In this letter to editor, we discuss the occurrence of radiological and clinical evidence of bronchiectasis syndrome three years after acute exposure to fire smoke in a Caucasian non-smoker asthmatic patient

Dario Andrisani

Enrico Clini

Fabrizio Luppi

Matteo Tacconi

Simone Rizzato

Stefania Cerri

English

Archivio istituzionale della ricerca - Università di Modena e Reggio Emilia

ARTICLE IN PRESSJID: PULMOE [mSP6P;October 7, 2023;4:31]Pulmonology 000 (xxxx) 13www.journalpulmonology.orgLETTER TO THE EDITORBronchiectasis as long-termcomplication of acute fire smokeinhalation?Dear Editor,Inhalation injury remains one of the most challenging inju-ries for burn care providers. Long-term complications ofsmoke inhalation have rarely been reported in literature andthese may be an unusual cause of bronchiectasis.1 In this let-ter to editor, we discuss the occurrence of radiological andclinical evidence of bronchiectasis syndrome three yearsafter acute exposure to fire smoke in a Caucasian non-smoker asthmatic patient. At the age of 40, he was diag-nosed with mild persistent eosinophilic asthma and nasalpolyposis and started ICS/LABA (inhaled steroids and longacting beta2-agonist receptor) therapy. Nasal polypectomywas performed three years after asthma onset without anyhistologic evidence of vasculitis. Family history for pulmo-nary disease was unremarkable. At the age of 41, in the fol-low-up of previous papillary thyroid cancer, he underwent achest high-resolution computed tomography (HRCT), whichexcluded any pulmonary or bronchial abnormalities. Oneyear later he aided during a house fire where he was exposedto fire burn over 15-minute and he inhaled large amounts ofsmoke without wearing adequate protective equipment. Atthe end of the intervention, he did not complain of physicalinjuries, therefore he didn’t seek referral to any physician.Three years later he presented to pneumological visit forworsening of respiratory symptoms, complaining about pro-ductive cough, worsening of dyspnoea, wheezing and chesttightness. Chest auscultation revealed inspiratory and expi-ratory wheezes. Lung function tests showed a mild restric-tive ventilatory defect and a mild reduction of DLCO(Diffusion Lung CO), that were not present in previous tests.Chest x-ray showed bilateral opacities. On the hypothesis ofasthma exacerbation with pneumonia, the patient wastreated with oral corticosteroids and antibiotic therapy,with improvement of symptoms. For diagnostic purposes herepeated a chest HRCT that showed the presence of bilat-eral, large and saccular bronchiectasis with mucoid impact(Fig. 1). Moreover, it confirmed the presence of left basalpneumonia. To identify the bronchiectasis aetiology, severalhttps://doi.org/10.1016/j.pulmoe.2023.09.0012531-0437/© 2023 Sociedade Portuguesa de Pneumologia. Published by ElsND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).Please cite this article in press as: S. Rizzato, M. Tacconi, D. Aacute fire smoke inhalation?, Pulmonology (2023), https://doi.otests were performed. Blood analysis showed high eosinophilcell count (Eos 1.22 £ 10^3/mmc), normal immunoglobulinlevels (except for total IgE 218 UI/ml), negative autoimmu-nity screening (in particular Anti-nuclear antibody (ANA) andAntineutrophil Cytoplasmic Antibodies (ANCA)). No specificIgE for Aspergillus fumigatus were identified. Sweat test wasalso performed, with a negative result. Bronchoscopy withbroncho-alveolar lavage (BAL) and transbronchial biopsiesshowed non-specific lymphocytic, histiocytic and eosino-philic inflammation, with negative microbiologic findings(including bacterial, mycobacterial and fungal culture, bac-terial and virus PCR assays, and galactomannan on BAL). Sev-eral sputum cultures were also performed, always withnegative results for bacteria, fungi and mycobacteria. Insummary, the extensive diagnostic workup excluded immunedeficiency, rheumatologic diseases (in particular eosino-philic granulomatosis with polyangiitis), cystic fibrosis, aller-gic bronchopulmonary aspergillosis, chronic bacterial ormycobacterial infections. In subsequent years the patientreported several episodes of bronchiectasis exacerbation forwhich he underwent several courses of antibiotic therapy.Radiological follow-up by chest HRCT confirmed the persis-tence of saccular bronchiectasis (Fig. 1), which remainedstable overtime.There are no standardised criteria for inhalation injurydiagnosis, which is usually based on clinical history and find-ings, with the help of instrumental tests (i.e. HRCT, carboxy-haemoglobin measurement and fiberoptic bronchoscopy).2Many of the airway consequences of smoke inhalation resultfrom an inflammatory response and they depend on theduration and the magnitude of the exposure, the presenceof particulate matter and individual host factors. Many prod-ucts of combustion, such as halogen acids, formaldehyde,and unsaturated aldehydes act as respiratory irritants.3Long-term complications have been poorly studied andinclude bronchiectasis, bronchiolitis