Chest Infections: Fellow Case Report Slide: Chest Infections I |

Not All Wheezing Is Asthma: A Rare Case of Chronic Progressive Granulomatous Infection FREE TO VIEW

Janvi Paralkar, MD; Navitha Ramesh, MD; Albert Miller, MD
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Mount Sinai Beth Israel, New York, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):133A. doi:10.1016/j.chest.2016.08.142
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SESSION TITLE: Fellow Case Report Slide: Chest Infections I

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Monday, October 24, 2016 at 03:15 PM - 04:15 PM

INTRODUCTION: Wheezing is a common complaint seen in patients in pulmonary clinics. Most are prematurely and inaccurately diagnosed as asthma. However, certain rare conditions affecting the respiratory tract must be kept in mind as part of the differential. We present a unique case of a patient with wheezing who was found to have tracheal rhinoscleroma.

CASE PRESENTATION: A 46 year old Hispanic female, who immigrated from Guatemala in 1998, was referred to our clinic for wheezing and suspicion of asthma. She had progressive difficulty breathing which was associated with orthopnea, sinus tenderness, headaches, and fullness in her nares. Patient had no family history of asthma. Denied smoking, seasonal allergies, hospitalizations, or endotracheal intubations. Her pulmonary function tests showed flat inspiratory and expiratory loops and her FEV-1 and FVC values were within the normal range, supporting evidence of fixed extrathoracic airflow obstruction with normal diffusing capacity. CT neck showed an irregular rind of nodular soft tissue lining the walls of the subglottis and the first tracheal ring without erosion of the cricoid cartilage. There was a uniform increased soft tissue density at the level of the posterior and anterior commissure. Bronchoscopy showed mild-moderate narrowing of the subglottic space; dynamic compression of the tracheal walls. The scope was easily transversed past the narrowed part of trachea. Biopsy results revealed Mukulicz cells. Hence, she had evidence of Klebsiella Rhinoscleromatis and was diagnosed with rhinoscleroma. She was initially treated with ciprofloxacin, however, disease progressed necessitating septoplasty and lysis of adhesions in her nasopharynx.

DISCUSSION: Rhinoscleroma is an infectious granulatomatous disease cause by the gram negative bacilli Klebsiella rhinoscleromatis. It is more commonly seen in female patients from endemic areas. Our patient had an atypical presentation having immigrated to North America 14 years prior to seeking treatment for her symptoms. Delayed onset of symptoms, along with respiratory symptoms and worsening of disease despite appropriate antibiotic therapy, makes our case unique.

CONCLUSIONS: As this case shows, it is important to recognize varying differentials for symptomatic wheezing. It is common to attribute wheezing to a diagnosis of asthma, however infectious etiologies should not be overlooked.

Reference #1: Klebsiella rhinoscleromatis of the membranous nasal septum.Chan TV1, Spiegel JH.J Laryngol Otol. 2007 Oct;121(10):998-1002. Epub 2007 Mar 15.

DISCLOSURE: The following authors have nothing to disclose: Janvi Paralkar, Navitha Ramesh, Albert Miller

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