Chest Infections: Student/Resident Case Report Poster - Chest Infections II |

An Unusual Cause for Post-Tracheostomy Subglottic Stenosis FREE TO VIEW

Nanette Bentley, MD; Andrew McAfee, MD; Adel El Abbassi, MD; Dima Youssef, MD
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Division of Pulmonary and Critical Care, Department of Internal Medicine, East Tennessee State University, Johnson City, TN

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

Chest. 2016;150(4_S):184A. doi:10.1016/j.chest.2016.08.193
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SESSION TITLE: Student/Resident Case Report Poster - Chest Infections II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Granulation tissue is commonly seen following tracheostomy tube insertion, but rarely causes airway occlusion or stenosis. We present a case of endotracheal cryptococcosis mimicking abundant granulation tissue in an immunocompromised patient with tracheostomy tube.

CASE PRESENTATION: A 65-year-old woman presented with complaints of worsening dyspnea with associated dry cough and wheezing. Past medical history was notable for non-Hodgkin’s lymphoma on chemotherapy, end stage renal disease on hemodialysis, and tracheostomy tube placed during prolonged ICU course with multiple abdominal surgeries. There was no history of prior respiratory disease or tobacco abuse. Laryngoscopy revealed subglottic stenosis with greater than 50% airway occlusion. The patient was referred to us for endobronchial argon plasma coagulation (APC) treatments. Bronchoscopy revealed extensive polypoid lesions in the subglottic space (Fig. 1). Re-accumulation of tissue continued to cause severe subglottic stenosis despite serial APC treatments. Tissue specimens were collected for biopsy, and histopathology revealed polypoid granulation tissue and abundant fungal organisms morphologically consistent with Cryptococcus neoformans. Cryptococcal antigen testing was positive in serum (1:10 titer), but negative in CSF. Amphotericin B was given for two weeks in the hospital followed by three months of treatment with Fluconazole 200 mg daily. After completing antifungal therapy, repeat bronchoscopy showed complete resolution of the subglottic tissue overgrowth and tissue sampling confirmed clearance of infection (Fig. 2A). The patient remains on chronic suppressive therapy with Fluconazole 400 mg three times weekly after dialysis. Upon more recent re-evaluation, the patient had no further respiratory complaints, and with no tissue regrowth seen on bronchoscopy, the patient was successfully decannulated (Fig. 2B).

DISCUSSION: Pulmonary cryptococcosis has a wide spectrum of disease, but isolated endotracheal infection is unusual. Chebbo et al., described a similar case of subglottic obstruction necessitating tracheostomy tube placement, with a comparable response to antifungal therapy (1). Because our patient was referred for a complication commonly seen with tracheostomy tubes, tissue sampling was not performed sooner.

CONCLUSIONS: This case elucidates the importance of tissue sampling for pathology in cases of granulation tissue re-accumulation post-tracheostomy despite repetitive bronchoscopic debulking techniques.

Reference #1: Chebbo A, Byrd T, Beckendorf R, Petersen W. Cryptogenic Progressive Tracheal Obstruction. Chest. 2011;140(4_MeetingAbstracts):135A-135A.

DISCLOSURE: The following authors have nothing to disclose: Nanette Bentley, Andrew McAfee, Adel El Abbassi, Dima Youssef

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