Plastic bronchitis associated with influenza virus infection in children: a report on 14 cases

Plastic Bronchitis in Children: A Review of 55 Cases over a 10-Year Period

Objective

To summarize the clinical characteristics and treatment experiences of patients with plastic bronchitis (PB).

Methods

All patients who were diagnosed with PB by bronchoscopic removal of tree-like casts at a single institution from January 2012 to May 2022 were retrospectively reviewed. Demographic and clinical data were retrieved from electronic patient records.

Results

A total of 55 patients, with a median age of 5.3 years, were eligible for the study. Nineteen cases had underlying diseases, among which asthma was the most common. The median course of the disease before admission was 11 days. Clinical symptoms were characterized by cough and fever, while moist rales (78.2%) and dyspnea (61.8%) were the most common signs. The most common laboratory finding was elevated C-reactive protein (58.2%). Patchy opacity was the most frequent radiographic finding (81.2%), followed by consolidation (60.0%) and pleural effusion (43.6%). Respiratory pathogens were detected in 41 cases, and M. pneumoniae was the most common one (41.8%), followed by adenovirus (20.0%) and influenza B virus (10.9%). The casts were removed by alveolar lavage, combined with ambroxol immersion (63.6%) and forceps (30.9%). Patients received an average of 2.3 bronchoscopies, and the median time for the first procedure was 3 days after admission. Antibiotics were given to all patients, methylprednisolone to 33 (60.0%), and gamma globulin to 25 (45.5%). A total of 53 cases were improved with an overall mortality rate of 3.6%.

Conclusions

PB in children is characterized by airway obstruction, mostly caused by respiratory infections, and timely removal of the cast by bronchoscopy is the most effective treatment.

Eosinophilic plastic bronchitis: Case series and review of the literature

Plastic bronchitis is a term used to describe group of life-threatening disorders characterized by the presence of large obstructing casts in the airways. Eosinophilic plastic bronchitis is a subtype of plastic bronchitis that occurs mainly in children and has not been well-described in the literature. Patients may have a history of asthma or atopy, but many do not. They often present with cough and wheezing, and frequently have complete collapse of one lung seen on imaging. The severity of presentation varies depending on the location of the casts, ranging from mild symptoms to severe airway obstruction and death. Bronchoscopy is often required to both diagnose and treat this condition. A variety of medical therapies have been used, although no formal studies have evaluated their efficacy. Symptoms may resolve after initial cast removal, but in some patients, cast formation recurs. Here, we report a case series of nine patients with eosinophilic plastic bronchitis and review the existing literature of this condition.

Plastic bronchitis associated with respiratory syncytial virus infection: a case report

BACKGROUND

The etiology of Plastic bronchitis (PB) is unknown. The incidence of pulmonary infection associated with PB has increased year by year, but respiratory syncytial virus (RSV) as a pathogen causes PB has rarely been reported.

CASE PRESENTATION

A 2-year-old immunocompromised girl was admitted to the hospital with cough, fever for 5 days, and aggravated with shortness of breath for 1 day. With mechanical ventilation, her respiratory failure was not relieved, and subcutaneous emphysema and mediastinal pneumatosis appeared. Extracorporeal membrane oxygenation (ECMO) was administrated, but the tidal volume was low. Therefore, a bronchoscopy was performed, by which plastic secretions were found and removed. Pathology of the plastic secretions confirmed the diagnosis of type I PB. RSV was the only positive pathogen in the alveolar lavage fluid by the next-generation sequencing test. After the bronchoscopic procedure, her dyspnea improved. The patient was discharged with a high-flow nasal cannula, with a pulse oxygen saturation above 95%. Half a year after discharge, she developed sequelae of bronchitis obliterans.

CONCLUSION

RSV could be an etiology of PB, especially in an immunocompromised child. In a patient with pulmonary infection, if hypoxemia is presented and unresponded to mechanical ventilation, even ECMO, PB should be considered, and bronchoscopy should be performed as soon as possible to confirm the diagnosis and to treat.

