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Case Based Discussion
A lesson in plasticity: a 74-year-old man with plastic bronchitis
  1. Anand Shah1,2,
  2. Jackie Donovan3,
  3. Phil Marino4,
  4. Pallav L Shah1,2,
  5. Anand Devaraj2,5,
  6. Kshama Wechalekar2,6,
  7. Toby M Maher2,7,
  8. Michael R Loebinger1,2,
  9. Robert Wilson1,2
  1. 1Host Defence Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK
  2. 2Imperial College London, London, UK
  3. 3Department of Biochemistry, Royal Brompton and Harefield NHS Foundation Trust, London, UK
  4. 4Lane Fox Respiratory Unit, Guy's and St Thomas’ NHS Foundation Trust, London, UK
  5. 5Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
  6. 6Nuclear Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
  7. 7Interstitial Lung Disease Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK
  1. Correspondence to Dr Anand Shah, Host Defence Unit, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London SW3 6NP, UK; s.anand{at}imperial.ac.uk

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AS: A 74-year-old male was transferred to the Royal Brompton hospital from a local hospital with respiratory failure and expectoration of bronchial casts (see figure 1A). The patient recalls recurrent chest infections with occasional haemoptysis in his teens with no prior history of asthma, TB or pertussis. Despite investigation and antibiotic treatment, his symptoms of intermittent, chronic recurrent bronchial cast expectoration continued. A fibreoptic bronchoscopy on the patient, aged 41, revealed erythematous bronchial mucosa in the right middle lobe, with a ventilation/perfusion scan revealing concomitant decreased ventilation. Bronchial washings were unremarkable, and given concern of a pathology originating from the right middle lobe, a right middle lobectomy was performed. Histology showed non-specific inflammatory fibrosis around the lobar bronchus.

Figure 1

(A) Representative image of an expectorated bronchial cast by the patient. (B and C) CT image demonstrating marked diffuse bronchial wall thickening with mild bilateral patchy ground glass opacities with extensive consolidation in the right upper lobe. Minimal interlobular septal thickening in the lower lobes is also noted. (D) Image following centrifugation of a liquefied bronchial cast expectorated by the patient revealing a turbid fatty layer confirming its chylous nature. (E) Images of lymphangioscintogram (anterior thorax with and without right shoulder and costal margin markers) showing abnormal tracer activity in the right lung (indicated by red arrow) confirming chylous leak. Tracer activity is also seen in the abdominal lymphatic channels and in the liver (indicated by red star) due to systemic circulation of radiotracer on delayed images.

His symptoms, however, did not resolve. Microbiological examination of his casts revealed no growth, and histological examination showed fibrin and mucus with some lymphocytes. Further trials of corticosteroids, nebulised N-acetylcysteine, hypertonic saline, prophylactic azithromycin, systemic antifungals and oral cyclophosphamide were unsuccessful. Extensive immunological and allergic tests were normal.

His symptoms remained stable till age …

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