INTRODUCTION: Recurrent respiratory symptoms in a child may result from infectious or noninfectious etiologies, including congenital airway abnormalities. This is the case of a previously healthy child who was referred for pulmonary evaluation because of recurrent pneumonia.
CASE PRESENTATION: A 13-year-old boy was healthy until one year prior to presentation when he was diagnosed with four separate episodes of radiographic proven right upper lobe pneumonias. Theses illnesses presented with fever, productive cough, and right-sided chest pain. Symptoms resolved intermittently with oral antibiotics. He denied hemoptysis, dyspnea, respiratory symptoms when eating, and weight loss. The child was athletic with no physical activity limitations. He had no tracheal surgeries, but was intubated once at three years of age for an adenotonsillectomy due to recurrent pharyngitis. Perinatal and family histories were non contributory. On exam, the patient had normal vital signs. He was well developed and his physical examination was unremarkable. The lungs were clear to auscultation over the tidal range. There was no digital clubbing. Spirometry revealed a mild obstructive pattern with no bronchodilator response. Chest radiographs revealed a persistent abnormality in the right upper lobe and lucency to the right of the trachea (Figure 1). Due to the abnormal radiographic findings, a chest computed tomography (CT) scan was obtained and demonstrated numerous diverticula or out pouches of the trachea in the right posterolateral region of the superior mediastinum (Figures 2 and 3). At least one fistulous communication was seen between the diverticula and the tracheal lumen. A barium esophagram showed no abnormalities; in particular, there was no evidence of a tracheoesophageal fistula. A flexible bronchoscopy revealed numerous, well-circumscribed diverticula along the posterior membranous tracheal wall and mainstem bronchi (Figure 4). The majority of diverticula were several millimeters in diameter. Injection of methylene blue into the trachea and diverticula did not result in its appearance in the esophagus or stomach. A concurrent esophagoscopy was unremarkable.
DISCUSSIONS: Recurrent respiratory tract diseases in children raise the suspicion of congenital airway anomalies, such as tracheoesophageal fistula, tracheal bronchus, or bronchopulmonary sequestration. Additionally, a rarely encountered finding is tracheal diverticulosis, characterized by multiple evaginations of the tracheal wall arising from congenital or acquired tracheal wall abnormalities. Although only a few adult cases have been reported, to our knowledge there are no reports describing children with such a profound number of tracheal diverticula, as seen in this patient, with no associated tracheomegaly. Tracheal diverticula are rarely seen in clinical practice and typically present in adulthood as an acquired single tracheal outpouching associated with chronic bronchopulmonary disease, diagnosed via radiographs or bronchoscopy. The diverticula typically occur between the cartilaginous and muscular portions of the tracheal wall along the right posterolateral region. On radiographs, the diverticula can appear as isolated paratracheal air cysts or communicating with the tracheal lumen, as in this patient. The cause of tracheal diverticulosis remains speculative, and may occur in isolation or in association with other congenital anomalies, such as tracheobronchomegaly (Mounier-Kuhn syndrome), in which there is herniation of the tracheal mucous membrane through an inherent muscular defect. Clinically, tracheal diverticula can lead to recurrent respiratory tract infections with cough, dyspnea, and chest pain. Supportive therapy, such as chest physiotherapy and aggressive treatment of respiratory infections, is aimed at minimizing the damage caused by the stasis of secretions in the diverticula.
CONCLUSION: Tracheal diverticulosis should be considered a cause of chronic respiratory symptoms and recurrent respiratory infections in children and adults. Thus, careful analysis of the central airways on radiographic studies and direct visualization should occur. Although most cases present in adulthood with a long history of respiratory symptoms, this case highlights the findings in a symptomatic child.
DISCLOSURE: Jason Caboot, No Financial Disclosure Information; No Product/Research Disclosure Information