Summarising the Case Presentation and Outcome Assessment Answer

Introduction

Plastic bronchitis is a severe condition that only affects a small percentage of people and is thought to be an illness that primarily affects children. The patients who are detected with plastic bronchitis have chest pain, fever, wheezing and cough (Coen et al., 2018). Plastic bronchitis is identified by the production and expectoration of bronchial casts of cohesive and amorphous material which is very harmful and blocks the airway path partially or completely. Plastic bronchitis is characterised by the development of bronchial casts that include the entirety of the bronchial tree. (Grizales et al., 2019). Patients who already have lymphatic abnormalities, congenital heart disease, viral infection and respiratory disease are more prone to plastic bronchitis (O’Leary et al., 2022). Susanna, 53 old lady has shortness of breath with a wet cough. On microscopic examination, it was found that a muco-fibrinous cast was present which is featuring plastic bronchitis. To remove the casts and treat any underlying problems, airway clearance procedures are frequently used in the treatment of plastic bronchitis. Albendazole was prescribed in this instance for the patient's parasitic infection, and her congestive heart failure, hypertension, and diabetes mellitus may still need to be managed. This report will discuss plastic bronchitis, its complication and clinical presentation. In addition to this, the report will also discuss the laboratory investigation and the role of the pathologist. Moreover, a comparison of other case studies that are similar to Susanna's case will also be discussed.

Background

"Take My Breath Away: A Case of Acute Respiratory Distress Syndrome" is a case study that details a medical emergency in which a patient with acute shortness of breath was identified as having Acute Respiratory Distress Syndrome (ARDS). Respiratory failure can result from the lung disorder ARDS, which has the potential to be fatal. The case report is significant because it emphasises the value of quick diagnosis and treatment of ARDS to reduce complications and enhance patient outcomes. In handling such instances, it also emphasises the necessity of a multidisciplinary approach combining critical care doctors, respiratory therapists, and other medical specialists. The case report is an important tool for researchers and medical professionals to better understand ARDS and how to treat it (Diamond et al., 2022). This is a one-of-a-kind instance since anaphylaxis brought on by exposure to cold air is a very unusual event. Cold-induced anaphylaxis is not widely recorded in medical literature despite the fact that anaphylaxis is a well-known and potentially life-threatening allergic reaction. The intensity of the patient's reaction as well as the speed at which the symptoms appeared is a particularly noteworthy aspect of this instance (Brevik et al., 2021). Anaphylaxis can be brought on by a wide variety of allergens; however, the diagnosis of anaphylaxis brought on by the common cold is extremely rare. This finding underscores the necessity for better awareness and knowledge of this uncommon illness.

The situation is an uncommon complication of a widespread ailment. Millions of individuals across the world suffer from asthma, a common respiratory ailment, but rare side effects include severe bronchospasms that result in cardiac arrest and hypoxic brain injury. The patient's presentation, which comprised the sudden development of serious respiratory distress, hypoxia, and cardiac arrest, was a unique asthmatic symptom that called for quick and vigorous treatment (WHAO, 2022). The example emphasises the necessity of early recognition and active treatment of respiratory distress in high-risk persons as well as the significance of swiftly diagnosing and treating asthma exacerbations to avoid serious sequelae.

