Of Plugs and Casts: Incidental Finding of Plastic Bronchitis Complicating "Mild" Asthma Vs. Allergic Bronchopulmonary Aspergillosis (ABPA)?

M. M. Gregoire-Bottex, R. Archemetre, M. Kadochi, J. Lamar, M. Leinwand;

Author address: 

Pediatrics and Adolescent Medicine, Western Michigan Homer Stryker, MD School of Medicine, Kalamazoo, MI, United States.

Abstract: 

Introduction: Plastic bronchitis or bronchial casts are rare cause of obstructive lung disease, respiratory failure and death. They are usually reported in congenital heart disease. Inflammatory casts occur in atopy. These are different from the mucus plug of asthma exacerbation. Therapy usually targets inflammation but no standard of care exists. We present a case discovered during a routine visit for sport physical.
Case report: This is a 17-year-old male with “mild” asthma and dust mite allergy kept on Albuterol as needed. Wheezing was heard during his sport physical. He denied viral illness, fever, sick contact or recent travel. CXR shows LLL opacity that failed multiple courses of oral antibiotics and steroids. His initial work up shows normal white count with18% eosinophils, normal ESR and partially reversible obstruction on PFT. Inhaled steroids were added. Chest CT shows persistent retrocardial opacity. He started to expectorate “stuffs”. Sputum culture showed many eosinophil and normal flora. Quantiferon was negative. Chest pain and shortness of breath ensued prompting pulmonology referral. Flexible bronchoscopy revealed obstruction of the RML and LLL with a whitish mucinous material tightly attached to the airway walls. During a 4-hour intervention aided by pediatric surgeon, we used a biopsy forceps, a grasper and Fogarty catheter, through a 2.0 channel of a 5.2 bronchoscope, the casts were removed, revealing brown, tissue-like materials expanding in size, initially thought to be food particles. Pathology shows fibrinous material with abundant eosinophils and Charcot-Leyden crystals. Bronchoalveolar lavage fluid shows 5% eosinophils, galactomannan and PCR for M. tuberculosis, AFB smear, AFB, bacterial and fungal cultures were negative. Repeat bronchoscopy for additional cast removal was needed 3 weeks later. Repeat CT after cast removal reveals bronchiectasis. IgE rose from 68 to 103, precipitins to Aspergillus fumigata (AF) were positive. Patient responded to tissue plasminogen activator, airway clearance and pulse steroids. His Spirometry was normal after voriconazole and long term oral steroids for a working diagnosis of allergic bronchopulmonary aspergillosis (ABPA). Skin testing to AF was negative after treatment.
Discussion: This is the first report of incidental finding of bronchial cast. The case raises awareness that bronchial cast is underreported and might present in asymptomatic patient with intermittent asthma. A high index of suspicion will help prevent airway obstruction or death from an expanding cast. ABPA was considered due to central bronchiectasis and positive precipitins to AF. His multiple courses of oral steroids may have masked his diagnosis.

Tables: 

2018

abstract No: 

A5578 / P1021

Full conference title: 

The American Thoracic Society Conference 2018
    • ATS 2018