SESSION TYPE: Bronchology Cases
PRESENTED ON: Wednesday, October 24, 2012 at 11:15 AM - 12:30 PM
INTRODUCTION: Patient with recurrent pneumonia or atypical asthma symptoms should prompt investigation for airway lesions such as respiratory papillomas.
CASE PRESENTATION: A 20 year old woman with a history of laryngitis, presumed asthma, and cerebral palsy was admitted to the hospital for three days fever, chest pain, productive cough and dyspnea. Her history was remarkable for five previous hospitalizations for pneumonia. Prior hospitalizations were uncomplicated without the need for critical care. Review of systems was negative. Family history was not known as the patient was adopted. Her medications included only albuterol. On exam she was febrile, tachycardic, and had diminished breath sounds over the left lower lung field. Chest radiograph showed an infiltrate in the left lower lobe, similar in location to prior hospitalizations. Chest tomography revealed narrowing of the left main stem bronchus, multiple thin walled parenchymal cysts (Figure 1) and a tracheal lesion. Fiberoptic bronchoscopy demonstrated a sessile polyp in the trachea and near occlusion of the left main stem bronchus (Figure 2). Vocal cord lesions were also identified as the etiology for the patient’s laryngitis. Biopsy of the lesions was consistent with respiratory papillomatosis. Fiberoptic bronchoscopy with argon plasma coagulation and debridement of the lesions allowed quick resolution of the post-obstructive pneumonia. With surveillance bronchoscopies and debridement, no further episodes of post-obstructive pneumonia occurred. Pulmonary function tests failed to demonstrate asthma.
DISCUSSION: Recurrent respiratory papillomatosis (RRP) is an uncommon manifestation of HPV infection thought to be secondary to vertical transmission of HPV during birth in susceptible individuals. It is characterized by recurrent papillomas of the larynx, trachea, and less commonly bronchi. RRP can present clinically with laryngitis, cough, recurrent respiratory infections, and airway obstruction. The disease is often misdiagnosed as asthma, laryngitis, bronchitis or croup. Diagnosis is by visualization of the papillomas with laryngoscopy or bronchoscopy and biopsy. The natural history is variable with aggressive and non-aggressive forms described; characterized by periods of recurrent papillomas causing airway obstruction and periods of remission. The mainstay of treatment is intermittent debulking via surgical removal and laser ablation. Few patients require tracheostomy due to aggressive disease. Adjunctive medical therapy with interferon, cidofovir, and indole-3-carbinol have been described with varying results.
CONCLUSIONS: Recurrent respiratory papillomatosis should be considered in patients presenting with recurrent pneumonia, hoarseness or atypical asthma.
1) Tasca, RA., Clarke, RW. “Recurrent respiratory papillomatosis” Arch Dis Child 2006;91:689-691.
2) Donne AJ, Clarke R. “ Recurrent respiratory papillomatosis” Int J STD AIDS. June 2011;21(6):381-385.
DISCLOSURE: The following authors have nothing to disclose: Ahmed Khan, Mohammad Zalt, David Berkowitz
No Product/Research Disclosure InformationEmory University - Department of Interventional Pulmonology, Atlanta, GA