(881) Noncardiac-Associated Bilateral Plastic Bronchitis

Introduction: Plastic Bronchitis is a rare condition identified by the formation of endobronchial casts of indeterminate etiology resulting in bronchial obstruction, impaired gas exchange, and potential life-threatening respiratory failure.

Description: We present a 7-year-old male without past significant medical history who presented with acute hypoxemic respiratory failure after a one-year indolent history of declining respiratory functional status. The child was prescribed albuterol with an outpatient diagnosis of asthma with limited improvement. On day of admission, the child’s albuterol inhaler was empty, and he developed inability to walk without dyspnea. He presented to our Emergency Department with tachycardia, tachypnea, hypoxemia, and increased work of breathing treated with nebulized ipratropium-albuterol and IV steroids with minimal improvement. Given his degree of respiratory distress, he was started on bilevel positive airway pressure. Chest x-ray showed near total collapse of the left lung beginning at the mainstem bronchus. He was admitted to the critical care unit for further management. Immediate CT chest imaging showed complete obstruction of the left lower lobe bronchus with soft-tissue density material, bronchiectasis, and tree-in bud formation. Bronchoscopy was obtained with concern for plastic bronchitis and confirmation after large volume rubbery material casts from bilateral airway via cryotherapy. Subsequent pathology showed fibrinous casts, degenerating neutrophils, and eosinophils consistent with Type 1C plastic bronchitis. Repeat x-ray showed improving aeration of his lungs and he was initiated on inhaled alteplase and heparin. Evaluation for underlying etiology has been unremarkable. Although he remains on room air, pulmonary function testing showed moderate restrictive lung disease.

Discussion: Plastic bronchitis is a rare disease in pediatric patients. Case reports in non-cardiac pediatric patients have been associated with severe asthma, sickle cell anemia, cystic fibrosis, or respiratory illnesses. This case is relatively unique in that it occurred in an otherwise healthy young male with no known medical history. Further understanding of pathophysiologic pathways for this disease are warranted to guide management, especially in otherwise healthy individuals.