Case #1 Surgical Pathology Evening Session USCAP, 2015 Samuel A. - - PowerPoint PPT Presentation

Case #1 Surgical Pathology Evening Session USCAP, 2015 Samuel A. Yousem, MD University of Pittsburgh School of Medicine UPMC – Presbyterian – C620 Pittsburgh, PA

Case #1 Clinical History

48-year-old WM smoker s/p CABGx2 with thoracic duct repair two years previously presents with cough and production of large mucous plugs (see image). Diagnosis ?

Diagnosis: Plastic bronchitis

A large and small airway inflammatory process characterized by the formation of large gelatinous or rigid branching airway mucous casts, that may or may not be spontaneously expectorated.

Syn: Hoffman’s bronchitis, fibrinous bronchitis, pseudomembranous bronchitis.

Plastic Bronchitis History/Background

• 1. Initially described by Galen as “venae

arteriosae expectorate” – expectorated pulmonary blood vessels.

• 2. Misinterpreted by others as regurgitated

noodles or chicken meat.

• 3. Most comprehensive description by

Osler in his Textbook of Medicine.

Madsen et al. Paed Resp Review, 2005

Plastic Bronchitis

The clinical presentation and histopathology of the mucous plug/bronchial cast are closely inter-related.

Cajaiba et al Intl J Surg Path 2008

Clinical Presentation

S&S: dyspnea, wheeze, chest pain, fever Exam: wheeze, “bruit de drapeau”. CXR/CT: collapse with secondary hyperinflation, patchy consolidation. Bronk: obstruction with casts. Gross appearance: cast reflects the pathology of the underlying bronchial tree.

Clinical Scenarios of Plastic Bronchitis

• 1. Congenital/structural heart disease with

repair (Fontan procedure/B-T shunt; includes disorders of lymphatics) - 2º to increased blood flow, mucous hypersecretion, disrupted lymphatics w/ retrograde flow

• 2. Asthma/atopy/allergic bronchopulmonary

microbial disease--mucoid impaction of bronchus.

• 3. Sickle cell disease – acute chest syndrome.
• 4. Infection – CF, post-obstructive, middle lobe

syndrome.

Histopathology Plastic Bronchitis

1. Mucus with fibrin, foamy macrophages, few cells (CHD) . 2. Mucus with fibrin, eosinophils, Charcot-Leyden crystalloids, “allergic mucin” (asthma related). 3. Mucus with fibrin, bile stained macrophages (Sickle cell). 4. Mucus with PMNs – infection.

• Type I / II plugs (Seear et al. AJRCCM, 1997)
• Do not throw plugs away in cyto/surgical

pathology laboratory.

• Look for histologic clues.
• Grocott stains/culture studies.

Brogan et al Ped. Pul., 2002

Treatment/Prognosis

Steroids/mucolytics/proteases/antibiotics Prognosis depends on clinical setting – 5 year mortality CHD – 30-60% Asthma – 5-50% Sickle cell – 0-5% Infection – 30-60%

Eberlein et al, 2008

Plastic Bronchitis Summary/Conclusions

• 1. Bronchial casts may be informative – do not

discard them.

• 2. Gross and microscopic appearance can give

clues to etiology.

• 3. Clinical scenarios and pathology correlate

Heart/lymphatic disease → mucin, fibrin, few cells. Asthma → mucus, fibrin, eos, allergic mucin Sickle cell → mucus, fibrin, sickled cells, bile Infection → mucus, PMNs, CF