Blood cast of the left bronchial tree caused by foreign body
aspiration in a 12-year-old boy
CASE: A 12-year-old boy was admitted to the PICU in Chongqing University
Tree Gorges hospital after 2 days of persistent hemoptysis and
exacerbation of respiratory hypoxia. This patient had a foreign body
aspiration while consuming sunflower seeds. During an episode of violent
coughing, several pieces of shell fragments were expectorated.
Approximately after 10 minutes, the patient had a small volume of
hemoptysis mixed with sputum that quickly turned into a bright red blood
clot. Although the precise incidence of hemoptysis was not clear, the
patient asserted it to be more than 10 times with a volume of more than
100ml. Neither did the patient vomit blood, nor did he have abdominal
pain, hematochezia, or melena. Though the patient was given
aminomethylbenzoic acid and
hemocoagulase in community medical
institutions, the hemoptysis persisted. The patient was eventually
transferred to our tertiary medical institution because of worsening
respiratory distress and hypoxia. An immediate
computed tomography (CT) scan of
his chest revealed blockage of the left bronchus and its branches,
emphysema in the left lower lobe, and exudative lesions in the left
upper and lower lobe (Figure 1A, 1B). An immediate rigid bronchoscopy
was performed under general anesthesia, and two blood casts were removed
respectively from the left main bronchus/the upper lobe bronchial tree
and the lower lobe bronchial tree (Figure 2). The inspection also showed
that there was a 5mm mucosal laceration on the left wall of the left
bronchus at the level of carina without active bleeding. There was no
further treatment of the laceration during the bronchoscopy. After a
rigid bronchoscopy, the patient received regular intravenous antibiotics
and hemostatic agents. The CT scan performed on the patient on the
fourth day after cast removal showed that his trachea and bronchi were
unobstructed, and the exudative lesions were significantly absorbed than
before (Figure 3A, 3B). The patient was discharged and affirmed not
feeling any discomfort. Throughout the 6-month outpatient follow-up
after discharge from the hospital, the patient did not report the
reappearance of hemoptysis.
DISCUSSION: A series of cases of
bronchial
cast formation have been reported in the last
decades.1-7 Most cases were found in
plastic bronchitis associated with
congenital heart disease with Fontan physiology, pulmonary lymphatic
anomalies, different types of infections and other
conditions,8; 9 and the others were blood bronchial
cast caused by bleeding associated with underlying lung lesions or
coagulopathy.10-12 Blood bronchial cast in adults,
especially the elderly, is predominantly associated with the hemoptysis
caused by underlying lung diseases, such as bronchiectasis,
tuberculosis, and lung cancer. Hitherto, massive hemoptysis in children
is rare. The case we introduced here had a history of sunflower seed
shell fragments aspiration. The bronchoscopy also detected a laceration
in the bronchial mucosa enabling us to deduce that a foreign body
scratched the bronchial wall and caused the bleeding. Bronchial foreign
bodies are more common during childhood, especially in younger children.
In some countries, peanuts, sunflower seeds, walnuts, and pistachios are
the most typical snacks, which are also the most common respiratory
foreign bodies found in bronchoscopy.13 This case
suggested the plausibility of bronchial foreign bodies causing blood
bronchial cast,notwithstanding the fact that similar cases have not
been reported to the best of our knowledge.
References
1. Zhang X, Vinturache A, Ding G. 2019. Plastic bronchitis in a
3-year-old boy. CMAJ : Canadian Medical Association journal = journal de
l’Association medicale canadienne. 191(48):E1336.
2. Li Y, Williams RJ, Dombrowski ND, Watters K, Daly KP, Irace AL,
Visner GA, Rahbar R, Fynn-Thompson F. 2020. Current evaluation and
management of plastic bronchitis in the pediatric population.
International journal of pediatric otorhinolaryngology. 130:109799.
3. Isobe M, Sasaki S, Hojo M, Emura S, Hoshina J, Kojima K, Torigoe T,
Onozuka J, Numata O, Torigoe K. 2011. A bronchial cast caused by
pulmonary hemorrhage due to a vitamin k deficiency. Pediatrics
international : official journal of the Japan Pediatric Society.
53(1):133-134.
4. Pérez-Soler A. 1989. Cast bronchitis in infants and children.
American journal of diseases of children (1960). 143(9):1024-1029.
5. Soyer T, Yalcin Ş, Emiralioğlu N, Yilmaz EA, Soyer O, Orhan D, Doğru
D, Sekerel BE, Tanyel FC. 2016. Use of serial rigid bronchoscopy in the
treatment of plastic bronchitis in children. Journal of pediatric
surgery. 51(10):1640-1643.
6. Werkhaven J, Holinger LD. 1987. Bronchial casts in children. The
Annals of otology, rhinology, and laryngology. 96(1 Pt 1):86-92.
7. Hasan RA, Black C, Reddy R. 2012. Plastic bronchitis in children.
Fetal and pediatric pathology. 31(2):87-93.
8. Singhi AK, Vinoth B, Kuruvilla S, Sivakumar K. 2015. Plastic
bronchitis. Annals of pediatric cardiology. 8(3):246-248.
9. Yuan L, Huang JJ, Zhu QG, Li MZ, Zhuo ZQ. 2020. Plastic bronchitis
associated with adenovirus serotype 7 in children. BMC pediatrics.
20(1):268.
10. Annangi S, Smith KH. 2020. Bloody bronchial cast-aftermath of
hemoptysis. American journal of respiratory and critical care medicine.
201(2):243-244.
11. Coonar A. 2005. Blood clot cast of the bronchial tree. European
journal of cardio-thoracic surgery : official journal of the European
Association for Cardio-thoracic Surgery. 28(3):490.
12. Okada Y, Okada A, Narumiya H, Iiduka R, Katsura K. 2017. Bloody
bronchial cast formation due to alveolar hemorrhage associated with h1n1
influenza infection. Internal medicine (Tokyo, Japan). 56(20):2747-2751.
13. Korlacki W, Korecka K, Dzielicki J. 2011. Foreign body aspiration in
children: Diagnostic and therapeutic role of bronchoscopy. Pediatric
surgery international. 27(8):833-837.
Legends
Figure 1. A/B, CT scan of the patient’s chest, showing blockage of the
left bronchus and its branches (black arrows).
Figure 2. Blood clot cast of the
left bronchial tree.
Figure 3.A/B, CT scan performed on the fourth day after cast removal,
showing that the trachea and bronchi were unobstructed.