Cavitary Lung Abscess Secondary to a Tracheal Bronchus: A Pediatric Patient With Noonan Syndrome

A 13-year-old male with a past medical history of Noonan syndrome, pulmonary valve stenosis status post balloon valvuloplasty and subsequent surgical valvotomy with main pulmonary artery augmentation, splenomegaly, and von Willebrand disease type 1 presents with chest pain, fever, and chronic, recurrent vomiting. At the outlying facility, computed tomography of the chest revealed a right upper lobe pulmonary cavitation. After an extensive workup, he was found to have a right-sided tracheal bronchus via bronchoscopy. Broad-range polymerase chain reaction analysis of the biopsied specimen demonstrated polymicrobial organisms consistent with an organized pneumonia identified upon pathological review. He was treated with six weeks of antibiotic therapy and made a full recovery. The development of his pulmonary cavitation was attributed to his anatomic abnormality of the tracheal-bronchial tree as well as chronic vomiting with aspiration, thought to be secondary to his significant splenomegaly (18.8 x 13.8 x 6.4 cm). The presence of a tracheal bronchus is rare in the pediatric population, and patients often remain asymptomatic. However, co-existing tracheobronchial anomalies are often found in patients with underlying congenital heart disease (CHD). Therefore, in patients with CHD and new-onset atypical pulmonary pathology, a multidisciplinary approach should commence to evaluate for possible tracheobronchial abnormalities. If identified, prompt recognition, treatment, and prevention measures should be used to prevent future pathology.