Medical Image of the Week: Plastic Bronchitis in an Adult Lung Transplant Patient

Figure 1. Representative coronal (A) and axial (B) views of the thoracic CT scan in lung windows revealing bilateral dense consolidations and bronchial filling.

Figure 2. Photograph of bronchial gelatinous casts after bronchoscopic forceps removal.

Plastic Bronchitis is a rare condition characterized by the formation of branching gelatinous casts of the bronchial tree which lead to regional airway obstruction. There are thought to be two classifications of casts; type I being the formation of cellular inflammatory casts while type II are acellular. This entity is a well described complication of the Fontan procedure, a therapeutic intervention in pediatric patients with univentricular congenital heart disease (1). The condition is less well reported and thus recognized in adult populations (2).

Our patient is a 37-year-old man who is status post bilateral lung transplantation undertaken for severe workplace inhalation injury complicated by constrictive bronchiolitis-obliterans. Post-transplant, the patient suffered from refractory severe persistent asthma of the donor lung and therefore was scheduled for elective initial bronchial thermoplasty. Post-procedure the patient developed progressive respiratory distress and ultimately extremis requiring mechanical ventilation. Pulse-dose corticosteroids were initiated given a suspected etiology of acute rejection, although response to therapy was poor. Bronchoscopy was conducted which revealed diffuse fibrin casts of the right lung consistent with the development of plastic bronchitis. Symptoms significantly improved with removal of these casts, although a repeat bronchoscopy with cast removal was necessary shortly afterward. Our patient’s cast formation is unique given that it likely has components of both etiologies given his underlying bronchial hyper-secretory disorder and lymphatic disruption after lung transplant. For this reason, we consider this a unique case in its ability to highlight the overlap of these two pathologic processes in an otherwise unlikely demographic to develop bronchial casts. In our comprehensive literature search, we were unable to find significant description of this disorder in adult lung transplant. However, given the disruption in lymphatics, host vs graft inflammatory factors, and infectious inflammatory factors, it would seem to be a perfect setup pathologically. The underlying pathophysiologic mechanism of plastic bronchitis is believed to be cast formation via pulmonary lymphatic disruption by either surgical intervention or inflammatory processes. Gelatinous casts are formed by way of alveolar capillary leak of proteinaceous material, lymphatic seepage, and exudate accumulation from airway inflammation. The majority of literature regarding this disease processes has been described in pediatric thoracic surgery. Lung transplant, especially in the setting of acute rejection, seems to be a setup for this condition in adult populations.

Sarika Savajiyani DO, Nafis Shamsid-Deen MD, and  Raed Alalawi MD

University of Arizona, College of Medicine-Phoenix

Phoenix, AZ USA

References

1. Singhi AK, Vinoth B, Kuruvilla S, Sivakumar K. Plastic bronchitis. Ann Pediatr Cardiol. 2015 Sep-Dec;8(3):246-8. [CrossRef] [PubMed]
2. Eberlein M, Parekh K, Hansdottir S, Keech J, Klesney-Tait J. Plastic bronchitis complicating primary graft dysfunction after lung transplantation. Ann Thorac Surg. 2014 Nov;98(5):1849. [CrossRef]

Cite as: Savajiyani S, Shamsid-Deen N, Alalawi R. Medical image of the week: Plastic bronchitis in an adult lung transplant patient. Southwest J Pulm Crit Care. 2018;17(1):39-40. doi: https://doi.org/10.13175/swjpcc088-18 PDF 

Medical Image of the Week: Medical Administrative Growth

Figure 1. Growth of administrators compared to physicians 1970-2010 (used with permission of David Himmelstein).

It is generally agreed that healthcare costs are too high in the US. Although there has been considerable finger pointing, there is little doubt that administrative costs are far outpacing other healthcare costs. In ground-breaking work published in 1991, Woolhandler and Himmelstein (1) found that US administrative health care costs increased 37% between 1983 and 1987. They estimated these costs accounted for nearly a quarter of all health care expenditures. They followed their 83-87 report by examining data from 1999 (2). US administrative costs had risen to 31% of US health care expenditures. Himmelstein now estimates that administrative costs may now account for up to 40% of healthcare costs (Robbins RA, personal communication). The trend is perhaps best illustrated by Figure 1 showing growth of administrators compared to physicians from 1970-2010 (3).

Richard A. Robbins MD¹ and Bhupinder Natt MD²

¹Phoenix Pulmonary and Critical Care Research and Education Foundation, Gilbert, AZ USA

²University of Arizona College of Medicine, Tucson, AZ USA

References

1. Woolhandler S, Himmelstein DU. The deteriorating administrative efficiency of the US health care system. N Engl J Med. 1991;324(18):1253-8. [CrossRef] [PubMed]
2. Woolhandler S, Campbell T, Himmelstein DU. Costs of health care administration in the United States and Canada. N Engl J Med. 2003;349(8):768-75. [CrossRef] [PubMed]
3. Bureau of Labor Statistics. NCHS. Himmelstein and Woolhandler analysis of current population survey. Available at: http://www.pnhp.org/ (accessed 7/9/18).

Cite as: Robbins RA, Natt B. Medical image of the week: Medical administrative growth. Southwest J Pulm Crit Care. 2018;17(1):35. doi: https://doi.org/10.13175/swjpcc087-18 PDF