INVESTIGATIONS AND TREATMENT
Figure 1 demonstrates the pre-dilatation subglottic view of the patient.
The patient underwent balloon dilatation, CO2 excision, Kenalog
injection, and mitomycin administration in January 2017. Figure 2
demonstrates the immediate post-dilatation subglottic view. These
interventions led to a 70% improvement in breathing.
She underwent similar treatment a year later, in July 2018, followed by
October 2019.
In December 2020, she presented with swelling, pain, and morning
stiffness around the bilateral 2nd-4th MCPs. Considering the son’s
suspected peripheral spondyloarthropathy and inflammatory bowel disease,
the underlying autoimmune processes were questionable, and she was
referred to the rheumatology clinic for further workup. The patient
tested negative for ANCA and MGUS. There had no history of saddle nose,
asthma, or inflammatory bowel disease.
On workup, she tested positive for ANA Hep 2, and a PET scan showed
diffuse uptake (including dens), including the shoulders, knees, and 1st
MTP supportive of spondyloarthropathy. She had been receiving 15 mg of
methotrexate (MTX) since September 2021, hoping it would alter the
course of her subglottic stenosis, but this did not help. Despite
starting MTX therapy in September 2021, she required dilatation in the
early summer of 2022. Leflunomide was added in July 2022.
As of January 2023, the last dilation was performed ten months ago. She
intermittently experienced dyspnea. In addition, no joint pain was
observed. Upon reviewing her laboratory results, we noticed a gradual
decrease in white blood cell count (WBC count=3100
/mm3) after starting leflunomide 20 mg in July 2022.
In May 2023, it was discontinued owing to increased leukopenia.
Furthermore, we escalated therapy with TNF alpha inhibitors and
initiated cimzia therapy.
She had undergone six dilatations and steroid injections.
Her last dilation procedure was performed in February 2022. However, the
patient noted that her overall dyspnea improved significantly.