Weather 
Where there’s fire … there’s smoke.
An 87-year-old man went to the emergency room for shortness of breath after inhaling thick smoke from a forest fire over several hours.
What came next was something out of a sci-fi movie: thick, black, branch-like plugs were observed in the unidentified patient’s windpipe and lungs.
His case was detailed last week in the New England Journal of Medicine. The man was put on a ventilator as doctors evaluated his airways because he was only able to take in short, shallow breaths and had dangerously low blood oxygen levels.
The doctors diagnosed the plugs as bronchial casts, a symptom of a rare and severe condition called plastic bronchitis.
The casts tend to appear in the trachea and bronchial tree, or air passages of the lungs, which resemble tree branches.
Composed of mucus and cellular material, they take on a rubbery or caulk-like texture and are typically white, tan or beige in appearance.
This respiratory condition is often connected to congenital heart disease in children or lymphatic flow disorders.
The plugs form when the flow of fluid through the lymphatic system is irregular, as this colorless fluid carries white blood cells and proteins to the veins, eventually returning to the bloodstream for necessary immune function.
The lymphatic system typically soaks up excess fluid from organs and returns it to the bloodstream.
If lymph fluid isn’t flowing properly, it can leak into airways, causing shortness of breath, difficulty breathing, chest pain, fever and a long-term wet or dry cough.
Early symptoms can resemble asthma, often leading to an incorrect diagnosis. Complications can result in severe respiratory distress and even death.
A bronchoscopy (a procedure where a camera-tipped tube is inserted to view the airways), chest CT scans or MRI lymphatic imaging are used to detect the casts, which are then loosened and removed.
To confirm the location of leaks, doctors may use “blue bronchoscopy,” where a special blue dye is injected into the thoracic duct (the body’s largest lymphatic vessel).
Further treatments depend on the underlying cause of the condition, whether it’s lymphatic leaks that need to be repaired or more specialized interventions if the patient is dealing with a heart condition.
The general outlook for plastic bronchitis is good if it’s caught and treated early.
The 87-year-old patient was discharged after a week battling pneumonia, and his breathing returned to normal by the two-week follow-up.
