Case Report: We report the case of a 26-year-old woman who was referred to our center in congestive
heart failure (CHF). Acute myocarditis with a high viral load of parvovirus B 19 was
diagnosed by means of myocardial biopsy. Atrial fibrillation/atrial flutter was terminated
by DC cardioversion, CHF improved after the start of ramipril 5 mg/d, metoprolol,
diuretics, immunoglobins, and a 24-hour infusion of levosimendan. Soon after starting
medical therapy, the patient started to expectorate bronchial casts with varying frequency
(three times per week to five times daily). Thorough pneumologic work-up including
histology of the casts, microbiology, and a CT scan of the lungs did not reveal any
cause for bronchial cast formation. Inhalative corticoids were started without any
benefit. Two years later, cardiac catheterization demonstrated normalized left ventricular
(LV) function; however, LV end-diastolic pressure was still elevated at a mean of
14 mm Hg. Endomyocardial biopsies at this time were negative for virus genome. Finally,
we changed afterload reduction therapy from ramipril to candesartan. Within 24 hours,
expectoration of bronchial casts terminated. Four weeks later, re-exposition to ramipril
prompted immediate reappearance of cast formation, which again stopped with switching
back to candesartan.
Conclusion: Bronchial cast formation is a potentially life-threatening complication encountered
in CHD. In our patient, cast formation occurred in the absence of CHD or any other
known cause. To the best of our knowledge, this is the first report of bronchial cast
formation due to ramipril treatment. Our case report may encourage other pediatric
cardiologists involved in care of patients with bronchial casts formation to focus
on ramipril or other ACE-blocking agents as part of their therapeutic regimen, as
cast formation may stop after switch to an alternative treatment.
