A case of excavated pneumopathy after bronchial thermoplasty

Abstract

A 60-year-old Caucasian woman with severe uncontrolled asthma despite maximal medical treatment was referred to our center for bronchial thermoplasty. She had an atopic asthma with a failure to Xolair treatment and low eosinophils in blood and sputum. There was no bronchial obstruction with a FEV1 of 103%. A chest computed tomography (CT) revealed moderate diffuse thickening of the bronchial walls with minimal trapping without significant bronchial dilation.

First two BT sessions were performed without major complications except for a mild asthma exacerbation. The third procedure was performed with 214 activations in the left and right upper lobe bronchi with minimal bleeding. There were no endoscopic abnormalities in the airway and unchanged chest radiography. The patient presented a new exacerbation of her asthma that required to continue the oral corticosteroid treatment with respiratory deterioration each time it was stopped. Chest CT scan revealed the appearance of thickening of the bronchial walls, peribronchial infiltration, mucoid impactions and nodular formations excavated in direct contact with the bronchial tree limited to the upper lobes and the lingula. There was no pulmonary embolism, no biologic inflammatory syndrome nor any germ in bronchial alveolar lavage (BAL). Leucocyte formula in BAL was normal. She was treated with ceftriaxone for 2 weeks and corticosteroids with a slow degressive posology on several weeks. Asthma exacerbation slowly improved. Control CT scans showed a decrease of wall thickenig of the excavated lesion.

A hypothesis is that intense thermal stimulation of the bronchi with use of high-dose systemic steroids to control asthma exacerbation may lead to a alveolar lung lesions.