Medical Image of the Week: Mucous Plugs Forming Airway Casts

Figure 1. Bronchoscopic view of the mucous plug.

Figure 2. Cast removed with cryo-adhesion probe.

A 64 -year-old man with a recent diagnosis of acute lymphocytic leukemia (ALL) on chemotherapy presented with acute hypoxic respiratory failure, multifocal pneumonia, neutropenic fever and septic shock. The patient was intubated and required vasopressors for septic shock. His blood and sputum cultures grew Pseudomonas aeruginosa. Chest computed tomography demonstrated extensive consolidation of the left lung mainly the left lower lobe with extensive endobronchial mucus plugs. The patient underwent bronchoscopy after noninvasive measures failed to resolve the left lung atelectasis. After multiple attempts to retrieve the mucus plugs (Figure 1) with suction failed, a cryo-adhesion probe was used to freeze and retrieve the mucus plug. The plug formed a cast taking the shape of the airway (Figure 2).

Flexible bronchoscopy is warranted in patients who have persistent atelectasis or pneumonia that is either of unknown cause or suspected of being due to airway obstruction (1). The use of cryo-adhesion and extraction has been particularly useful in the management of airway obstruction caused by foreign bodies especially mucus plugs and blood clots that are not easily extracted by more standard means such as suction or forceps (2).

Huthayfa Ateeli, MBBS and Cameron Hypes MD, MPH

Division of Pulmonary, Critical Care, Sleep and Allergy Medicine

University of Arizona, Tucson, AZ USA

References

1. Feinsilver SH, Fein AM, Niederman MS, Schultz DE, Faegenburg DH. Utility of fiberoptic bronchoscopy in nonresolving pneumonia. Chest. 1990 Dec;98(6):1322-6. [CrossRef] [PubMed]
2. Strausz J, Bolliger CT. Interventional pulmonology. Sheffield: European Respiratory Society; 2010: 165.

Cite as: Ateeli H, Hypes C. Medical image of the week: mucous plugs forming ariway casts. Southwest J Pulm Crit Care. 2017;15(6):278-9. doi: https://doi.org/10.13175/swjpcc147-17 PDF 

Medical Image of the Week: Carcinoid at the Carina

Figure 1. Flow-volume loop showing flattening of expiratory loop suggesting variable intra-thoracic obstruction.

Figure 2. CT of the chest showing pedunculated tracheal lesion at the level of main carina.

Figure 3. Bronchoscopic view of endobronchial tumor before (Panel A) and after removal (Panel B).

A 74-year-old woman with history of 30 pack-year smoking, allergic rhinitis and asthma presented to pulmonary clinic with cough and dyspnea on exertion. She was placed on inhaled corticosteroids and long-acting beta-agonist. Pulmonary function test showed moderate obstructive ventilator defect and flow volume loop suggested variable intra-thoracic obstruction (Figure 1). In the meantime, she was hospitalized with complaint of dyspnea and possible COPD exacerbation. Het CT chest revealed an endobronchial 12 mm pedunculated lesion at anterior aspect of main carina (Figure 2). She underwent flexible bronchoscopy and lesion was removed using electro-surgical snare and cryoprobe (Figure 3). Her symptoms improved post-procedure. Pathologic examination of lesion revealed a carcinoid tumor.

Endobronchial tumors are masses confined within the bronchus, and may be associated with atelectasis or pneumonia of the distal parenchyma. These tracheobronchial tumors are classified as malignant or benign. Malignant tumors arising from surface epithelium include squamous cell carcinoma and neuro-endocrine tumors; and those arising from mesenchyme include sarcoma and malignant lymphoma. On the other hand, benign tumors arising from surface epithelium include squamous cell papilloma and mucus gland adenoma; and those arising from mesenchyme include hamartoma, lipoma, fibroma, leiomyoma, and neurogenic tumor. Hamartomas may present as a fatty mass, nodules with calcification, or as soft-tissue-density nodules on CT scans. The lipomas manifested as fat density on CT scans. The other benign tumors were low-attenuating, soft-tissue-density masses without characteristic findings on CT scans.

Tauseef Afaq Siddiqi, MD; Muhammad Alzoubaidi, MD; James Knepler, MD and Kenneth Knox, MD

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, The University of Arizona, Tucson, AZ

Reference

1. Ko JM, Jung JI, Park SH, Lee KY, Chung MH, Ahn MI, Kim KJ, Choi YW, Hahn ST. Benign tumors of the tracheobronchial tree: CT-pathologic correlation. AJR Am J Roentgenol. 2006;186(5):1304-13. [CrossRef] [PubMed] 

Reference as: Siddiqi TA, lzoubaidi M, Knepler J, Knox KS. Medical image of the week: carcinoid at the carina. Southwest J Pulm Crit Care. 2015;10(6):341-2. doi: http://dx.doi.org/10.13175/swjpcc052-15 PDF