Radiological and clinical characteristics of plastic bronchitis complicated with H1N1 influenza viral pneumonia in children Poster No.: C-1727 Congress: ECR 2012 Type: Scientific Exhibit Authors: H. Fujisawa, T. Kushihashi, Y. Umeda, M. Tonouchi, M. Tanisaka, N. Sunaoshi; Kanagawa/JP Keywords: Lung, Pediatric, CT, Plain radiographic studies, Diagnostic procedure, Infection DOI: 10.1594/ecr2012/C-1727 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 17
Purpose Plastic bronchitis is a rare but potentially fatal condition characterized by the formation of a cast of the bronchial tree. In this exhibit, we describe detailed radiological and clinical features of the plastic bronchitis in the H1N1 influenza viral pneumonia in children. Images for this section: Fig. 6: Case 1. As large amounts of white and hard mucous plug were found filling the right lower bronchus upon bronchoscopic exploration, aspiration was performed repeatedly without any evidence of airway obstruction. Page 2 of 17
Fig. 10: Case 3. As large amounts of white and hard mucous plug were found filling the right B6 upon bronchoscopic exploration, aspiration was performed repeatedly without any evidence of airway obstruction. Page 3 of 17
Methods and Materials A total of 72 children patients admitted to our hospital with a confirmed diagnosis of H1N1 influenza viral infection who underwent chest CT within 24 hours, 4 out of 72 patients received bronchoscopic examination and were diagnosed at plastic bronchitis. Radiographic findings were characterized by type and pattern of opacities. Pulmonary parenchymal abnormalities (consolidation, GGO, and nodular opacity,), bronchial abnormalities (stenosis, bronchial wall thickening, mucus plug, and atelectasis), and distribution on chest CT findings were evaluated. Results All 4 patients underwent urgent bronchoscopic extraction of casts and required mechanical ventilation treatment. The clinical features of these patients are summarized in Figure 1. In all four patients, mucous casts were removed successfully; however, one patient with acute myocarditis died as a result of ARDS. Radiographical findings were consolidation (n=4), bilateral (N=2). The chest CT findings of these patients are summarized in Figure 2. Chest CT findings included the following: consolidation (n=4), GGO (n=2), nodular opacities (n=1), atelectasis (n=1), airway stenosis (n=4), bronchial wall thickening (n=2), mucous plug (n=3), pleural effusion (n=3), pneumomediastinum (n=1), and lymphnode enlargement (n=1). Bilateral multifocal consolidation and GGO were seen in 2 patients including 1 died cases. Images for this section: Page 4 of 17
Fig. 1: Summary of clinical findings in patients of plastic bronchitis in S-OIV pneumonia Fig. 2: Summary of chest CT findings in patients of plastic bronchitis in S-OIV pneumonia Page 5 of 17
Fig. 3: Case 1. Chest plain radiograph in a 5-year-old boy with an S-OIV infection who presented with a fever and cough shows bilateral consolidation, pneumomediastinum and subcutaneous emphysema. Page 6 of 17
Fig. 4: Case 1. Chest CT demonstrate consolidation, ground-glass opacity, bronchial wall thickening, and airway stenosis are visible. Bilateral pleural effusion and pneumomediastinum can also be seen. The patient's symptoms rapidly progressed despite advanced intensive care, and he died 3 days later. Page 7 of 17
Fig. 5: Case 1. Page 8 of 17
Fig. 6: Case 1. As large amounts of white and hard mucous plug were found filling the right lower bronchus upon bronchoscopic exploration, aspiration was performed repeatedly without any evidence of airway obstruction. Page 9 of 17
