INTRODUCTION: Benign bronchial stenosis is a well known complication of infection, sarcoidosis, chemical or thermal burns, prolonged unilateral lung intubation, post lung transplant or other bronchial injuries. It can produce significant morbidity and be potentially life-threatening when it produces critical airway narrowing. Frequency of restenosis depends on etiology of stricture and modality of prior treatment. We report a case of pregnant women with accelerated restenosis of right(R) proximal bronchus.
CASE PRESENTATION: 22 year-old woman was referred to clinic in January, 2010 with worsening dyspnea for two months. She has a history of a motor vehicle accident in March, 2008 when she sustained multiple injuries including pelvic and R side rib fractures with prolonged R sided pneumothorax, recurrent pneumonias and R main stem bronchus obstruction requiring balloon dilation and argon plasma coagulation (APC). After being discharged from a prolong rehab stay, she presented with stridor. She was only able to walk twenty steps without dyspnea. She denied hemoptysis, cough, sputum, fever, chills, sick contacts or tuberculosis exposure. She also denied smoking, substance or toxic chemicals exposures. There is no family history of any lung disease. On exam, she had tachycardia and inspiratory wheezing on R side. Pulmonary function tests showed moderately-severe obstruction without significant bronchodilator response. CT Chest showed severely narrowed proximal right mainstem bronchus. The stenosis was approximately one centimeter long. Laryngoscopy found no vocal cord dysfunction. Patient was very symptomatic and at risk for fetal hypoxia, thus outpatient bronchoscopy was performed which revealed extremely narrowed (3-4 mm) proximal R mainstem bronchus. Balloon dilatation with APC was performed on February 12, 2010. The patient was then hospitalized on March 7, 2010 for a R lung collapse due to restenosis of proximal R mainstem bronchus. Patient again underwent a balloon dilation of the R mainstem stenosis. Two week after this procedure, she returned with hypoxia and worsening dyspnea. Bronchoscopy at that time showed no visibly patent R mainstem airway, although dilation was performed with guide wire perforation and mechanical debridement with forceps. Due to increased risk of fetal hypoxia with recurrent restenosis, emergent Cesarean section was performed to deliver the infant. Patient was referred to cardiothoracic surgeory to remove proximal right bronchus segment. Three weeks after Cesarean section she underwent another balloon dilatation. Endobronchial biopsy revealed benign bronchial mucosa with no inflammation or granulation tissue.
DISCUSSIONS: Upon review of literature, we found no similar pathophysiology in pregnant women. We suspect the initial etiology of stenosis was prolonged R lung collapse. She accelerated proximal R bronchial stenosis during her pregnancy and peripartum state. We are unclear as to the cause for the recurrence. We propose that patient’s pregnant status contributed to promote fibrous tissue formation and cause rapid restenosis in this benign bronchial lesion. We must consider the hormonal influences on the rate of restenosis. She had stenosis at the same site in 2008, although at that time she did not require repetitive dilatation. More definitive and appropriate therapies such as surgical removal of stenotic segment and reconstruction is recommended for young patients who can tolerate this procedure. In a pregnant patient with limited management options, balloon dilation or APC can be a bridge until definitive treatment.
CONCLUSION: Clinicians should be vigilant about the restenosis rate of benign bronchial stenosis in pregnant patients. Since hypoxia can be detrimental to fetal survival, early fetal delivery may be required. It is imperative to have close follow-up with high-risk maternal-fetal medicine and pulmonary physicians.
DISCLOSURE: Paresh Patel, No Financial Disclosure Information; No Product/Research Disclosure Information