Abstract Introduction Congenital tracheobronchial anomalies are identified in approximately 1% of the population, with displaced or supernumerary bronchi being particularly uncommon in adults. These anomalies are often asymptomatic but may predispose to recurrent respiratory infections, chronic cough, or airway obstruction, especially in individuals with underlying pulmonary or genetic conditions. We present a case of bilateral eparterial displaced bronchi with accessory lobation discovered during evaluation of persistent cough in a patient with Wolff-Parkinson-White (WPW) syndrome and heterozygous alpha-1 antitrypsin (A1AT) deficiency. Case Presentation A 63-year-old male with WPW and heterozygous A1AT deficiency presented with a persistent non-productive cough and dyspnea for one week. He was initially treated at an urgent care center for presumed community-acquired pneumonia with doxycycline, albuterol, benzonatate, and prednisone without improvement. Subsequent evaluation by his primary care physician led to sequential courses of levofloxacin and moxifloxacin for five days each, with continued cough and wheezing despite frequent use of inhaled bronchodilators. He denied fever, chills, or recent hospital exposure. He was a lifelong non-smoker. Due to persistent symptoms despite three antibiotic regimens, bronchoscopy with bronchoalveolar lavage (BAL) was performed to evaluate for atypical infection. Bronchoscopy revealed a displaced eparterial bronchus arising from the left mainstem bronchus, bifurcating separately from the lingular division, resulting in three distinct left-sided lobes with an accessory fissure. A similar, though less pronounced, displaced eparterial bronchus was visualized on the right. BAL cultures were negative. Symptoms improved with supportive therapy, including benzonatate, without antimicrobial escalation. Discussion Congenital tracheobronchial anomalies such as tracheal bronchus (∼1%) and accessory cardiac bronchus (∼0.1%) are rare, while accessory lobes occur in only 0.3-1.2% of the population. Displaced or supernumerary bronchi represent an even smaller subset, and the coexistence of multiple anomalies in a single patient, as seen here, is exceedingly uncommon. These variants may alter airway anatomy, impair mucociliary clearance, and predispose to persistent cough or infection. In this case, underlying A1AT deficiency may have compounded respiratory symptoms and susceptibility to airway irritation. Recognition of such anomalies is important to avoid misdiagnosis as recurrent pneumonia and for procedural planning, as variant anatomy may increase complexity of airway interventions. Conclusion This case highlights the importance of thorough bronchoscopic and imaging evaluation in patients with persistent respiratory symptoms unresponsive to standard therapy. Early identification of rare congenital airway anomalies can guide appropriate management and prevent unnecessary antimicrobial use. This abstract is funded by: None
Khalid et al. (Fri,) studied this question.