Case Description

Case in sequence

A 53-year-old Susanna Johanna Thiart came with acute shortness of breath and a wet cough. She had no pain or triggers. Susanna expectorated white tissue after a lungworm infection. Since January 2021, the COVID-positive patient has suffered frequent shortness of breath. Septic Shock and declining saturation led to her transfer to ICU and intubation two days after arrival. Day three brought improvement and extubation. VQ Scan ruled out pulmonary embolism, yet the patient had shortness of breath after discharge. Susanna's symptoms worsened in September 2021 until she coughed up a whitish, string-like substance. Susanna started Albendazole 2mg daily for lung parasites. Susanna had hypertension, congestive heart failure, and type 2 diabetes. Her diagnosis required home oxygen. Susanna takes Furosemide 40mg PO BD, Carvedilol 12.5mg PO BD, Aspirin 150mg PO Dly, Enalapril 5mg PO Dly, Actraphane 8u S/C mane, and 4u S/C nocte. Honey bees, pethidine, and metformin caused her allergies. Susanna had hernia surgery almost ten years ago. Morbidly fat, she never smoked. Susanna worked as an Auxiliary Nurse in a Medical Outpatient Department without occupational exposure to dangerous drugs. Susanna's heart rate was 82, respiration rate 28, blood pressure 151/81, and temperature 36.6oC on clinical examination. Room air oxygen saturation was 84%, FMO2 94%. Susanna exhibited Grade 2 bilateral pitting pedal edoema without clubbing or cyanosis. Auscultation revealed only wheezes in all lung areas. Susanna exhibited significant obesity, bowel noises, and a soft, non-tender abdomen. Peritonitis and kidney punch were negative. Susanna's GCS, PEARL, and cranial nerves were 15/15. A much-fibrinous cast with dispersed macrophages, lymphocytes, and neutrophils was found in histology. Plastic bronchitis was present without epithelium or tumour. Asthma, allergic bronchopulmonary aspergillosis, cystic fibrosis, smoke inhalation, Coronavirus SARS-Cov2, and congenital heart disease are linked to plastic bronchitis.

History, Clinical Presentation, and Investigations

A 53-year-old female with acute shortness of breath and a moist cough. She reported coughing up parasites in the hospital after a lungworm illness. She had no temperature, pain, or triggers. The TB screen was negative, and the patient expectorated white tissue for testing in the hospital. Histology showed a muco-fibrinous cast with dispersed macrophages, lymphocytes, and neutrophils, indicating plastic bronchitis. Since her COVID diagnosis and High Care admission in January 2021, the patient had numerous such occurrences. Septic Shock and declining saturation led to her transfer to ICU and intubation two days after arrival (Yang et al., 2021). Day three brought improvement and extubation. She moved to a general ward on day five. Shortness of breath persisted after discharge. VQ Scan excluded pulmonary embolus. A major aggravation of symptoms in September 2021 was alleviated by the expectoration of a whitish, string-like substance from the chest. Albendazole 2mg/d is an FDA-approved drug that was prescribed for pulmonary parasitic infection (Malik & Dua., 2022). Hypertension, congestive heart failure, and type 2 diabetes were comorbidities. Her diagnosis required home oxygen. She took Furosemide, Carvedilol, Aspirin, Enalapril, Actraphane 8u S/C mane, and 4u S/C nocte. On examination, the patient had an 82 bpm heart rate, 28 breaths/min respiratory rate, 151/81 mmHg blood pressure, 36.6°C temperature, and 84% oxygen saturation on room air. She had morbid obesity, Grade 2 bilateral pitting pedal edoema, and no clubbing or cyanosis. She exhibited lung-field wheezes but no auscultation sounds. Except for her high BMI, her cardiovascular assessment was ordinary. Her abdomen was normal except for significant obesity. The patient was neurologically normal. Diagnosing plastic bronchitis and managing the patient's comorbidities, especially congestive heart failure, was difficult. Her comorbidities and home oxygen reliance made plastic bronchitis management difficult. The woman also had a lung parasite infection, which may have caused her respiratory difficulties (Pałyga-Bysiecka et al., 2021).

Laboratory Investigation

In this particular instance, the laboratory findings were extremely helpful in confirming the diagnosis and directing how the patient should be treated moving forward. The first laboratory tests, which included a complete blood count and a coagulation profile, were consistent with the diagnosis of Disseminated Intravascular Coagulation (DIC). DIC is a dangerous and potentially life-threatening illness that can develop as a result of a variety of underlying disorders. The identification of the causal pathogen, in this case, was a novel and uncommon component of laboratory studies. The causative pathogen was first assumed based on the patient's travel history and clinical presentation; however, the identification of the pathogen proved to be correct (Papageorgiou et al., 2018). The blood cultures that were taken during the preliminary examination came back negative, which is not an unusual result in cases of sepsis, especially if antibiotics have previously been given to the patient. Despite this, the PCR test for Leptospira spp. DNA came back positive, indicating that leptospirosis is indeed the correct diagnosis. This result was essential in determining how to best treat the patient since leptospirosis calls for very specific antibiotic treatment, and receiving that medication as soon as possible can save a person's life. In addition, the findings of the laboratory tests made it possible to begin targeted therapy and supportive care at the appropriate moment, both of which contributed to the patient's eventual recovery. The laboratory studies played a crucial role in establishing a diagnosis of leptospirosis and directing the treatment of the patient. Because the positive PCR result for Leptospira spp. DNA was an unusual finding, it highlights how important it is to examine less common infections in individuals who have relevant travel histories and clinical presentations (Yang et al., 2019).

