Severe bronchial obstruction and lung atelectasis following suspected massive inhalation of gluten-free flour: a case report

Acute respiratory failure in children is most commonly caused by respiratory infections, asthma, foreign body aspiration, trauma, and disorders affecting the respiratory pump or the central control of breathing. We describe an unusual and underreported cause of severe respiratory compromise in a previously healthy 2-year-old boy. The patient presented with acute hypoxemic respiratory failure that was poorly responsive to inhaled bronchodilators, systemic corticosteroids, and oxygen therapy, requiring endotracheal intubation and invasive mechanical ventilation. Extensive diagnostic investigations did not identify a common infectious cause or a conventional aspirated foreign body. Chest imaging demonstrated complete left lung atelectasis and right upper lobe atelectasis. Flexible bronchoscopy with therapeutic bronchoalveolar lavage revealed and removed abundant white, highly viscous endobronchial material, resulting in progressive re-expansion of the affected lung and marked clinical improvement. The child was successfully extubated and discharged from the hospital after 20 days of hospitalization. A subsequent review of the clinical history identified the likely precipitating event: inhalation of gluten-free flour after accidental activation of a planetary mixer during cake preparation. We hypothesize that inhalation of a large amount of powder contributed to airway obstruction through direct particulate deposition and/or secondary inflammatory mucus formation; hydration of a hydrocolloid component may also have contributed to the marked viscosity of the endobronchial material, although this mechanism could not be directly demonstrated. This case highlights the importance of meticulous history-taking in identifying rare causes of acute respiratory failure and illustrates how seemingly innocuous environmental exposures may result in life-threatening airway obstruction requiring prompt recognition and intervention.