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Pulmonary Papillomatosis in a Patient Presenting With Cough and Hemoptysis FREE TO VIEW

Zhou Zhang, MD; Melisa Chang, MD; Arzhang Javan, MD; Luis Moreta-Sainz, MD
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Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA

Chest. 2014;146(4_MeetingAbstracts):159A. doi:10.1378/chest.1958977
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SESSION TITLE: Infectious Disease Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Recurrent pulmonary papillomatosis (RPP) is an uncommon clinical entity with incidence of 1.8 per 100,000 adults. We describe an adult patient with RPP who presented with cough and hemoptysis.

CASE PRESENTATION: A 43 year-old male presented with one month of dry cough and one day of hemoptysis. He emigrated from South Korea at age 2. He had heavy cigarette exposure as well as multiple illicit drug usage with marijuana, LSD, cocaine, and amphetamine. His examination was unremarkable. Admission chest CT revealed 5.4 cmx5.2cmx6.1cm superior right lower lobe lung mass as well as two masses (sizes 1.7cm and 1.3 cm) in superior segment of left lower lobe. These findings were suspicious for malignancy and patient subsequently underwent CT guided biopsy of RLL mass which was nondiagnostic. A diagnostic bronchoscopy was subsequently performed, which found a polypoid lesion beneath the right false vocal cord and an endobronchial mass at takeoff to superior segment of RLL. The biopsy result of the endobronchial mass revealed squamous pulmonary papillomatosis.

DISCUSSION: RPP is a disease caused most commonly by HPV serotype 6 and 11; it may also be caused by serotypes 16, 18, 31, and 33. HPV infect stem cells within basal layer of mucosa and viral DNA reactivates host replication genes to induce cellular proliferation. Histologically, squamous papilloma demonstrates polypoid growth and fibrovascular core containing lymphocytes. RPP commonly affect children younger than five (juvenile-onset RPP is caused by exposure to HPV during peripartum period) or adults older than thirty (adult-onset RPP due to sexual transmission). In adults, RPP most commonly affect the larynx; followed by trachea, bronchi, oral cavity, and esophagus. Patients may present with hoarseness, cough, dyspnea, stridor, or recurrent pneumonia. Diagnostic work-up include imaging finding of nodules or cyst and bronchoscopy finding of warty growth. Surgical treatments include cold steel excision using microinstrumentation, carbon dioxide laser, argon laser, and endoscopic microdebrider. Adjuvant therapy may be needed in 20% of patients and is indicated if more than four surgical procedures were performed per year, if there is rapid regrowth of papilloma with airway compromise, or if there is distal multisite spread of disease. Adjuvant therapies include interferon, ribavirin, acyclovir, or Intralesional injection of cidofovir. There is no cure for RPP and 3-5% of RPP will undergo malignant transformation to squamous cell carcinoma.

CONCLUSIONS: Our patient had multiple right lower lobe post-obstructive pneumonias for the next 6 months. Decision was made to perform VATS right lobectomy. Biopsy was positive for squamous cell carcinoma.

Reference #1: Derkay CS and Wiatrak B. Recurrent respiratory papillomatosis: a review. Laryngoscope, 118:1236-1247, 2008.

DISCLOSURE: The following authors have nothing to disclose: Zhou Zhang, Melisa Chang, Arzhang Javan, Luis Moreta-Sainz

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