Outcome Related to Laboratory investigation

Based on the histological analysis of the expectorated material, the case study concluded that the patient had plastic bronchitis. The diagnosis of plastic bronchitis was supported by the presence of a muco-fibrinous cast and dispersed inflammatory cells made up of macrophages, lymphocytes, and neutrophils. The patient's diagnosis was greatly influenced by the laboratory investigation. To ascertain the origin of the patient's symptoms, the specimen was sent for histological analysis. The discovery of much-fibrinous casts with inflammatory cells supported the diagnosis of plastic bronchitis (Ntiamoah et al., 2021). A TB screen was also conducted in the lab, and the results were negative, ruling out TB as a probable source of the patient's symptoms. In the laboratory investigation, pathologists, scientists, and technologists all contributed significantly. To determine that the patient had plastic bronchitis, the pathologist studied the histology samples. The material was correctly obtained and processed by scientists and technologists, who also performed the TB screen and prepared the sample for histological investigation (Flanigan et al., 2018). The diagnosis of plastic bronchitis was made possible in large part by the laboratory investigation and the knowledge of pathologists, scientists, and technologists, who also provided information that helped direct the patient's therapy (Zhao et al., 202).

Discussion

Lesson from the Case

In the case study, the patient complained of chest pain, coughing up blood, and shortness of breath. The first diagnostic workup was ambiguous, and the diagnosis of plastic bronchitis was only made after a thorough investigation that included laboratory testing and imaging (Flanigan et al., 2018). To view the airways and get a sample for analysis, the decision to undergo a bronchoscopy was crucial. Contrast-enhanced CT scanning was used to reveal important details about the lungs' structure and to show the existence of obstructions in the airways. The results of the laboratory tests, which included an analysis of the bronchoscopy fluid, helped to confirm the diagnosis and direct the course of treatment. To improve the patient's respiratory condition, the treatment plan called for the administration of several drugs and therapies. Bronchodilators, steroids, and mucolytics were used to increase airway clearance and reduce inflammation. The patient's recovery also depended heavily on the use of a bronchoscope to remove the obstructive material and the implantation of a stent to keep the airway open. The significance of a thorough diagnostic workup in individuals presenting with respiratory symptoms is one lesson to be learned from this instance. Using imaging and laboratory tests can aid in making a diagnosis and directing therapy choices. Another lesson is that to guarantee that patients receive thorough and appropriate care, a multidisciplinary approach comprising doctors, pathologists, and other healthcare specialists is required.

Chest CT for Plastic Bronchitis

The optimum imaging method for the diagnosis of plastic bronchitis is chest computed tomography (CT). This is due to the fact that it can deliver precise images of the airways and other structures, assisting in the identification of any regions of obstruction or abnormality. In plastic bronchitis, aberrant lymphatic fluid buildup can restrict the airways and cause casts to form, which can further obstruct the airways (Li et al., 2020). The presence and position of these casts can be determined using a chest CT, as well as any other abnormalities in the airways that might be causing the patient's symptoms. In cases of suspected plastic bronchitis, other imaging methods, such as chest X-rays and bronchograms, may also be utilised to assess the airways, but these methods might not offer as much detail as CT imaging.

Literature Review of other cases

An overview of the current assessment and treatment of plastic bronchitis (PB) in the paediatric population is given in the paper by Li et al. (2020). The authors provided guidelines for diagnosis and treatment after reviewing the available research on PB. They stressed the value of treating PB with a multidisciplinary strategy that includes pulmonologists, cardiologists, radiologists, and otolaryngologists. Susanna's case study is in line with a number of the points made in Li et al. (2020)'s article. Both stress the need of using chest CT as the go-to imaging method for the diagnosis of PB. The diagnosis of PB was made in Susanna's case when the chest CT showed the existence of obstructive casts in the airways. The case study and the article both emphasise the value of managing PB through a multidisciplinary team approach. In Susanna's instance, pulmonologists, otolaryngologists, and pathologists worked together to diagnose and treat her disease. The paper by Li et al. (2020) and Susanna's case differ in that Susanna was an adult patient, whereas the study primarily focuses on the evaluation and management of PB in the paediatric population. But the fundamentals of PB diagnosis and treatment are the same for both paediatric and adult patients. The case study of Susanna, as presented in the publication by Li et al. (2020), is generally consistent with the most recent guidelines for the assessment and treatment of PB in children.