Outcomes and Risk Factor Analysis of Plastic Bronchitis Among 321 Children with Influenza Pneumonia After Bronchoscopy Examination

Background

Plastic bronchitis (PB) is a rare and severe lung disease. It can be triggered by influenza virus infection, which is a common respiratory infection in children. Bronchoscopy can aid in the early detection and treatment of PB. However, the outcomes and risk for PB development in pediatric patients with influenza virus infection are not fully understood.

Methods

Data from 321 children diagnosed with influenza virus pneumonia who underwent bronchoscopy examinations between 1st January, 2009 and 31st December, 2020 were retrospectively analyzed to assess the outcomes and risk factors associated with PB development.

Results

This study included 97 girls and 224 boys with influenza virus pneumonia with a median age of 42 months. Among them, 36 patients (11.2%) were categorized as having PB based on bronchoscopy findings. PB patients had significantly longer fever durations (p=0.010) and higher risks of developing severe conditions including respiratory failure (p<0.001), acute respiratory distress syndrome (p<0.001), and air-leak syndrome (p<0.001) compared to non-PB patients. Conventional treatment including the use of neuraminidase inhibitors and antibiotics did not differ between the PB and non-PB patients, but PB patients required more anti-inflammatory treatment (p=0.019) and ventilator support (p<0.001). Combined univariate and multivariate analyses suggested that radiographic findings, including mediastinal emphysema (p=0.012) and lung consolidation (p=0.012), as well as increased levels of neutrophils (p=0.026), aspartate aminotransferase (p=0.004), and lactate dehydrogenase (p<0.001), were identified as risk factors for PB development in patients with influenza virus pneumonia. Although PB patients required more intensive care and had longer hospital stays, they all recovered well after treatment.

Conclusion

Influenza virus infection is linked to PB development in children. Identifying risk factors and early intervention such as bronchoscopy can improve the prognosis of children with PB.

Asthma with recurrent middle lobe syndrome in children: Clinical features and lung function patterns

BACKGROUND

Middle lobe syndrome (MLS) is a complication of childhood asthma. This study aimed to compare the clinical features and lung function between asthmatic children with recurrent MLS and transient right middle lobe (RML) and/or lingula atelectasis.

METHODS

This study retrospectively analyzed asthmatic children with RML and/or lingula atelectasis between 2010 and 2020 using data from the pediatric pulmonary department. According to the episodes of atelectasis, children were divided into recurrent (≥2 episodes) and non-recurrent (only 1 episode) MLS groups, to compare clinical features and lung function. Spirometry during acute asthma exacerbation and stable stages were recorded, and variations were calculated.

RESULTS

A total of 35 children with asthma and RML and/or lingula atelectasis were included, 15 of whom had recurrent MLS. The recurrent MLS group had a higher proportion of girls, infections, family allergy history, severe asthma, severe exacerbation, and higher levels of total IgE than the non-recurrent MLS group (P < 0.05). The recurrent MLS group had a significantly higher % predicted and z-scores for forced expiratory volume in 1 s (FEV₁) and forced vital capacity (FVC), a greater proportion of high FEV₁ and higher variations in FEV₁ and FVC than that in the non-recurrent group (P < 0.05). After excluding children with mild to moderate asthma in the recurrent MLS group, the differences in clinical features disappeared, but the results regarding lung function remained similar, when compared to severe asthma patients without RML and/or lingula atelectasis.

CONCLUSIONS

Childhood asthma with recurrent MLS has more frequent severe asthma and exacerbation but high lung function and variations.

