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Images in Thorax
The curious incident of the cast in the airway
  1. Yueqi Ge1,
  2. Emily C Bartlett2,3,
  3. Thomas Semple2,3,
  4. Alexandra Rice4,
  5. Anand Shah1,5,
  6. Elisabetta A Renzoni1,3
  1. 1 Respiratory Department, Royal Brompton Hospital, London, UK
  2. 2 Radiology Department, Royal Brompton Hospital, London, UK
  3. 3 National Heart and Lung Institute, Imperial College London, London, UK
  4. 4 Histopathology Department, Royal Brompton Hospital, London, UK
  5. 5 Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
  1. Correspondence to Dr Yueqi Ge, Respiratory Department, Royal Brompton Hospital, London SW3 6NP, UK; yueqi.ge{at}nhs.net

https://doi.org/10.1136/thoraxjnl-2020-216426

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    Case presentation

    A 52-year-old man presented with progressive dyspnoea and productive cough over 4 months. He was in type 2 respiratory failure (pO2 7.99 kPa/60 mm Hg; pCO2 9.32 kPa/70 mm Hg) with fluid overload and was started on non-invasive ventilation and intravenous diuresis in intensive care. Physical examination was significant for his short neck, small jaw and body mass index of 50. He was expectorating thick branching sputum, and bronchial casts were retrieved on bronchoscopy (figure 1A).

    Figure 1

    (A) Image of bronchial cast removed during bronchoscopy. (B) Section of laminated proteinaceous cast material (black arrow) with admixed small lymphocytes and foamy macrophages (black arrow) with scale bar (H&E ×40).

    A chest CT showed endobronchial material and extensive bilateral ground glass opacification (figure 2A,B). Sputum cultures were negative but biochemical analysis revealed high triglycerides. Histopathological analysis revealed a fibrinous sample with foamy macrophages, occasional eosinophils and mildly atypical epithelioid cells (figure …

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    Footnotes

    • Twitter @drAnand_Shah_

    • Contributors YG drafted the manuscript. ECB and TS provided radiological input. AR provided histopathological analysis. EAR and AS revised the manuscript and all authors assisted in the editorial process.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

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