Abstract Introduction Infantile bronchial hemangioma is a rare primary endobronchial lesion and has only been described in a few case reports. Delayed diagnosis can lead to life-threatening airway obstruction. This case report describes hallmark features of an infant presenting with acute respiratory failure, where early imaging and bronchoscopy revealed a large bronchial hemangioma. Case Description A term 3-month-old female presented for the first time to the emergency department in acute hypoxemic respiratory failure. Caregivers reported progressive dyspnea since about one month old without any stridor at rest, hypoxemia, or poor weight gain. They confirmed no significant family, prenatal, or birth history. Her physical exam was notable for barrel-shaped chest with subtle asymmetric hyperinflation of right chest wall, and asymmetric breath sounds with focal wheeze in the right lower lung fields when compared to the left side. Initial interventions included back-to-back trials of nebulized bronchodilators without improvement, followed by bi-level non-invasive ventilation, which improved oxygenation and dyspnea. Initial workup included a negative viral respiratory panel. Chest x-ray revealed mild right lung hyperinflation without anatomical abnormalities or radio-opaque foreign body (Figure 1A). She was admitted to the pediatric intensive care unit where Pediatric Pulmonology recommended CT Angiogram to rule out congenital lung malformation and further characterize asymmetric lung exam findings. This revealed near complete effacement of right mainstem bronchus and global hyper-expansion of right lung relative to the left (Figure 1B). Urgent combined micro-laryngoscopy and bronchoscopy (MLB) performed by Pediatric Pulmonology and ENT revealed a large, vascularized endobronchial in right mainstem bronchus at the level of the carina (Figure 1C). MRI Chest confirmed a solid hyper-vascular lesion in the right mainstem bronchus consistent with hemangioma. Oral propranolol therapy was promptly initiated and titrated to a dose of 1 mg/kg twice a day. Respiratory support was weaned, and she was discharged home on room air. Follow-up MLB performed after 8 weeks of starting propranolol showed the hemangioma had flattened to the surface of lateral wall of right mainstem bronchus, indicating near complete resolution of airway obstruction (Figure 1D). Discussion Bronchial hemangiomas, though exceedingly rare in infancy, can proliferate and lead to severe airway compromise. This case emphasizes the importance of pursuing cross sectional imaging and direct airway visualization in infants with progressive dyspnea and focal wheeze, particularly if initial imaging is inconclusive. Prompt diagnosis and treatment with propranolol can lead to rapid resolution of lesion and avoid life-threatening complications. This abstract is funded by: CFF0077027B124, NIH/NCATS Colorado CTSA T32TR004366
Paracha et al. (Fri,) studied this question.