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Special Feature
Sep 2011

Picture of the Month—Diagnosis

Arch Pediatr Adolesc Med. 2011;165(9):866. doi:10.1001/archpediatrics.2011.141-b
Denouement and Discussion: Plastic Bronchitis

A symmetry was noted in the radiograph, with hyperinflation of the right hemithorax and near-complete opacification on the left. The patient was taken emergently to the operating room for suspected airway foreign body. Bronchoscopic examination revealed an endobronchial cast, which was removed from the left mainstem bronchus (Figure 2). Ventilation of the left lung following removal of the cast revealed a laceration of the left mainstem bronchus (Figure 3). Final pathological analysis of the cast revealed large numbers of eosinophils with mixed cells. Five months after admission, he is doing well with no residual pulmonary deficits.

Figure 2. The cast of the left bronchial tree was removed from the left mainstem bronchus using telescopic forceps. The cast is in saline.

Figure 2. The cast of the left bronchial tree was removed from the left mainstem bronchus using telescopic forceps. The cast is in saline.

Figure 3. Laceration of the left mainstem bronchus was noted after removal of the cast.

Figure 3. Laceration of the left mainstem bronchus was noted after removal of the cast.

Plastic bronchitis, also referred to as cast bronchitis, is a rare disease characterized by the formation of mucoid branching impressions of the bronchial tree. These rigid casts can cause obstruction of large and small bronchi at multiple levels and may lead to significant respiratory distress or death.

Plastic bronchitis commonly presents with acute respiratory distress, wheezing, dyspnea, and cough. Therefore, it is easily mistaken for foreign body aspiration or status asthmaticus. Failure to improve following conventional asthma therapies often prompts further evaluation, leading to the diagnosis.1 Both the clinical presentation and radiographic findings in plastic bronchitis can vary depending on the degree of airway obstruction and presence of any underlying disease process.2

Plastic bronchitis is most commonly seen in association with congenital heart disease, particularly in patients who have undergone a Fontan procedure.3 Plastic bronchitis can also occur in patients with allergic or atopic conditions or as a complication of acute chest syndrome in children with sickle cell disease.4,5

Treatment of plastic bronchitis is tailored to the type of cast and underlying cause. Patients with underlying asthma and inflammatory casts have traditionally had favorable outcomes when treated with inhaled and systemic corticosteroids, chest physiotherapy, and bronchodilators. In patients with underlying cardiac disease, mucolytics have been reported to be useful.

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Article Information

Correspondence: Lindsey Burghardt, MD, Division of Emergency Medicine, Children's Hospital Boston, 300 Longwood Ave, Boston, MA 02115 (lindsey.burghardt@childrens.harvard.edu).

Accepted for Publication: December 7, 2010.

Author Contributions:Study concept and design: Burghardt, Neuman, Capraro, and Nagler. Acquisition of data: Neuman and Volk. Analysis and interpretation of data: Neuman. Drafting of the manuscript: Burghardt, Neuman, and Capraro. Critical revision of the manuscript for important intellectual content: Burghardt, Neuman, Volk, and Nagler. Administrative, technical, and material support: Neuman and Volk. Study supervision: Burghardt, Neuman, Capraro, and Nagler.

Financial Disclosure: None reported.

References
1.
Pérez-Soler A. Cast bronchitis in infants and children.  Am J Dis Child. 1989;143(9):1024-1029PubMed
2.
Jett JR, Tazelaar HD, Keim LW, Ingrassia TS III. Plastic bronchitis: an old disease revisited.  Mayo Clin Proc. 1991;66(3):305-311PubMed
3.
Quasney MW, Orman K, Thompson J,  et al.  Plastic bronchitis occurring late after the Fontan procedure: treatment with aerosolized urokinase.  Crit Care Med. 2000;28(6):2107-2111PubMedArticle
4.
Bowen A, Oudjhane K, Odagiri K, Liston SL, Cumming WA, Oh KS. Plastic bronchitis: large, branching, mucoid bronchial casts in children.  AJR Am J Roentgenol. 1985;144(2):371-375PubMed
5.
Raghuram N, Pettignano R, Gal AA, Harsch A, Adamkiewicz TV. Plastic bronchitis: an unusual complication associated with sickle cell disease and the acute chest syndrome.  Pediatrics. 1997;100(1):139-142PubMedArticle
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