Plastic bronchitis associated with influenza B virus infection: A case report

Plastic bronchitis (PB) is a severe acute respiratory disease that develops as a result of the formation of branching mucus plugs in the bronchial tree. PB is known as a complication of influenza A virus infection, but some cases have been associated with influenza B virus infections. This patient was a 3-year-old boy with no history of allergic disease who developed PB requiring ventilator management after influenza B virus infection. He was hospitalized and managed with ventilator support because of acute respiratory failure. Influenza B virus infection was diagnosed via rapid antigen test and real-time reverse-transcription polymerase chain reaction (RT-PCR). A bronchoscopy performed after a chest X-ray and computed tomography confirmed the presence of extensive atelectasis in the right lung field and mucus plugs in the right bronchus. The patient’s respiratory condition improved rapidly after removal of the plugs. Quantitative real-time RT-PCR performed with nasal and aspirated sputum samples obtained at hospitalization revealed a higher viral RNA load in the upper rather than in the lower respiratory tract. Viral replication in the lower respiratory was not found to be a major contributor toward mucus plug formation. The finding of increased serum IgE in the absence of a history of allergic disease suggests that an allergic reaction contributed to the formation of mucus plugs.

Analysis of Clinical Characteristics and Risk Factors of Plastic Bronchitis in Children With Mycoplasma pneumoniae Pneumonia

Objective: To analyze the clinical characteristics of plastic bronchitis (PB) in children with Mycoplasma pneumoniae pneumonia (MPP) in order to explore its risk factors. Methods: A retrospective analysis was performed in MPP children receiving bronchoscopy admitted to department of respiratory medicine in Shanghai Children's Hospital from January 2018 to December 2020. According to the bronchoscopic findings, the patients were divided into PB group and non-PB group. The clinical manifestations, laboratory examination, etiology, treatment methods and outcomes of the children were analyzed. Logistic regression was used to analyze the risk factors for PB in children with MPP. Results: A total of 296 children with MPP were enrolled in the study, including 42 (14.2%) children in the PB group and 254 (85.8%) children in the non-PB group. There was no difference in the ratios of gender, age, proportion of fever, cough, wet rales, and wheezing rales between the two groups (P > 0.05). The univariate analysis showed that there were significant differences between the PB group and the non-PB group in LDH, D-dimer, CD3+CD4+(%), CD3+CD4+/CD3+CD8+, CD3 count, CD4 count, CD8 count, complement 3, IL8, IL-1β, IL-2, IL-10 (P < 0.05). The multivariate logistic regression analysis showed that fever duration > 12 d, IL-8 > 2,721.33 pg/ml, LDH > 482 U/L and complement 3 <1.02 g/L were independent risk factors for PB in children with MPP. Conclusions: Children with PB caused by MPP have protracted fever, a strong inflammatory response and immune function disturbance.

Tumor Necrosis Factor Alpha Gene Polymorphisms Increase Susceptibility to Adenovirus Infection in Children and Are Correlated with Severity of Adenovirus-Associated Pneumonia

Objective: To study the relationships between single nucleotide polymorphisms (SNPs) in the intron of the tumor necrosis factor α (TNFα) gene and the susceptibility and severity of disease associated with adenovirus infection in children. Methods: Four polymorphic loci of the TNFα gene (rs3093661, rs1800610, rs3093662, and rs3093664) were characterized allelically and genotypically in 320 children with adenovirus-associated pneumonia (AP) and compared with 320 healthy controls. Enzyme-linked immunosorbent assays (ELISAs) were used to detect the plasma TNFα protein levels in all subjects. Results: The TNFα gene rs3093661 locus A allele, the rs1800610 locus A allele, the rs3093662 locus G allele, and the rs3093664 locus G allele were identified as susceptibility alleles for development of AP, and they were also positively correlated with the severity of AP. In children who had the GGAA haplotype, AP susceptibility was significantly reduced (0.28-fold) (95% confidence interval, CI: 0.20-0.40, p < 0.001). Conversely, among the subjects with the AGGG haplotype, their AP susceptibility risk was significantly increased (2.76-fold) (95% CI: 1.77-4.29, p < 0.001); and in the subjects with the AP GGGG haplotype their AP susceptibility risk was significantly increased (2.49-fold) (95% CI: 1.67-3.72, p < 0.001). The TNFα rs3093661, rs1800610, rs3093662, and rs3093664 SNPs were significantly correlated with plasma TNFα levels (p < 0.05). Conclusion: The TNFα gene rs3093661, rs1800610, rs3093662, and rs3093664 loci are associated with AP susceptibility and severity. This relationship might be due to the effect on TNFα levels found in the plasma. Clinical Trial Registration number: LL20190723.

