PLASTIC BRONCHITIS: A RARE CASE REPORT

Abstract

TOPIC: Lung Pathology TYPE: Fellow Case Reports INTRODUCTION: Plastic bronchitis (PB) is a rare condition that most clinicians are unaware of. We present a case of this disease and discuss its pathogenesis, clinical presentation, and management. CASE PRESENTATION: 50-year-old nonsmoker female with a past medical history of stage IV non-small cell lung cancer of the left lung presented with chief complaints of chest pain, shortness of breath, and a productive cough of thick secretions (photos showing what appeared to be firm bronchial casts) every few weeks. She has coughed casts at least three times, with a noted transient improvement in her respiratory status a few hours after expectoration of one of these casts. She had two previous bronchoscopies that resulted in the removal of thick mucus from her airways. Physical exam revealed reduced excursion of the left chest wall and bronchial breath sounds on the left. Chest X-ray showed complete opacification of the left hemithorax and elevation of the left hemidiaphragm. CT chest revealed nearly complete multifocal consolidation along with loss of left lung aeration. PFT was remarkable for FVC and FEV1 reductions with preservation of the ratio and reduced lung volumes consistent with restrictive physiology. The patient underwent bronchoscopy and a large congeal white-colored cast (bland in appearance) suggestive of PB was found obstructing the left mainstem bronchus and distal airway. The cast was removed from the airways using cryotherapy and therapeutic aspiration. Following the procedure, the patient's respiratory system improved noticeably. Pathology revealed inspissated mucin with acute and chronic inflammatory cell debris in the cast. DISCUSSION: PB was first described by Galen and is a rare condition characterized by expectoration of firm bronchial casts of varying sizes from the airways. It can be potentially fatal if mechanical obstruction of major airways occurs causing respiratory compromise. The casts are classified into type I or type II depending on the presence or absence of inflammatory cells. Numerous systemic illnesses are associated with PB but most commonly it involves abnormalities of lymphatic flow. To relieve airway obstruction, the initial treatment for PB includes bronchoscopic removal of the obstructing cast. Further management aims to resolving the underlying hypersecretory process. Due to the disease's rarity, there is a scarcity of data on its treatment. A good pulmonary toilet is indispensable. Inhaled medications (Beta-agonists, corticosteroids, idornase), expectorants (guaifenesin, hypertonic saline), mucolytics, and aerosolized heparin are used with varying benefits. Further research is needed to better understand the development of lymphatics and regulation of mucus production leading to cast formation. CONCLUSIONS: This case highlights case of PB which is a rare and underdiagnosed disease. REFERENCE #1: Eberlein M.H., Drummond M.B., Haponik E.F. Plastic bronchitis: a management challenge.Am. J. Med. Sci. 2008;335:163–169. REFERENCE #2: Mendoza Soto A., Galletti L., Gómez de Quero P., Ramos Casado M.V., Velasco Bayón J.M. Plastic bronchitis. A case report and review of the literature. REFERENCE #3: Johnson R.S., Sita-Lumsden E.G. Plastic bronchitis. Thorax. 1960;15:325–332. DISCLOSURES: No relevant relationships by Sarah Elsayed, source=Web Response No relevant relationships by Ahmed Gohar, source=Web Response no disclosure on file for Zinobia Khan; No relevant relationships by Sudhir Krishnan, source=Web Response No relevant relationships by Mani Latifi, source=Web Response No relevant relationships by Mariam Saeed, source=Web Response