obliterans, endobron-chial polyposis, tracheal and main bronchial stenosis. Thesecomplications have been mainly described as chronic conse-quences of an acute pulmonary manifestation (i.e. endo-bronchial steam burns, pneumonia and acute respiratorydistress syndrome ARDS).1 It is worth noting that our patientdeveloped clinically significant BE three years after acutesmoke exposure, apparently without acute pulmonary mani-festations. Few cases like the one presented have beendescribed in the literature. Putman et al.4 analysedevier España, S.L.U. This is an open access article under the CC BY-NC-ndrisani et al., Bronchiectasis as long-term complication ofrg/10.1016/j.pulmoe.2023.09.001Fig. 1 Timeline of the patient’s clinical history. HRCT high-resolution computed tomography.Table 1 Bronchiectasis as long-term complication of acute fire smoke inhalation: Pros and Cons.Pros Cons No evidence of pulmonary or bronchial abnormalities onchest HRCT performed before the event. History of exposure to fire burn over 15-minute withoutwearing adequate protective equipment. Exclusion of other causes of BE Pathophysiological basis for the development of anatomi-cal derangement of the airways caused by combustionproducts.3 Similar case in the literature4,5 Absence of clinical evidence of acute pulmonary injurysoon after the event. Late development of clinically significant BE three yearsafter acute smoke exposure. Possible correlation between long-standing asthma andbronchiectasis.Possible interpretation: The presence of eosinophilic asthma may have caused predisposition to the development of bronchiectasis, wheresmoke and irritants inhalation might have acted as a trigger.ARTICLE IN PRESSJID: PULMOE [mSP6P;October 7, 2023;4:31]S. Rizzato, M. Tacconi, D. Andrisani et al.radiographic manifestations in a cohort of 21 patients afteracute smoke inhalation and noted that one patient subse-quentially developed significant chronic lung disease with BEat a 10-months follow-up evaluation. Slutzker et al.5described a patient with progressive dyspnea and chronicproductive cough with multiple exacerbations for 11 yearsafter acute smoke inhalation injury, who was finally diag-nosed with saccular bronchiectasis.In our patient, some important points should beaddressed: first of all, the lack of a medical evaluation soonafter the event; second, the possibility of an interrelation-ship between asthma and bronchiectasis, even in theabsence of ABPA. Indeed, long-standing asthma per se mighthave complicated with bronchiectasis on chest imaging.6,7However, our patient had normal chest HRCT at baseline.2The presence of eosinophilic asthma may have caused pre-disposition to the development of bronchiectasis in whichsmoke and irritants inhalation may have acted as a trigger.Arguments in favour and against our hypothesis are summa-rized in Table 1.In conclusion, we hypothesise a causal correlationbetween acute exposure to fire smoke inhalation and devel-opment of bronchiectasis as a long-term complication, with-out any other apparent cause. However more evidence isneeded to corroborate our hypothesis.Conflicts of interestThe authors have no conflicts of interest to declare.ARTICLE IN PRESSJID: PULMOE [mSP6P;October 7, 2023;4:31]Pulmonology 00 (xxxx) 13References1. Cancio LC. Airway management and smoke inhalation injury inthe burn patient. Clin Plast Surg. 2009;36(4):55567.2. Walker PF, Buehner MF, Wood LA, Boyer NL, Driscoll IR, Lundy JB,et al. Diagnosis and management of inhalation injury: an updatedreview. Crit Care. 2015;19:351.3. Enkhbaata Pr, Pruitt BA, Suman O, Mlcak R, Wolf SE, Sakurai H, et al.Pathophysiology, research challenges, and clinical management ofsmoke inhalation injury. Lancet. 2016;388(10052):143746.4. Putman CE, Loke J, Matthay RA, Ravin CE. Radiographic manifes-tations of acute smoke inhalation. AJR Am J Roentgenol.1977;129(5):86570.5. Slutzker AD, Kinn R, Said SI. Bronchiectasis and progressive respira-tory failure following smoke inhalation. Chest. 1989;95(6):134950.6. Mao B, Yang JW, Lu HW, Xu JF. Asthma and bronchiectasis exacer-bation. Eur Respir J. 2016;47(6):16806.7. Paganin F, Seneterre E, Chanez P, Daures JP, Bruel JM, Michel FB,Bousquet J. Computed tomography of the lungs in asthma:3influence of disease severity and etiology. Am J Respir Crit CareMed. 1996;153:1104.S. Rizzatoa, M. Tacconia, D. Andrisania,b, F. Luppic, E. Clinia,S. Cerria,b,*a Respiratory Disease Unit, AOU di Modena  Policlinico,Modena, Italyb Center for Rare Lung Disease, AOU di Modena Policlinico, Modena, Italyc UOC Pneumologia, Fondazione IRCCS San Gerardo deiTintori, Monza, Italy* Corresponding author.E-mail address: stefania.cerri@unimore.it (S. Cerri).Received 25 June 2023; Accepted 6 September 2023Available online xxx

Bronchiectasis as long-term complication of acute fire smoke inhalation?

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Bronchiectasis as long-term complication of acute fire smoke inhalation?

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