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.