Efficacy of fiberoptic bronchoscopy and bronchoalveolar lavage in childhood-onset, complicated plastic bronchitis

BACKGROUND

Plastic bronchitis (PB) is a rare, variable, and potentially fatal disease. This study aimed to assess the efficacy of fiberoptic bronchoscopy (FOB) and bronchoalveolar lavage (BAL) in treating children with PB.

METHODS

In total, 15 children with PB, between 2012 and 2020, were enrolled in our study. Within 12 hours of admission, FOB and BAL were performed and reviewed under local anesthesia and sedation. Before and after FOB, clinical findings and chest imaging were evaluated.

RESULTS

Regarding the onset of symptoms before FOB, all cases had prominent cough for 7.00 ± 4.55 days, and 14 had persistent high fever. In total, 13 cases had complete obstruction from bronchial casts, consistent with consolidated lesions; 2 had partial airway obstruction. Within 3 days, complete resolution was revealed in nine cases. Overall, six cases underwent repeated FOB (range, 2-3 times) for persistent atelectasis and airway obstruction. Except for two cases with type 2 PB, cast histology confirmed type 1 PB for all cases. Only eight children had minor intra- and post-procedure complications. Reverse transcription-polymerase chain reaction for Mycoplasma pneumoniae in sputum and BAL samples were positive in 13 cases. Next-generation sequencing of the BAL samples was positive for adenovirus and Human parainfluenza virus in one case, respectively. During 1 month to 7 years of follow-up, no patient developed PB recurrence, asthmatic attacks, or chronic cough.

CONCLUSIONS

Early FOB and BAL were effective in alleviating clinical findings, atelectasis, and airway obstruction. Serial FOB could be performed in patients with recurrent symptoms.

[Clinical features of children with influenza and plastic bronchitis: an analysis of 63 cases]

OBJECTIVE

To study the clinical features of children with influenza and plastic bronchitis (PB).

METHODS

A retrospective analysis was performed on the medical data of 63 children with influenza and PB, including clinical manifestations, laboratory examination results, imaging findings, treatment, and outcome.

RESULTS

Among the 63 children, there were 52 boys (83%) and 11 girls (17%), and 42 children had influenza A and 21 had influenza B. Among these children, 38 (60%) aged 3-6 years, and 15 (24%) had underlying diseases. The main clinical manifestations were high fever (90%), cough (95%), and shortness of breath (73%). Twenty-four children (38%) were found to have atelectasis by imaging examination. Auscultation showed that 16 children (25%) had no rales in the lungs. Of all children, 41 were admitted to the intensive care unit, and 32 required mechanical ventilation. All children underwent fiberoptic bronchoscopy and alveolar lavage. Among the 63 children, 60 recovered and 3 died.

CONCLUSIONS

Influenza with PB is often observed in boys and preschool children. For influenza children with shortness of breath, even if there is no atelectasis on chest X-ray or no rales are found by auscultation, the possibility of PB still needs to be considered.

[Clinical features of influenza with plastic bronchitis in children]

OBJECTIVE

To study the clinical features of influenza with plastic bronchitis (PB) in children, and to improve the awareness of the diagnosis and treatment of PB caused by influenza virus.

METHODS

A retrospective analysis was performed for the clinical data of 70 children with lower respiratory influenza virus infection from October 2018 to October 2019. According to the presence or absence of PB, they were divided into an influenza+PB group with 12 children and a non-PB influenza group with 58 children. Related clinical data were collected for the retrospective analysis, including general information, clinical manifestations, laboratory examination, imaging findings, treatment, and prognosis.

