Presentation
ICU patient who presented with shortness of breath, tachypnea and viral prodromal symptoms following travel overseas. Previous wedge resection of his right middle lobe.
Patient Data
There is extensive fibrosis and volume loss in both upper lobes and right lower lungs. There is suture material seen in the right lung base. Over-inflation of the lungs is noted on background of COPD.
The trachea is noted to be dilated up to almost 4 cm in diameter. This is likely secondary to parenchymal disease in the upper lobes and cartilagenous weakness of the tracheal rings. No pleural effusion is noted.No definite pulmonary consolidation is noted.
Tracheomegaly and bronchiectasis prominent throughout with deviation to the right secondary to extensive parenchymal disease. Maximum tracheal diameter reaching 3.8 cm. Calcified subhilar and carinal lymph nodes bilaterally.
Bilateral upper lobe fibrosis, with multifocal longstanding parenchymal fibrosis especially extend to superior segment of both lower lobes, right greater than left. No new focal areas of consolidation or collapse.
Case Discussion
The patient's presenting symptoms are likely to be related to a concurrent exacerbation of an acuired viral illness confirmed with positive swabs for Influenza B and Human metapneumovirus. On the ward he was noted to be going into an acute hemolytic crisis as part of pre-existing cold agglutinin disease. He was admitted to ICU for urgent plasmapheresis and observation post-procedure.
Findings of this tracheobronchomegaly manifested as part of his 20 year history of sarcoidosis. Concerns about the inability to achieve invasive ventilation in the current ICU setting have been raised as endotracheal tube balloons would not be large enough to prevent sizable cuff leak.
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