Of plugs and Casts: A case Plastic Bronchitis in a 17-year-old patient with Mild Asthma
Plastic bronchitis or simply bronchial casts are rare cause of obstructive lung disease , cough, chest pain, respiratory failure and death. They are related to cyanotic congenital heart disease as a mucinous or lymphatic cast or inflammatory cast in atopy or a fibrinous cast in sickle cell disease. In atopy, cast are usually described with abundant eosinophilic and Charcot-Leyden crystals with fibrinous framework. These is different from the mucus plug seen during asthma exacerbation. Therapy usually target inflammation but no standard of care exists. Mortality rate range from 0-60%. We present a case discovered during a routine visit for sport physical. This 17 –year-old with asthma and environmental allergies to dust mites diagnosed at age 3, was kept on Albuterol as needed use infrequently twice a year. Has not been on any long term anti-inflammatory medication. Few month before he presented to the pulmonary clinic, he had wheezing and rhonchi. He had no viral illness, no fever and no sick contact. No recent travel. A CXR was done and shows LLL opacity and he was treated with antibiotics including Zithromax, Augmentin, Doxycycline, several prolonged courses of oral steroids , started on inhaled corticosteroids. Multiple CXR and a CT scan shows persistent retrocardial opacity suggesting atelectasis or pneumonia. He started to expectorate “stuff” before his pulmonary visit, reported as many eosinophil with normal flora. On treatment, he started complaining of chest pain and shortness of breath. Flexible bronchoscopy reveals mucinous/tissue-like materials in the RML and posterior sub segment of the LLL initially thought to be food pieces. The gelatinous/fibrinous material was tightly attached to the airway wall. During a 4-hours process using biopsy forceps, a grasper and Fogarty catheter, through a 2.0 channel of a 5.2 Bronchoscope, the casts was removed. The airway was inflamed. Pathology as for the expectorated cast shows fibrinous material with abundant eosinophils and Charcot-Leyden crystals. Further work up ruled out ABPA Patient continue to expectorate smaller cast. Azithromycin and airway clearance device were added. This is the first incidental presentation plastic bronchitis related to atopy discovered at sport physical on a patient with mild asthma. This confirm that plastic bronchitis may be underreported.