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    A Case of Tracheal Tumor Masquerading As Asthma

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    mastansk84
    This case report describes a 57-year-old female who presented with intractable dry cough, dyspnea, and wheezing for 3 months that was initially treated as asthma. Pulmonary function tests showed severe restriction but an abnormal flow-volume loop. Chest X-ray showed left lung collapse. CT scan and virtual bronchoscopy revealed a distal tracheal mass almost completely occluding the trachea and left main bronchus. The mass was removed via bronchoscopy and found to be a carcinoid tumor. The case highlights how tracheal tumors can masquerade as asthma and emphasizes the importance of further evaluation when asthma symptoms and treatments are not responsive.

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    A Case of Tracheal Tumor Masquerading As Asthma

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    mastansk84
    22 views4 pages
    This case report describes a 57-year-old female who presented with intractable dry cough, dyspnea, and wheezing for 3 months that was initially treated as asthma. Pulmonary function tests showed severe restriction but an abnormal flow-volume loop. Chest X-ray showed left lung collapse. CT scan and virtual bronchoscopy revealed a distal tracheal mass almost completely occluding the trachea and left main bronchus. The mass was removed via bronchoscopy and found to be a carcinoid tumor. The case highlights how tracheal tumors can masquerade as asthma and emphasizes the importance of further evaluation when asthma symptoms and treatments are not responsive.

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    tracheal tumor masquerading as asthma

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    150-1-1052-1-10-20171207

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    This case report describes a 57-year-old female who presented with intractable dry cough, dyspnea, and wheezing for 3 months that was initially treated as asthma. Pulmonary function tests showed severe restriction but an abnormal flow-volume loop. Chest X-ray showed left lung collapse. CT scan and virtual bronchoscopy revealed a distal tracheal mass almost completely occluding the trachea and left main bronchus. The mass was removed via bronchoscopy and found to be a carcinoid tumor. The case highlights how tracheal tumors can masquerade as asthma and emphasizes the importance of further evaluation when asthma symptoms and treatments are not responsive.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    22 views4 pages

    A Case of Tracheal Tumor Masquerading As Asthma

    Uploaded by

    mastansk84
    This case report describes a 57-year-old female who presented with intractable dry cough, dyspnea, and wheezing for 3 months that was initially treated as asthma. Pulmonary function tests showed severe restriction but an abnormal flow-volume loop. Chest X-ray showed left lung collapse. CT scan and virtual bronchoscopy revealed a distal tracheal mass almost completely occluding the trachea and left main bronchus. The mass was removed via bronchoscopy and found to be a carcinoid tumor. The case highlights how tracheal tumors can masquerade as asthma and emphasizes the importance of further evaluation when asthma symptoms and treatments are not responsive.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 4

    BMH Med. J.

    2018;5(1):12-15 Case Report


    A Case Of Tracheal Tumor Masquerading As Asthma
    Shaik Mastan, Noufal Poongadan, A Preena, R Renju, CP Rauf

    Chest Hospital, Kozhikode, Kerala, India

    Address for Correspondence: Dr. Shaik Mastan, Chest Hospital, Kozhikode, Kerala, India. Email:
    [email protected]

    Abstract

    There are a variety of disease processes that either masquerade as asthma or contribute to worsening
    asthma symptoms in patients with asthma. Obstruction in the large airways of the chest commonly
    presents with expiratory wheezing and dyspnea, which is mistaken for asthma. Identifying the nature
    and location of the obstruction is essential because it may be a life-threatening process. We report a
    case of lower tracheal mass which was being treated as asthma with abnormal flow volume loop
    which was evaluated and turned out to be carcinoid tumor in the lower part of trachea.

    Keywords: Tracheal Tumor; Masquerading As Asthma

    Case Report

    A 57 year old female presented to Out Patient Department with history of intractable dry cough and
    grade 2 dyspnea on exertion associated with wheeze of 3 months duration. There was no h/o fever,
    chest pain, chest tightness, hemoptysis, loss of weight, loss of appetite, hoarseness of voice, allergic
    rhinitis, bronchiectasis or tuberculosis. No family h/o of asthma or allergic rhinitis. On Examination
    she was afebrile, BP 120/70 mm Hg, PR 82/min, RR 20/min, no lymphnode enlargement or
    clubbing. Trachea was shifted to left with tactile fremitus on trachea during normal breathing, dull
    percussion note on left side of chest and low pitch polyphonic wheeze on right side with absent
    breathsounds on left side. Routine laboratory investigations and ECG were normal. Pulmonary
    function test (PFT) showed FEV1-19% of predicted FEV1, FVC-24% predicted and FEV1/FVC
    was 81% with no variation in post bronchodilator values (severe restriction) but flow volume loop
    (Figure 1) was abnormal, which was not consistent with flow volume loop described for intra
    thoracic or extrathoracic large airway obstruction. Chest X-ray showed collapse of left lung with
    ipsilateral shift of mediastinum (Figure 2). Bronchoscopy was advised; as patient was not willing a
    CT thorax and virtual bronchoscopy (Figure 3, 4) was done which showed distal tracheal mass
    almost occluding the complete lumen and filling left main bronchus causing collapse on left side.
    Patient was referred to a higher centre where the mass was removed using brochoscopic snaring
    (Figure 5) with electrocautery and histopathology revealed it to be carcinoid tumour.

