Unusual Case of Plastic Bronchitis Presenting with Pneumopericardium.

BACKGROUND Lymphatic circulation in the thorax enters the systemic blood flow at the subclavian vein. Instances where diversion occurs leads to complications such as pleural effusion. A rare complication of lymphatic diversion results in fluid accumulation in the bronchial tree, causing plastic bronchitis. The following case is the first ever report of plastic bronchitis presenting with pneumopericardium. CASE REPORT A 24-year-old female presented to our Emergency Department with an asthma exacerbation. After initiating bronchodilators, a chest radiograph (CXR) showed extensive subcutaneous emphysema, pneumomediastinum, and pneumothorax with atelectasis of the left lung. Chest tomography supported the CXR findings, as well as a finding of pneumopericardium. A thoracostomy tube was placed and a mediastinal window and pericardial window procedure were performed in an attempt to relieve the pressure upon the collapsed lung. Despite these invasive procedures, there was minimal improvement of lung volume with further respiratory deterioration; the patient eventually required mechanical ventilation. Bronchoscopy was performed, which evacuated a white chalky and rubbery substance that created a mold of the bronchial airways. Following the bronchoscopy, the patient's respiratory status improved, requiring less ventilator support, and that patient was successfully extubated. CONCLUSIONS This case highlights the most crucial management of a patient presenting with pneumomediastinum, pneumothorax, and pneumopericardium due to plastic bronchitis. Plastic bronchitis should be high on the list of differential diagnoses. The management of plastic bronchitis with bronchoscopy is supported by the fact that no invasive therapy such as thoracostomy tube or mechanical ventilator alleviated the problem, however, bronchoscopy removed the worm-like cast lodged within the lumen of the bronchial tree.

Systemic inflammatory response syndrome and platelet count ≥250×10(9) are associated with venous thromboembolic disease.

INTRODUCTION: Prior research has demonstrated that platelet count and inflammation are dominant contributors to hypercoagulability. Our objective is to determine whether elevated platelet count and systemic inflammatory response syndrome (SIRS) have an association with the development of venous thromboembolism (VTE) in hospitalized patients with a high clinical index of suspicion for thromboembolic disease. METHODS: We performed a retrospective medical record review of 844 medical and surgical patients with suspected VTE hospitalized from July 2012 to May 2013 who underwent screening by venous duplex and computed tomography pulmonary angiogram. For our purposes, thrombocytosis was arbitrarily defined as platelet count ≥250×10(9)/L. RESULTS: Venous thromboembolic disease was detected in 229 patients (25.9%). Thrombocytosis was present in 389 patients (44%) and SIRS was present in 203 patients (23%) around the time of imaging. Thrombocytosis and SIRS were positively correlated with VTE (P<0.001). There was no correlation between thrombocytosis and SIRS. Multivariate analysis revealed that SIRS (odds ratio 1.91, 95% confidence interval 1.36-2.68, P<0.001) and thrombocytosis (odds ration 1.67, 95% confidence interval 1.23-2.26, P=0.001) were independently associated with VTE. CONCLUSION: Patients at high risk for VTE should be routinely assessed for thrombocytosis (≥250×10(9)/L) and SIRS; if either is present, consideration for empiric anticoagulation should be given while diagnostic imaging is undertaken.