Everything That Wheezes Is Not Asthma: A Case Report

Background: This case report provides the general pediatrician with insight on a unique presentation of an already rare disease. Plastic bronchitis (PB) is an exceedingly rare disease that presents with the formation of casts in the endobronchial tree. This typically occurs in patients with congenital heart defects that have undergone repair, however, it is atypical to be seen in otherwise healthy patients. Influenza A, lymphatic abnormalities, and single ventricle physiology are the only proven causes of PB. Asthma, toxic inhalation, and acute chest syndrome, however, are a few of the many conditions that have been proposed to predispose patients toward developing PB. Case Presentation: Thus, it is important to discuss the case of a 9-year-old boy with a history of uncontrolled asthma who presented with cough, chills, weight loss, and fevers. This patient was initially treated with broad-spectrum antibiotics due to concerns for necrotizing pneumonia, but due to failure in improvement, a direct laryngoscopy and bronchoscopy was performed, revealing the diagnosis of PB. Although this patient had a history of uncontrolled asthma, this was the only predisposing respiratory condition that put him at risk of developing PB. This patient went on to be treated with corticosteroids, chest physiotherapy, inhaled fibrinolytics, and direct fibrinolytic therapy with marked improvement in symptoms and imaging. Conclusion: PB, though rare, is a condition that all pediatricians must keep in their minds when patients present with respiratory symptoms with an unclear etiology. The delay in diagnosis and treatment of patients with PB can be detrimental as expectoration of these casts can result in asphyxiation and death. This article goes on to remind all providers, at all levels, the importance of conducting a thorough history/physical examination, creating a broad differential, and treating each patient holistically.