Abstract Introduction Mucous plugging is a common radiologic finding in patients with chronic obstructive pulmonary disease (COPD), often attributed to airway mucous hypersecretion. On imaging, mucous plugs typically appear as benign tubular or branching opacities. However, computed tomography (CT) findings initially attributed to mucous plugging may in fact be malignant lesions, subsequently delaying diagnosis and treatment.Bladder urothelial carcinoma is known to metastasize to lymph nodes, lung parenchyma, and bone, but endobronchial metastases are exceedingly rare. Endobronchial metastases can present with nonspecific pulmonary symptoms such as cough, dyspnea, or hemoptysis. In rare cases, these metastases may mimic benign airway obstruction, especially in patients with coexisting pulmonary disease or anti-coagulation related bleeding. Case An 81-year-old male with a history of COPD, cerebrovascular accident (CVA), atrial fibrillation, hypertension, and prior superficial bladder cancer presented to the emergency department with acutely worsening hemoptysis, which had been intermittent for the past year. The patient’s initial bladder cancer diagnosis was 20 years prior, with a treated local recurrence approximately 5 years prior. Cystourethroscopy performed within three months of presentation noted no recurrence. Notably, the patient was also taking apixaban in the preceding three months following a CVA. On admission, contrast-enhanced chest CT revealed linear, tubular branching opacities in the right anterior upper lobe consistent with mucous impaction, and progression was noted from imaging within five months. The “finger-in-glove” sign was initially interpreted as a classic diagnosis of mucous impaction. An initial bronchoscopy performed off anticoagulation had no visualized bleeding; therefore, a repeat bronchoscopy was performed one week later after resumption of anticoagulation and continued hemoptysis. Significant blood in the anterior segment of the right upper lobe with evidence of a clot was found, and a distal intraluminal obstructing mass was also noted. Thoracic surgery was consulted, and the obstructing mass was fully excised via bronchoscopy. Histopathology identified a malignant epithelial neoplasm with an indistinct immunophenotype, favoring metastatic urothelial carcinoma. The patient has since received several cycles of pembrolizumab (Keytruda) mono-immunotherapy, and lung nodules previously noted on CT/PET scans have resolved. Discussion Metastatic urothelial carcinoma can rarely present as an endobronchial mass mimicking classic mucous impaction on radiologic findings. In patients with persistent hemoptysis and a history of malignancy, bronchoscopy and tissue sampling is critical for identifying the correct diagnosis. This abstract is funded by: None
Mahally et al. (Fri,) studied this question.