A Case of Pediatric Tracheal Stenosis Secondary to Chronic Retching in the Setting of Bulimia Nervosa

dc.creatorPatel, Arpanen_US
dc.creatorJoshi, Eeshanen_US
dc.creatorSrikalyani, Sathviken_US
dc.creatorLal, Kevinen_US
dc.creatorSaadeh, Charlesen_US
dc.creator.orcid0009-0007-1873-380X (Patel, Arpan)
dc.creator.orcid0009-0009-2669-0373 (Joshi, Eeshan)
dc.creator.orcid0009-0007-3205-1143 (Srikalyani, Sathvik)
dc.creator.orcid0000-0001-6424-0642 (Lal, Kevin)
dc.descriptionResearch Appreciation Day Award Winner - Texas College of Osteopathic Medicine, 2024 Pediatric Case Study Awarden_US
dc.description.abstractBackground: Tracheal stenosis is an important life threatening pathology in the pediatric population. The prompt diagnosis and management of tracheal stenosis is crucial to prevent complications of airway obstruction. Common etiologies include congenital anomalies, traumatic injury, complications of infection, and autoimmune disorders. Diagnosis is made with a combination of cross sectional imaging and rigid bronchoscopy. Endoscopic assessment and intervention will generally relieve acquired tracheal stenosis, with more severe cases requiring open surgical approaches. Historically, pediatric tracheal stenosis has had a poor prognosis; however, notable advances in endoscopic and open surgical treatments have led to a decline in morbidity and mortality. Case Information: A 14 year old female presented to the Emergency Department at Cook Children’s Medical Center with biphasic stridor and evidence of airway obstruction. The patient had never been tracheally intubated, and had no other significant medical history except for one year of frequent retching in the setting of bulimia nervosa. Symptoms were gradual in onset over the course of several weeks, with an initial working diagnosis of asthma with no improvement with inhaled steroids. A CT scan was obtained that revealed severe tracheal stenosis involving the cervical trachea. Initial lab work revealed an elevated WBC of 16.7, Potassium of 2.8mmol/L, Normal c-reactive protein, erythrocyte sedimentation rate, and procalcitonin. Her initial assessment was concerning for impending airway obstruction and she was taken to the operating room for emergent rigid bronchoscopy. She was found to have an irregular circumferential scar extending for 1.5cm, starting 2cm distal to the glottis involving the second through fourth tracheal rings. The initial stenosis was grade three with pinpoint 2-3mm patency. The scar was biopsied, and the stenosis easily dilated to normal caliber. Circumferential submucosal Kenalog was applied and the patient ultimately did very well clinically and was discharged on postoperative day 1 in stable condition. Her workup included anti-neutrophil cytoplastic antibodies, myeloperoxidase antibodies, serine proteinase 3 antibodies which were all normal. Her pathology revealed chronic tracheitis without evidence of bacterial tracheitis or vasculitis. Intraoperative cultures were unremarkable. She was taken back to the operating room six weeks later with findings of a normal lumen trachea with no evidence of restenosis or granulation. Of note, she had refrained from further retching since her initial presentation. At the time of this report, the patient was doing well with no concern for recurrent stenosis and compliant with avoidance of retching. Conclusions: This case emphasizes the diverse etiologies of tracheal stenosis and, specifically, the potential development of acquired tracheal stenosis related to self-induced retching in patients with eating disorders. Furthermore, this case underscores the need to consider the systemic effects of mental health disorders in pediatric patients, and helps add to our fund of knowledge regarding aerodigestive complications of bulimia nervosa.en_US
dc.titleA Case of Pediatric Tracheal Stenosis Secondary to Chronic Retching in the Setting of Bulimia Nervosaen_US