A60-17 Persistent Wheezing in an Adolescent Patient

Abstract Introduction Primary endobronchial carcinoids are the most common primary pulmonary neoplasms in pediatrics. Obstructive tumors can present as cough, asymmetric wheezing, and imaging changes. Symptoms are often misdiagnosed as asthma in pediatric patients causing delays to diagnosis. Early recognition and resection offer definitive treatment with low recurrence. Case Presentation A 13-year-old female with asthma and allergies presented to the pediatric pulmonary clinic for evaluation of persistent cough, exertional dyspnea, and wheezing following a viral infection. She recently completed a 10-day course of prednisone and started Symbicort without improvement. Family endorsed persistent cough, exertional dyspnea, nightly fevers, fatigue, anorexia, and weight loss. Family denied hemoptysis, night sweats, recurrent infections, or environmental exposures. Examination demonstrated asymmetric monophonic wheezing over the left chest. Pulmonary function testing (PFT) showed moderate restrictive airflow limitation without bronchodilator response. Chest radiograph demonstrated asymmetric hyperinflation of the left lung and rightward cardiac displacement. She was admitted for expedited workup, including a computed tomography (CT) chest.CT chest revealed a 19 mm endobronchial mass with possible extra-bronchial component compressing the left mainstem bronchus and complete occlusion of the left upper lobe bronchus with diffuse post-obstructive atelectasis throughout. Laboratory evaluation revealed leukocytosis and elevated inflammatory markers but otherwise normal tumor and metabolic markers.Bronchoscopy with ultrasound-guided endobronchial biopsy demonstrated a neuroendocrine neoplasm consistent with carcinoid tumor. After bronchoscopic debulking she improved clinically and was discharged for definitive surgical management. Repeat PFTs at discharge demonstrated improved forced vital capacity (FVC) with unchanged forced expiratory volume in one second (FEV₁) resulting in obstructive airflow limitation. Plethysmography with normal total lung capacity (TLC) with high residual volume to TLC ratio at 190% predicted suggesting air trapping.She subsequently underwent left upper lobe sleeve lobectomy, confirming atypical carcinoid tumor with increased mitotic activity but no necrosis or nodal metastasis. Six months postoperatively, PFTs normalized and she remained asymptomatic, off inhaled corticosteroids. Her FVC improved from 88% to 116%, FEV1 from 73% to 106%, and FEV1/FVC normalized at 82% predicted. Discussion Although bronchial carcinoid tumors are rare, they should be considered in cases of recurrent or asymmetric wheezing unresponsive to asthma therapy. PFTs are not routinely performed in workup of bronchial carcinoid tumors, limiting data on expected spirometry changes in pediatrics. This report uniquely trends serial PFTs demonstrating an initial restrictive pattern that progressed to obstructive with air trapping and ultimately normalized postoperatively. The PFT changes correlate with the degree of airway occlusion as proper airflow is gradually restored. This abstract is funded by: none