Fig. 7: Case 1. Histopathologically, the bronchial cast was mainly composed of inflammatory cells with eosinophils and fibrin; thus, the cast was diagnosed as type I plastic bronchitis. However, the patient's symptoms rapidly progressed despite advanced intensive care, and he died 3 days later. Fig. 8: Case 3. Chest CT in a 7-year-old boy with an S-OIV infection complicated with plastic bronchitis. The patient presented with a fever, cough, impaired consciousness, and hypoxia requiring advanced mechanical ventilation and aspiration for a mucous plug. A chest CT revealed bilateral multifocal consolidation and ground-glass opacity with nodular opacities; moreover, a mucous plug is visible in the right lower bronchus. Also, bilateral pleural effusion is apparent. Page 10 of 17
Fig. 9: Case 3. Page 11 of 17
Fig. 10: Case 3. As large amounts of white and hard mucous plug were found filling the right B6 upon bronchoscopic exploration, aspiration was performed repeatedly without any evidence of airway obstruction. Fig. 11: Case 3. Histopathologically, the bronchial cast was mainly composed of inflammatory cells with eosinophils and fibrin; thus, the cast was diagnosed as type I plastic bronchitis. The patient eventually recovered from the S-OIV infection after a 12day hospitalization period. Page 12 of 17
Fig. 12: Case 4. Chest plain radiograph with an S-OIV infection who presented with a fever and cough demonstrate consolidation and atelectasis at the right lobe. Page 13 of 17
Fig. 13: Case 4. Chest CT shows multifocal consolidation, atelectasis, airway stenosis and mucus plug. Page 14 of 17
Fig. 14: Case 4. Chest CT of the mediastinal setting shows right lobe atelectasis and mediastinal lymphnode enlargement. Page 15 of 17
Conclusion CT can identify pulmonary and airway abnormalities in children with plastic bronchitis complicated with H1N1 pneumonia. The presence of a mucous plug in addition to extensive consolidation with airway stenosis may suggest plastic bronchitis with H1N1 pneumonia in children, in which case an urgent bronchoscopy to remove the bronchial cast should be performed. References # Lee EY, McAdam AJ, Chaudry G,et al.swine-origin influenza a (H1N1) viral infection in children: initial chest radiographic findings. Radiology. 2010 ;254(3):934-941 #Mollura DJ, Asnis DS, Crupi RS, et al. Imaging findings in a fatal case of pandemic swine-origin influenza A (H1N1). AJR Am J Roentgenol. 2009 ;193(6):1500-1503 # Agarwal PP, Cinti S, Kazerooni EA. Chest radiographic and CT findings in novel swine-origin influenza A (H1N1) virus (S-OIV) infection. AJR Am J Roentgenol.2009;193(6):1488-1493 # Ajlan AM, Quiney B, Nicolaou S,et al. Swine-origin influenza A (H1N1)viral infection: radiographic and CT findings. AJR Am J Roentgenol. 2009;193(6):1494-1499. #Itoh Y, Shinya K, Kiso M, et al. In vitro and in vivo characterization of new swine-origin H1N1 influenza viruses. Nature. 2009 ;460(7258):1021-1025 #Guo HH, Sweeney RT, Regula D, Leung AN. Best cases from the AFIP: fatal 2009 influenza A (H1N1) infection, complicated by acute respiratory distress syndrome and pulmonary interstitial emphysema. Radiographics. 2010;30:327-333 #Soto-Abraham MV, Soriano-Rosas J, Díaz-Quiñónez A, et al. Pathological changes associated with the 2009 H1N1 virus. N Engl J Med. 2009 Nov 12;361:2001-2003 #Bongaerts D, Wojciechowski M, Suys B, et al. Plastic bronchitis in a 5-year-old boy causing asystoly and fatal outcome. JAsthma. 2009 ;46(6):586-590 Page 16 of 17
#Bowen A, Oudjhane K, Odagiri K, Liston SL, Cumming WA, Oh KS. Plasticbronchitis: large, branching, mucoid bronchial casts in children. AJR Am J Roentgenol. 1985;144(2):371-375 #Seear M, Hui H, Magee F, et al. Bronchial casts in children: aproposed classification based on nine cases and a review of the literature. Am J Respir Crit Care Med. 1997;155(1):364-370 Personal Information Hidefumi Fujisawa M.D, Ph.D. Department of Radiology Showa University Northern Yokohama Hospital Japan hfuji@med.showa-u.ac.jp Page 17 of 17