Unusual case of a vanishing bronchus of the left allograft in a lung transplant recipient
A 17-year-old female lung transplant recipient for cystic fibrosis underwent bronchoscopy to assess response to both intravenous (IV) pulse methylprednisolone for acute A2B0 allograft rejection diagnosed 2 weeks earlier and ongoing IV ganciclovir and foscarnet for cytomegalovirus (CMV) infection. Upon inspection of the left main bronchus, there were substantial changes as compared to the bronchoscopy 2 weeks before, showing narrowing of the airway lumen and mucosal edema with friability to the point of not being able to advance the bronchoscope into either the left upper or lower lobe segments. Subsequently, the right allograft was evaluated with bronchoalveolar lavage and transbronchial biopsies of both right middle and lower lobes being performed without difficulty. The patient tolerated the procedure well including biopsies until 5 min after withdrawing the bronchoscope when she dropped her oxyhemoglobin saturation (SaO2) to 86% despite mechanical ventilation. Chest radiograph revealed left lung collapse [], so the bronchoscope was immediately re-inserted with the discovery of complete occlusion or vanishing of the left main bronchus []. The bronchoscope was not able to be advanced through this tissue occluding the airway, so alligator forceps were used to try to perforate it. After numerous attempts, eventually a small opening [] was obtained. However, her respiratory status declined due to severe hypoxic respiratory failure with no improvement with inhaled nitric oxide and trial of high-frequency oscillatory ventilation. She was therefore placed on VV ECMO with immediate normalization of SaO2. While on VV ECMO, balloon dilatation of the left main bronchus was successfully performed through the small opening attained earlier. A CRE™ balloon was used to dilate the area from 4 mm initially to 6 mm, and then to 8 mm diameter. The balloon was passed through a 6.4 mm dia Olympus bronchoscope. She was removed from ECMO the following day and extubated 3 days later. The remaining part of her hospital course was unremarkable with her being discharged 2 weeks later.