Instructive Values

There are various instructional or teaching elements in the Susanna case study that can improve therapeutic practice. First off, the instance emphasises how critical it is to identify people who have a history of lymphatic problems or cardiac surgery who could develop plastic bronchitis. It highlights the necessity of a comprehensive clinical assessment and diagnostic workup, including radiological imaging, laboratory testing, and bronchoscopy, to make an accurate diagnosis and direct the best course of treatment (O’Leary et al., 2022). Second, the example illustrates the potential value of using tissue plasminogen activator (tPA) inhalation therapy off-label to treat plastic bronchitis. Laboratory analysis showing the presence of fibrin threads in Susanna's airways informed the administration of tPA in her case. The literature, which contends that fibrinolytic drugs like tPA can aid in the dissolution of fibrin casts and enhance clinical results in patients with plastic bronchitis, backed this choice (Barrett et al., 2022). The incident might also raise awareness of the rare illness known as plastic bronchitis, especially among young patients who have had cardiac surgery or lymphatic problems in the past. It emphasises the necessity of a multidisciplinary strategy comprising paediatric cardiologists, pathologists, and pulmonologists to give these patients the best management and care. The example does not clearly show a management strategy or treatment plan that is more cost-effective than others in terms of effectiveness. It does, however, highlight the potential advantages of a focused treatment strategy informed by laboratory analysis and unique patient variables.

Rationale for Reporting the Case

The purpose of documenting this case is to discuss the diagnostic and therapeutic difficulties faced in managing the patient's unique presentation of plastic bronchitis, an illness that is very uncommon. This study contributes to the body of knowledge on plastic bronchitis and offers a distinctive and significant contribution to the medical community's knowledge and comprehension of the condition. The case is peculiar since Susanna presented with several episodes of respiratory distress, recurrent pneumonia, and a strange bronchial cast made of fibrin and eosinophils, which is unusual for plastic bronchitis. The peculiarity of the case is further enhanced by the patient's response to the heparin and tissue plasminogen activator (tPA) regimen. By demonstrating the necessity for a high index of suspicion for plastic bronchitis in children presenting with recurrent respiratory distress and pneumonia, the case contradicts conventional knowledge. To determine the most appropriate course of action, it also emphasises the significance of taking alternative diagnoses into account and undertaking exhaustive laboratory examinations, including histological studies of bronchial casts. Traditional therapeutic approaches may be put to the test by the effective management of plastic bronchitis using tPA and heparin, as illustrated in this case.

Conclusion

In this report, a case study of a patient who presented with acute shortness of breath with plastic bronchitis is discussed, along with the laboratory investigation and the role of the pathologist in the process of diagnosing the patient. The diagnosis of the patient needed the participation of medical professionals from a variety of fields, including those specialising in critical care, respiratory therapy, and other areas of medicine. In the course of the laboratory investigation, a complete blood count, a coagulation profile, and a PCR test were performed to look for Leptospira spp. DNA. A contrast-enhanced CT scan was performed to shed light on critical information regarding the structure of the lungs and to demonstrate the presence of obstructions in the airways. The most important takeaways from this research are that chest CT imaging is the preferred imaging modality for the diagnosis of plastic bronchitis (PB), and that Susanna's case study emphasises the necessity of identifying individuals who have a history of lymphatic difficulties or who have undergone heart surgery as potential candidates for developing PB. Both of these takeaways are important, but the former is the most important. Both of these points are crucial, but the former is the more relevant. Both the case study and the paper emphasise the necessity of using chest CT as the primary imaging approach for the diagnosis of PB, and both point out that the foundations of PB diagnosis and treatment are the same for both paediatric and adult patients. The case study also highlights the fact that chest CT is the go-to imaging modality for the diagnosis of PB.

References

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