Not All That Wheezes Is Bronchial Asthma - eScholarship

The n e w e ng l a n d j o u r na l of m e dic i n e images in clinical medicine Not All That Wheezes Is Bronchial Asthma B C Flow (liters/sec) Flow (liters/sec) A Volume (liters) Volume (liters) A 10-year-old previously healthy girl presented with episodic Inderpal Randhawa, M.D. wheezing, dyspnea, and progressive exercise intolerance, which had developed Eliezer Nussbaum, M.D. during the preceding 9 months. On physical examination, RETAKE the patient 1st had AUTHOR Randhawa ICM Miller Children’s Hospital 2nd with REG F She moderate bilateral expiratory wheezing. was treated for presumed asthma FIGURE 1 of 1 Long Beach, CA 3rd CASE TITLE inhaled corticosteroids, Revised multiple courses of inhaled bronchodilators, montelukast, docrandhawa@verizon.net EMail Line her 4-C and oral corticosteroids. Though the patient reported that condition SIZE had im- Enon ARTIST: mst H/T H/T proved somewhat, there was no demonstrable objective improvement. Further 39p6 evalu- FILL Combo ation by spirometry revealed severe expiratory AUTHOR, obstruction (Panel A). The patient PLEASE NOTE: Figure has been redrawn and type has been reset. (>90%) underwent flexible fiberoptic bronchoscopy, which revealed nearly complete Please check carefully. occlusion of the distal trachea by a vascular mass. Computed tomographic angiog- raphy showed that the mass did not extend beyond the trachea ISSUE: (Panel 7-1-10 B, arrow). The JOB: 36301 mass was ablated endoscopically with the use of a potassium titanyl phosphate laser. Pathological analysis revealed an inflammatory pseudotumor, a benign tumor com- posed of a proliferation of inflammatory cells. Rarely invasive, this type of tumor is usually cured by local excision. One month after surgery, the patient was free of symptoms and had normal results on spirometry (Panel C). Pulmonary pseudotu- mors are rarely the cause of wheezing. However, a lack of response to first-line therapies warrants further investigation, including spirographic analysis. Copyright © 2010 Massachusetts Medical Society. n engl j med 363;1 nejm.org july 1, 2010 The New England Journal of Medicine Downloaded from nejm.org at Irvine (UCD) on January 19, 2017. For personal use only. No other uses without permission. Copyright © 2010 Massachusetts Medical Society. All rights reserved. e1