KG, Rosenow EC, Staats BS, Morgenthaler TI. Chyloptysis in Adults: Presentation, Recognition, and Differential Diagnosis. Chest. 2004; 125:336-304. Reference #3: Stoddart A, Dincer HE, Iber C, Tomic R, Bhargava M. Chyloptysis causing plastic bronchitis. Respiratory Medicine Case Reports. 2014; 13:4-6. DISCLOSURES: No relevant relationships by Michael Cruz, source=Web Response No relevant relationships by Ricardo Fernandez, source=Web Response No relevant relationships by Giovanni Veloz Irizarry, source=Web Response