It started with a cough. In the fall of 2019, months before a tickle in the throat would send anyone into COVID-19 panic, Susan Bosanko, 59, was unalarmed.
“I initially thought it was probably just allergies. It would come and go. I didn’t want to go to the doctor, because I’d be coughing really bad one day, and the next few days, I’d be fine,” said Bosanko, an insurance claims examiner who lives in Albany, New York.
Then, she started to cough up the “awful things” — soft, rubbery, branch-like structures, which she said resembled “baby umbilical cords.”
Bosanko, a former smoker, was accustomed to bouts of bronchitis. But she had quit the habit five years earlier, so the coughing seemed unusual. She was also dealing with other — seemingly more urgent — health issues, like lumps in her neck and her breast, and so, she decided to try her best to ignore the strange symptoms.
By December, her cough intensified, and she went to the doctor, bringing with her pictures of the foreign objects that had projected from her lungs. She was sent home with oral steroids and a nebulizer.
Finally, in February, a work colleague brought her an oximeter to measure her blood oxygen levels. The reading said 80 percent — the point at which a person’s vital organs are in danger. She called her primary care doctor’s office and told a nurse about her reading over the phone. “That’s impossible,” the nurse said. A few hours later, an ambulance was transporting Bosanko to St. Peter’s Hospital in Albany, where she was intubated and placed on a ventilator.
A Rare Diagnosis and a Sister’s Intuition
When Susan Bosanko, 59, began coughing up rubbery branches, she knew her health was in danger. She later found out that the branches were fluid molds of her own airways — a hallmark of plastic bronchitis.
When Marion Groetch, 57, found out Bosanko was in the hospital, she left her home in Manhattan and arrived in upstate New York that same day. She assumed her sister would receive medication and be able to return home soon after. But the doctor treating Bosanko presented Groetch with an unsettling diagnosis: plastic bronchitis.
As Groetch would later understand, the lymphatic system is a network of tissues and organs that help rid the body of toxins. Its primary function is to transport lymph, a fluid containing infection-fighting white blood cells, throughout the body’s vessels. Most often in children, but sometimes in adult patients, something goes awry, and that lymph fluid leaks from the thoracic duct into the lungs, where it hardens into casts that replicate the shape of the bronchial tree — a hallmark of plastic bronchitis. The “umbilical cords” that Brosanko had been coughing up for months? They were actually fluid molds of her own airways.
No one at St. Peter’s specialized in treating the rare disorder. The medical team’s main goal was to stabilize Bosanko. The untreated plastic bronchitis was causing acute respiratory distress.
“At one point, they had removed 400 mL of fluid from her lungs. I was scared to go into her room. I started thinking, ‘What if this doesn’t work?’”
For two weeks in the Intensive Care Unit, the team worked around the clock to stabilize Bosanko, with bronchoscopies, proning, oxygen therapy, and careful titrating of medications.
That same week, the New York Times happened to publish a “Diagnosis” column, about a 65-year-old man with a relentless cough and shortness of breath. One of Groetch’s neighbors sent her the article.
The columnist, Lisa Sanders, MD, reported that the cause of the man’s symptoms was an abnormal flow of lymph fluid into the lung, where it hardens to form casts that obstruct the exchange of oxygen. Groetch read, with interest and hope, about a team of interventional radiologists at Penn Medicine who had developed a way to visualize and repair the abnormal lymphatic flow.
Groetch and Bosanko's extended family and friends, searched on PubMed for studies authored by the doctor who had saved the man’s life: Maxim Itkin, MD, a professor of Radiology at the Perelman School of Medicine. They quickly came to realize that Itkin is one of the top doctors in the world specializing in the treatment of lymphatic disorders.
Immediately, Groetch called Penn and connected with Itkin’s assistant.
“Can you have your sister’s doctor call him in the next 10 minutes?” the assistant asked her.
Bosanko’s doctor was not working that day, but she happened to be stopping by the hospital for a visit when Groetch called St. Peter’s. The doctor spoke with Itkin, and consulted with Groetch and Bosanko’s boyfriend, Matt Magin. The group decided that it would be in Bosanko’s best interest for Itkin to treat her himself.
Soon after, Bosanko arrived by helicopter at the Hospital of the University of Pennsylvania.
Finding the Leak
Penn Medicine interventional radiologist Maxim Itkin treated Bosanko with a special glue, which closed the thoracic duct and blocked the flow of lymphatic fluid that was leaking into her lungs.
For Itkin, repairing a leaky lung is as unremarkable as a plumber fixing a faucet.
“I’ve done this procedure 1,000 times,” said the interventional radiologist.
But if not for a discovery that Itkin himself helped to make nearly a decade ago, plastic bronchitis could still be a death sentence.
As far as researchers know, an abnormal lymphatic system is a condition that people are born with, and it often does not cause major medical problems. Doctors see it most commonly in children who have undergone a Fontan operation for congenital heart disease. But for adults like Bosanko, symptoms can appear out of the blue much later in life. For others, like the patient featured in the New York Times column, the coughing can go undiagnosed for years.
“It’s like a faucet that opens up, and it starts to leak,” he said. “Eventually the lymph leaks into the bronchial tree, and it gets harder and harder, until that fluid turns into casts — like an egg white that’s become dry.”
Itkin became interested in the lymphatic system while a medical resident in Israel, after he read a paper by Constantin “Stan” Cope, MD. Itkin eventually ended up as a fellow at HUP, where Cope serendipitously was on faculty.
Cope became Itkin’s mentor, and then Itkin and colleagues later went on to make even greater improvements in lymphatic imaging, making treating cases like Bosanko’s a breeze.
A Life-Saving Procedure
Bosanko is now recovering with family and friends in New York.
Bosanko does not remember being airlifted the 250 miles from Albany to Philadelphia.
When she arrived at HUP, she was too sick for an MRI, so Itkin began right away with the two-hour procedure to fix her lungs — called a thoracic duct embolization. During the minimally invasive procedure, Itkin first inserted a catheter into Bosanko’s thoracic duct and injected X-ray dye in order to identify the leak. To further confirm the leakage, Anthony R. Lanfranco, MD, an assistant professor of Pulmonary Medicine, performed a technique called “blue bronchoscopy,” in which a special blue dye is injected into the patient while a pulmonologist looks at the airways through a thin, lighted tube, called a bronchoscope. Then, using a special glue, Itkin was able to close the thoracic duct and block the flow of lymphatic fluid that was leaking into her lungs.
“She’s fine. I fixed it,” Itkin said to Bosanko’s family as he entered the waiting room where they were pacing anxiously. Groetch hugged the doctor. Bosanko’s boyfriend burst into tears.
Bosanko stayed in the hospital for two more weeks. In the months since the procedure, she has experienced some uphill battles, but her breathing is back to normal. She returned to her office job in May.
After her sister’s recovery, Groetch wrote to Sanders at the New York Times, thanking the writer-physician, Itkin, and Bosanko’s medical team in New York.
“I think about what they are all going through now during this global pandemic, how hard they work to ensure the best outcome for every patient, and how painful it must be for them to be fighting for so many patients who are just not recovering,” her email read. “Because I witnessed how much they really care. I want them to know, and I want you and Dr. Itkin to know, that there is one 59-year-old woman who is alive today because of you.”