RESULTS

In the influenza+PB group, most children experienced disease onset at the age of 1-5 years, with the peak months of January, February, July, and September. Major clinical manifestations in the influenza+PB group included fever, cough, and shortness of breath. The influenza+PB group had significantly higher incidence rates of shortness of breath and allergic diseases such as asthma than the non-PB influenza group (P<0.05). Of the 12 children in the influenza+PB group, 7(58%) had influenza A virus infection and 5 (42%) had influenza B virus infection, among whom 1 had nephrotic syndrome. For the children in the influenza+PB group, major imaging findings included pulmonary consolidation with atelectasis, high-density infiltration, pleural effusion, and mediastinal emphysema. Compared with the non-PB influenza group, the influenza+PB group had a significantly higher proportion of children who were admitted to the pediatric intensive care unit (P<0.05). Bronchoscopic lavage was performed within 1 week after admission, and all children were improved and discharged after anti-infective therapy and symptomatic/supportive treatment.

CONCLUSIONS

Influenza with PB tends to have acute onset and rapid progression, and it is important to perform bronchoscopy as early as possible. The possibility of PB should be considered when the presence of shortness of breath, allergic diseases such as asthma or nephrotic syndrome in children with influenza.

Plastic Bronchitis in an AIDS Patient with Pulmonary Kaposi Sarcoma

Plastic bronchitis is the expectoration of bronchial casts in the mold of the tracheobronchial tree. It is a rare occurrence of unknown etiology that has been primarily described in children with congenital heart disease. In this case report, we present the first reported case of plastic bronchitis in a patient with pulmonary Kaposi sarcoma and underlying HIV infection.

Clinical characteristics of influenza virus-induced lower respiratory infection during the 2015 to 2016 season

Background

Influenza A(H1N1)pdm09 virus infections often manifest severe respiratory symptoms, particularly in patients with a past history of allergic disease. Most of these findings were reported during the 2009 pandemic. The purpose of this study was to detail the clinical characteristics of influenza virus-induced lower respiratory infection (LRI) during the A(H1N1)pdm09-predominant 2015–2016 season.

Methods

We retrospectively reviewed the clinical characteristics of influenza-induced LRI cases in children admitted to a tertiary children's hospital. Molecular diagnostic evaluation was performed on samples obtained from the most severe cases.

Results

We identified 66 patients with influenza-associated hospitalization and included 21 patients with influenza virus-induced LRI for analyses. Twelve patients (57%) were admitted to the pediatric intensive care unit, seven (33%) required mechanical ventilation, and three (14%) required extracorporeal membrane oxygenation. Plastic bronchitis (PB) was identified in six patients (29%), among whom a past medical history of asthma or food allergy were noted in all six patients. A past history of allergic disease was more common among patients with, than among those without, PB (p = 0.009). A(H1N1)pdm09 was detected from all the PB cases, and phylogenetic analyses of the hemagglutinin and neuraminidase genes demonstrated that this virus belonged to subclades 6B.1 and 6B.2. In the six PB cases, we found one patient with H275Y mutation in neuraminidase.

Conclusion

Allergic disease was a risk factor for developing PB due to influenza A(H1N1)pdm09 infection during the 2015–16 season.

Plastic bronchitis arising from solitary influenza B infection: A report of two cases in children

Plastic bronchitis (PB) is characterized by thick, inspissated, tracheobronchial casts. It is classified as either inflammatory or acellular based on the content of the endobronchial casts. PB has never been reported in a healthy child with solitary influenza B infection. This study is a retrospective case series of two children who presented to our institution in acute respiratory distress. Emergency rigid bronchoscopy was performed with extraction of casts from the L mainstem bronchus in both patients. Influenza B was the only isolate identified. In otherwise healthy children with respiratory distress, influenza B-mediated inflammatory PB must be considered in the differential diagnosis.