Abstract Background Greater than 1/3 of patients who survive hospitalization with severe SARS-COV-2 infection develop significant peribronchiolar changes, which can have variable clinical presentations and thus is often challenging to diagnose. Case Presentation Our patient is a 39-year-old female with history of seasonal allergic rhinitis, obesity, and GERD who was in her usual state of health until she suffered from a viral URI in October 2022 while living in California. Subsequently, she developed a persistent cough, wheeze, and dyspnea. Notably, she was never diagnosed with asthma as a child. Full PFTs were unremarkable with no bronchodilator response. Given her symptoms she was diagnosed with adult-onset asthma and was started on ICS-LABA-LAMA triple therapy and ultimately Tezepelumab. Over the following 2 years, she had more than 10 ED visits for respiratory exacerbations and received multiple steroid courses leading to 45 pounds of weight gain. After moving to Pittsburgh in 2024, she tested positive for SARS-COV-2 resulting in an 11-day admission. Her exam was notable for diffuse expiratory wheeze without crackles and persistent non-productive cough. Vitals were normal on room air. Viral panel and bronchoalveolar lavage were unrevealing. Testing for mast cell activation syndrome and carcinoid syndrome were negative. Bronchoscopy showed mild tracheal excessive dynamic airway collapse. CT chest showed mosaic attenuation on expiration indicative of air trapping. ENT evaluation revealed Muscle Tension Dysphonia and she was referred to voice therapy. She was ultimately discharged on steroids. Given her lack of response to inhalers, systemic corticosteroids and Tezepelumab, she was gradually weaned off without change in symptoms. Repeat PFTs showed no airflow limitations nor emergent bronchodilator response and fractional exhaled nitric oxide level remained low. Given this, an alternative diagnosis was suspected. VATS wedge biopsy was performed which showed peribronchiolar fibrosis with diffuse interstitial thickening with fibrotic change without any hallmark features of asthma, representing post-SARS-CoV-2 bronchiolitis. Since biopsy, the patient has been maintained off asthma medication, has lost weight, and is feeling better. Discussion Our patient developed post-viral wheeze, cough and imaging consistent with air trapping. Despite mimicking asthma our patient did not respond to escalation of therapy. Further, biopsy did not show mucosal inflammation, basement membrane thickening, goblet cell metaplasia or submucosal gland hyperplasia. Instead, the striking feature on biopsy was peri-bronchiolar thickening and fibrotic change. It is helpful to consider length of COVID-19 hospitalization as patients with longer than 7-day admission are more likely to develop bronchiolitis. This abstract is funded by: None
Tepper et al. (Fri,) studied this question.