    Discussion

    Various causes of extra thoracic and intrathoracic obstruction of airways may masquerade as
    asthma. Vocal cord dysfunction a form of extrathoracic airway obstruction is commonly confused

    BMH Medical Journal (ISSN 2348-392X), 5(1): 12-15 (2018)


    Mastan S et al, “Tracheal Tumor Masquerading As Asthma” 13

    with asthma. A list of other causes [1] of airway obstruction of the hypopharynx, larynx, and
    proximal trachea includes laryngeal spasm, lymph node enlargement, tumor, tracheomalacia,
    tracheal stricture and extrinsic compression. All of these conditions may present with dyspnea,
    wheezing and cough, which is localized to the throat or neck but can be perceived in the chest.
    Extrathoracic lesions tend to be more symptomatic with inspiration which can be depicted in flow
    volume loops, although combined inspiratory and expiratory obstruction can occur. Diagnostic
    procedure of choice for extrathoracic lesions is fibreoptic bronchoscpy along with laryngoscopy
    which helps in direct visualization of the airway and to confirm the site of obstruction.

    Figure 1: Pulmonary function test showing severe restriction but abnormal flow volume loop

    Figure 2: Chest x ray showing left side collapse with mediastinal shift
    Mastan S et al, “Tracheal Tumor Masquerading As Asthma” 14

    Figure 3: CT thorax showing intraluminal mass and collapse of left lung with hyperinflation of right lung

    Figure 4: Virtual bronchoscopy showing near complete occlusion of tracheal lumen and left bronchus

    Figure 5: Bronchoscopic removal of tracheal mass using snare


    (Picture courtesy: Dr. VR Pattabhi Raman, Consultant In Interventional Pulmonology And Sleep Medicine, Royal Care
    Super Speciality Hospital)

    BMH Medical Journal (ISSN 2348-392X), 5(1): 12-15 (2018)


    Mastan S et al, “Tracheal Tumor Masquerading As Asthma” 15

    Clinicians should consider vocal cord dysfunction in any patient with a history of asthma and
    persistent symptoms after being treated. Visualization of the vocal cords, preferably while the patient
    is symptomatic is diagnostic feature of vocal cord dysfunction. Complete adduction of the vocal
    cords during inspiration, with formation of a posterior glottic 'chink' is diagnostic [2]. PFT shows
    airflow obstruction, with no significant bronchodilator response. Bronchoscopy is the procedure of
    choice for diagnosis, if necessary, thoracoscopic or open lung biopsy are done.

    Symptoms and signs of airway obstruction due to other causes may masquerade as Asthma.
    Absence of these key diagnostic features should prompt further evaluation for other disorders that
    can present as asthma [3]. Our patient had cough, dyspnea and wheezing with lack of response for
    asthma treatment. PFT showed abnormal flow volume loop with FEV1/FVC ratio (81%) suggesting
    severe restriction which does not fit with either flow volume loops described for extrathoracic or
    intrathoracic large airway obstruction prompted further evaluation. Flow volume loop was very
    peculiar showing a sudden a rise and fall during both in expiration and inspiration. Chest X-ray
    showed collapse with ipsilateral shift followed by Chest CT and virtual bronchoscopy which
    revealed intraluminal tracheal mass almost occluding the lumen, which explains the sudden
    cessation of the flow both during inspiration and expiration in flow volume loop. Mass was removed
    using brochoscopic snaring and electrocautery and turned out to be carcinoid. Metastatic tumor
    deposits from breast, colorectal, ovarian, renal, uterine, thyroid, testicular, nasopharynx, prostate and
    adrenal carcinomas have been reported to present as masqueraders of asthma. Bronchoconstriction
    with wheezing which may be due to bronchial carcinoid tumor or as the result of high circulating
    levels of serotonin and other mediators causing bronchoconstriction [1]. Chest radiographic findings
    may be normal or show collapse, hilar mass and mediastinal adenopathy. Computed tomography is
    sensitive in detecting and localizing the lesions but bronchoscopy is diagnostic and biopsy will
    eventually have diagnostic and prognostic singnificance in these centrally located lesions. Urine 5-
    hydroxyindoleacetic acid is an effective screening test in carcinoid tumors [1].

    Acknowledgement

    Dr. VR Pattabhi Raman, Consultant In Interventional Pulmonology And Sleep Medicine, Royal Care
    Super Speciality Hospital.

    References

    1. Tilles, Stephen A. Differential diagnosis of adult asthma. Medical Clinics 2006; 90 (1): 61-76.

    2. King, Christopher S., and Lisa K. Moores. "Clinical asthma syndromes and important asthma
    mimics." Respiratory care2008; 53(5): 568-582.

    3. Kanagarajan, Karthikeyan, et al. "Endobronchial metastatic disease masquerading as bronchial


    asthma." Chest Journal. Meeting Abstracts 2005; 128 (4): 408S-a.

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