An Autopsy Case of Idiopathic Pleuroparenchymal Fibroelastosis with Left Vocal Cord Paralysis and a Rapid Deterioration without an Acute Exacerbation

A middle-aged man with dyspnea and hoarseness: an unusual case of vocal cord paralysis

BACKGROUND

Pleuroparenchymal fibroelastosis (PPFE) is a rare and distinct form of Interstitial lung disease predominantly affecting the upper lung zones. It is characterized by fibrotic thickening of the visceral pleura and adjacent subpleural parenchyma. While common complications include spontaneous pneumothorax and pneumomediastinum, vocal cord paralysis (VCP) or paresis has been increasingly recognized as a potential manifestation in recent reports.

CASE PRESENTATION

We present a 49-year-old man presenting with progressive dyspnea, hoarseness, and left-sided vocal cord paralysis. Imaging studies revealed upper lobe-dominant fibrotic changes associated with significant pleural thickening consistent with PPFE. A comprehensive evaluation ruled out secondary causes of PPFE and other potential etiologies of VCP. Despite supportive management, the patient's VCP persisted, likely due to architectural distortion of the lung affecting the recurrent laryngeal nerve pathway.

CONCLUSIONS

This case adds to the limited but growing body of literature on the association between PPFE and VCP. Understanding this rare complication is crucial for early recognition and appropriate management, as it highlights the diverse clinical manifestations of PPFE and its impact on patient outcomes.

Vocal cord paralysis associated with pleuroparenchymal fibroelastosis: A case report and literature review

Here, we report a case of idiopathic pleuroparenchymal fibroelastosis (PPFE) that progressed to pulmonary aspergilloma, aspiration pneumonia, and left vocal cord paralysis (VCP). To date, five cases of PPFE with VCP have been reported, including the present case. Aspiration pneumonia occurred in three cases, leading to death in two cases. Four cases had left-sided paralysis, in two of which, the paralysis occurred on side opposite to the predominant side (right side) of PPFE. Structural mechanisms underlying the recurrent laryngeal nerve could be involved. This report may further highlight the existence of hoarseness and dysphagia in PPFE.

Right-sided vocal cord paralysis following stereotactic body radiation therapy for non-small-cell lung cancer: A case report

Vocal code paralysis (VCP) is a rare complication of stereotactic body radiation therapy (SBRT). In most previously reported cases of VCP after SBRT, VCP was left-sided because of anatomic vulnerability. Here, we report a case of right-sided VCP following SBRT for non-small-cell lung cancer. The patient was an 81-year-old man who underwent SBRT for synchronous lung cancer of the right upper and inferior lobes. He subsequently developed radiation pneumonitis and received corticosteroids. Lung contraction persisted, and the mediastinum shifted to the right because of lung volume reduction. After corticosteroids discontinuation, the patient developed hoarseness and voice weakness. An endoscopic test showed right-sided VCP. Imaging examinations did not reveal new lesions, including lung cancer recurrence. Therefore, we diagnosed the patient with SBRT-associated VCP and speculated that the injury to the right vagal nerve and recurrent laryngeal nerve resulted from mechanical traction due to intense lung contraction, which might have induced VCP. We should be alert to VCP following SBRT, even if the target lesions are right-sided.

The pathogenesis and pathology of idiopathic pleuroparenchymal fibroelastosis

Idiopathic pleuroparenchymal fibroelastosis (IPPFE) is a rare subtype of idiopathic interstitial pneumonias that consists of elastofibrosis involving the lung parenchyma and pleural collagenous fibrosis predominantly located in the upper lobes. IPPFE has various distinct clinical and physiological characteristics, including platythorax and a marked decrease of forced vital capacity with an increased residual volume on a respiratory function test. The concept of IPPFE is now widely recognized and some diagnostic criteria have been proposed. In addition, the accumulation of cases has revealed the pathological features of IPPFE. However, little is known about the pathogenesis or the process of disease formation in IPPFE. This review article will provide a summary of the pathological features and previously reported hypotheses on disease formation in IPPFE, to discuss the potential etiologies and pathogenesis of IPPFE.