Lung Pathology: Student/Resident Case Report Poster - Lung Pathology I |

A Case of Unilateral Wheezing: A Surprise in the Right Lower Lobe FREE TO VIEW

Eva Otoupalova, MD; Shaiva Meka, DO; Emily Schuiteman, DO; Bhavinkumar Dalal, MD; Nader Mina, MD
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William Beaumont Hospital, Royal Oak, MI

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

Chest. 2016;150(4_S):802A. doi:10.1016/j.chest.2016.08.898
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SESSION TITLE: Student/Resident Case Report Poster - Lung Pathology I

SESSION TYPE: Student/Resident Case Report Poster

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

INTRODUCTION: Cough and wheezing are the most common presenting symptoms of asthma and bronchitis in the outpatient setting and are often treated empirically. However, when atypical features of wheezing are present, such as localization over one lung field, bronchial obstruction must be considered in the differential. We present a rare benign cause of unilateral wheezing and hemoptysis.

CASE PRESENTATION: A 66 year-old male with a long history of tobacco abuse presented with a 5-month history of cough and wheezing followed by development of minimal hemoptysis. In the past, he was treated with several courses of antibiotics for presumed bronchitis with no improvement. Lung examination revealed localized expiratory wheezes over the right lower lung (RLL) zone. Chest x-ray was unremarkable. Chest CT scan showed a 1.3 cm endobronchial soft tissue lesion in the RLL bronchus with distal post-obstructive changes and atelectasis (Fig. 1). Bronchoscopy was performed and revealed a fleshy, lobulated endobronchial mass causing near-complete occlusion of the RLL bronchus (Fig. 2). Biopsy demonstrated papillary proliferation composed of fibrovascular cores with acute and chronic inflammation, lined by both glandular and metaplastic squamous epithelium without atypia, dysplasia, or definitive stromal invasion. PET scan only showed a max SUV of 1.6 over the RLL lesion. Repeat bronchoscopy, mechanical debridement, and excision of the mass using argon plasma coagulation were performed, restoring patency of the RLL bronchus. Pathology of the mass again confirmed solitary endobronchial papilloma (SEP), and the patient’s symptoms resolved after excision.

DISCUSSION: SEP is a rare benign neoplasm of the lung. Presentation of SEP is highly variable, ranging from asymptomatic to severe cough, hemoptysis, wheezing and dyspnea. Pneumonia and lobar collapse can occur due to bronchial obstruction. Multiple histological subtypes of SEP exist. Solitary squamous papillomas, as in this case, are seen predominantly in middle-age men and are related to tobacco abuse. Bronchoscopy typically shows a polypoid, red glistening lesion. Surgical resection was previously the gold standard for treatment; however, since SEPs are often benign, endobronchial therapy with YAG laser or electrocautery can be successfully used.

CONCLUSIONS: Wheezing is often treated empirically. However, when unilateral wheezing is present, a search for localized obstruction should be pursued. SEP can cause bronchial obstruction and unilateral wheezing. Bronchoscopic resection is curative in most patients.

Reference #1: Solitary pulmonary papillomas in adults: a clinicopathologic and in situ hybridization study of 14 cases combined with 27 cases in the literature. Flieder DB1, Koss MN, Nicholson A, Sesterhenn IA, Petras RE, Travis WD. Am J Surg Pathol. 1998 Nov;22(11):1328-42.

DISCLOSURE: The following authors have nothing to disclose: Eva Otoupalova, Shaiva Meka, Emily Schuiteman, Bhavinkumar Dalal, Nader Mina

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