Um, I Don't Think That Should be There: Tracheal Bronchus Found Incidentally in a 23-Year-Old Female with Moderate Persistent Asthma.

Document Type

Conference Proceeding

Publication Date

10-2025

Publication Title

CHEST

Abstract

INTRODUCTION: Tracheal bronchus (TB) is a rare anatomic variant where the accessory bronchus originates directly from the trachea [1]. It occurs in approximately 0.1-2% of the world population and is associated with other congenital anomalies [2] [3]. TB is usually found incidentally on Chest X-ray, CT of Chest, and primarily bronchoscopy. Multi-detector CT with 3D imaging is the gold-standard in diagnosing tracheobronchial anomaly [4]. There are 3 types of TB classified by approximation of bronchus to the carina along with the diameter of the distal trachea. The most common symptoms for TB are cough, chest pain, and shortness of breath [5].   CASE PRESENTATION: A 23-year-old G1P0 female at 28 weeks pregnant with history of moderate persistent asthma with exacerbation, nasal polyposis, allergic rhinitis, COVID infection in 2023 presenting to the ED for 3-week history of worsening dyspnea and cough. She presented to urgent care eleven days before arrival and again to the ED three days before arrival for lower respiratory tract infection, receiving antibiotics both visits. Upon presentation, the patient was febrile, tachycardic, and on room air. She was wheezing and had conversational dyspnea. Initial labs were significant for normal white blood count and positive Influenza A infection. Chest X-ray showed a focal pulmonary opacity in the right mid lung. Appropriate treatment was started, however the patient developed acute hypoxic respiratory failure requiring oxygen upon admission. Computed tomography angiogram (CTA) thorax was unremarkable for pulmonary embolism. Imaging notable for tracheal bronchus into the right upper lobe, partial anomalous venous return with prominent right superior pulmonary vein draining into the superior vena cava, a branch of the right superior pulmonary vein abuts the right upper lobe pulmonary artery branch concerning for possible arteriovenous malformation or close approximation of vessels, dilated main pulmonary artery, patchy consolidation and ground glass opacity in right upper lobe, and few opacities in right lower lobe, and mildly dilated heart. Other notable findings during admission included positive MRSA nasal PCR and Mycoplasma pneumonia with negative streptococcus/legionella antigen along with unremarkable MPO, pANCA, and PR3. Prior to discharge, adult congenital heart disease commended further cardiac imaging after pregnancy.   DISCUSSION: Our patient was found to have Type III TB, which is less common than Type II but more common than Type I. Furthermore, she was found to have cardiac anomalies, which is common with patients with TB [2]. It will be interesting to look at her cardiac MRI to investigate other cardiac anomalies. At this time, it is unknown whether the patient's persistent pneumonia was due to complications of TB vs ineffective treatment of outpatient antibiotics as she had not required ED visit or hospital admission for recurrent infection or dyspnea since 2007. Furthermore, it could be possible that her asthma symptoms could be masked by her TB, although she was diagnosed with childhood asthma.   CONCLUSIONS: Tracheal bronchus is a rare respiratory tract anatomical variance usually found incidentally on CT chest and bronchoscopy with high association with other congenital anomalies and increase risk for infection.

Volume

168

Issue

4 Suppl

First Page

A5361

Last Page

A5362

Comments

CHEST Annual Meeting, October 19-22, 2025, Chicago, IL

DOI

10.1016/j.chest.2025.07.3002

ISSN

0012-3692

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