TOPIC: Pediatrics TYPE: Medical Student/Resident Case Reports INTRODUCTION: Plastic bronchitis is seen in congenital heart disease, cystic fibrosis, asthma, and less commonly sickle cell disease. It has high morbidity and can be difficult to treat. CASE PRESENTATION: We present an 11-year-old African American boy with past medical history of hemoglobin SS disease, acute chest syndrome, pain crises, and obstructive sleep apnea status post tonsillectomy and adenoidectomy who presented with vaso-occlusive pain crisis consisting of chest pain. CXR was clear without consolidation. He was placed on a pain regimen of morphine and ketorolac. Acute chest prophylaxis was initiated with albuterol plus PEP every 4 hours, incentive spirometry, and oxygen saturation maintenance ≥95%. Over the next two days he developed fevers, increased oxygen requirement, and crackles. CXR progressed to consolidation of left lung. He was transferred to the Pediatric ICU for BiPAP and given 2 units pRBCs, 7 days ceftriaxone, and 5 days azithromycin for acute chest treatment. Despite intense respiratory treatments while on BiPAP with albuterol every 4 hours, dornase alfa every 12 hours, CPT every 4 hours, and home mometasone/formoterol every 12 hours, his CXR demonstrated persistent opacification of left lung. Pulmonology was consulted for bronchoscopy which demonstrated large white mucoid material in the left mainstem consistent with plastic bronchitis. The cast was unable to be removed on initial bronchoscopy. He was initiated on inhaled tissue plasminogen activator 4 times daily in addition to above respiratory treatments. Bronchoscopy was repeated two days later and cast was successfully removed. BiPAP and oxygen were weaned as tolerated and he was discharged home on mometasone/formoterol twice daily. DISCUSSION: Plastic bronchitis describes endobronchial plugs of rubber-like casts in the bronchial trees. It is more commonly seen in patients with congenital heart disease after single-ventricle palliation. There have been various treatments trialed including bronchoscopy, chest physiotherapy, inhaled steroids, hypertonic saline, dornase alfa, nebulized heparin, lymphatic embolization, and inhaled tissue plasminogen activator. Studies performed on casts have demonstrated a substantial fibrin component supporting inhaled tissue plasminogen activator as a potentially effective treatment option. CONCLUSIONS: We present a case of pediatric plastic bronchitis in the setting of a patient with sickle cell disease. This case emphasizes that plastic bronchitis must be considered in patients diagnosed with acute chest. Additionally, inhaled tissue plasminogen activator may be considered as a treatment modality in pediatric patients with plastic bronchitis, particularly in patients who are unable to undergo bronchoscopy or when it has been unsuccessful for removal. REFERENCE #1: Feray S, Mora P, Decavele M, Pham T, Hafiani EM, Fartoukh M. Plastic bronchitis: An unusual complication of acute chest syndrome in adult. Respir Med Case Rep. 2017 Apr 7;21:93–5. REFERENCE #2: Li Y, Williams RJ, Dombrowski ND, Watters K, Daly KP, Irace AL, et al. Current evaluation and management of plastic bronchitis in the pediatric population. Int J Pediatr Otorhinolaryngol. 2020 Mar 1;130:109799. REFERENCE #3: Heath L, Ling S, Racz J, Mane G, Schmidt L, Myers JL, et al. Prospective, Longitudinal Study of Plastic Bronchitis Cast Pathology and Responsiveness to Tissue Plasminogen Activator (tPA). Pediatr Cardiol. 2011 Dec;32(8):1182–9. DISCLOSURES: No relevant relationships by Megan Lilley, source=Web Response No relevant relationships by Carla Roberts, source=Web Response No relevant relationships by Heather Staples, source=Web Response