Expectoration of Bronchial Casts Caused by Ramipril Treatment

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.