SHM Converge Scientific Abstract ePoster Gallery-Coughing Up Lymph: A Rare Case of Plastic Bronchitis

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This case describes a 54-year-old man with obesity, asthma, alcohol use disorder, tobacco use, and hepatic steatosis who developed a prolonged, progressive illness ultimately diagnosed as plastic bronchitis. He initially presented with edema, minimal proteinuria, hypoalbuminemia, hepatomegaly, and anasarca. Cardiac, renal, and hepatic causes were investigated but not supported by testing. Over the following months, he returned with worsening edema and dyspnea, then later with acute hypoxemic respiratory failure and expectoration of branching airway casts, raising concern for plastic bronchitis.<br /><br />Imaging showed evolving ground-glass opacities and airway secretions, while lung biopsy demonstrated acute and organizing alveolar damage. Infectious and rheumatologic evaluations were largely negative. The diagnosis became clearer after bronchoscopy removed multiple casts and pathology showed fibrin, lymphocytes, and macrophages consistent with lymphatic material. Lymphangiography identified a thoracic duct leak, supporting a lymphatic cause.<br /><br />The patient was treated with repeated diuresis, airway clearance therapies, bronchoscopy, antibiotics, corticosteroids, oxygen support, and ultimately thoracic duct embolization. Diuresis helped temporarily, with oxygen needs improving as weight decreased, but outpatient airway clearance required significant adherence. After embolization, the lymphatic leak appeared reduced.<br /><br />The authors emphasize that plastic bronchitis is a rare, potentially life-threatening condition often associated with lymphatic abnormalities and hypoxemic respiratory failure. Cast expectoration is a classic clue, but imaging may be nonspecific and diagnosis can be delayed. This case highlights the importance of pathology, bronchoscopy, and lymphatic imaging in guiding management, and suggests that thoracic duct embolization may offer meaningful benefit when a lymphatic leak is present.

Asset Subtitle

Luke J. Richard

Meta Tag

Author List Alexandra A. Wick, Luke J. Richard

Category Clinical Vignettes

Concept Plastic Bronchitis

Concept Hypoxemic Respiratory Failure

Concept Bronchial Cast

Concept Bronchoscopy

Concept Lymphatic Leakage

Distinguished Finalist

Presenter Organization University of Wisconsin School of Medicine and Public Health

Presenting Author Luke J. Richard

Track Adult

Keywords

plastic bronchitis

thoracic duct leak

lymphatic abnormality

airway casts

hypoxemic respiratory failure

bronchoscopy

thoracic duct embolization

ground-glass opacities

alveolar damage

hypoalbuminemia

Plastic Bronchitis

Hypoxemic Respiratory Failure

Bronchial Cast

Bronchoscopy

Lymphatic Leakage