What other organ is likely affected in a patient with recurrent chest infections and bronchiectasis?

Pancreas is the Most Likely Affected Organ in Bronchiectasis with Recurrent Chest Infections

In a 27-year-old male with recurrent chest infections and bronchiectasis on chest X-ray, the pancreas is the most likely organ to be affected, strongly suggesting cystic fibrosis as the underlying cause. 1, 2

Rationale for Pancreatic Involvement

Cystic fibrosis (CF) is the most common identifiable cause of bronchiectasis in young adults in the United States and Europe 1. The CF transmembrane conductance regulator (CFTR) protein mutation affects multiple organ systems, particularly:

• Lungs: Causing excessive mucus production, impaired clearance, and bronchiectasis
• Pancreas: Leading to pancreatic insufficiency due to abnormal fluid and electrolyte transport
• GI tract: Affecting digestive function
• Sweat glands: Resulting in elevated sweat chloride

The combination of recurrent chest infections and bronchiectasis in a young adult (27 years) strongly points to CF as the underlying diagnosis 2.

Diagnostic Considerations

The American College of Chest Physicians recommends:

1. Confirming bronchiectasis with HRCT (sensitivity and specificity >90%) 1
2. Testing for CF with sweat chloride test (pilocarpine iontophoresis) 1, 2
3. Considering genetic testing for CF mutations 2
4. Evaluating pancreatic function 2

Why Not Esophagitis?

While esophagitis can be associated with bronchiectasis through aspiration mechanisms, it is not typically a primary affected organ in the most common causes of bronchiectasis in young adults. Gastroesophageal reflux disease (GERD) may contribute to respiratory symptoms but is not characteristically affected by the same pathophysiological process that causes bronchiectasis 1.

Clinical Implications

The identification of pancreatic involvement has significant therapeutic and prognostic implications:

• Necessitates evaluation for pancreatic insufficiency
• May require pancreatic enzyme replacement therapy
• Indicates need for nutritional support and monitoring
• Suggests consideration of CFTR modulator therapies
• Warrants genetic counseling

Common Pitfalls to Avoid

1. Misattribution to acquired causes: In young adults with bronchiectasis, congenital/genetic causes like CF should be prioritized over acquired causes 2

2. Incomplete evaluation: Focusing only on respiratory management without addressing potential pancreatic insufficiency can lead to malnutrition and poor outcomes 3

3. Delayed diagnosis: CF should be considered in any young adult with bronchiectasis, even without obvious GI symptoms 1

4. Missing other CF manifestations: Sinusitis and male infertility are other important manifestations to assess 2

The British Thoracic Society guidelines also recommend investigating for bronchiectasis in patients with persistent production of mucopurulent or purulent sputum, particularly with relevant associated risk factors 1.