A 20-year-old female Ethiopian refugee presented with a 6-month
history of cough and progressive left shoulder tip pain. After
extensive investigation, which failed to demonstrate a cause, she
proceeded to thoracotomy, where a 25-cm length of tubing was found that
had perforated the left hemidiaphragm and had extended into the apex of
the left lung. This appeared to have arisen as a complication of a
termination of pregnancy performed years previously. This represents
the first reported case of significant pulmonary trauma arising as a
complication of a termination of pregnancy.
Termination of pregnancy (TOP) is the
most widely performed surgical procedure in the world, with an annual
incidence of up to 53 million.1 While complications are
infrequent, sepsis, hemorrhage, and uterine perforation with trauma to
adjacent organs have been reported.
In this report, we describe an Ethiopian refugee who presented with
progressive cavitatory lung disease. After extensive investigation and
treatment, at thoracotomy she was found to have a 25-cm length of
obstetric tubing perforating the diaphragm and extending into the left
upper lobe (LUL). This appeared to have arisen as a complication of a
TOP performed years previously in Ethiopia.
We believe there are two unique features of this report. To our
knowledge, this is the only recorded description of pulmonary trauma
arising from a TOP, and it is the first reported case of the migration
of a foreign body from the abdomen or pelvis to the lung that has not
occurred via the blood stream.
A 20-year-old female Ethiopian refugee presented with a 6-month
history of left shoulder pain, productive cough, and minor hemoptysis.
Prior to emigration, screening undertaken in Khartoum, Sudan,
demonstrated no evidence of active tuberculosis. The initial chest
radiograph demonstrated a left basal infiltrate with associated pleural
change (Fig 1
In Australia, ongoing symptoms necessitated further evaluation. CT scan
of the thorax showed additional changes of cavitation and consolidation
in the LUL (Fig 2
). No endobronchial
abnormality was evident at fiberoptic bronchoscopy, and bronchial
washings were negative for tuberculosis. CT-guided biopsy showed
changes of fibrosis. Given a high clinical and radiologic suspicion of
tuberculosis, empiric quadruple antituberculosis therapy with
isoniazid, rifampicin, ethambutol, and pyrazinamide was commenced. Due
to ongoing symptoms and progressive LUL cavitation, she proceeded to
thoracotomy. A 25-cm stiff plastic tube was found to perforate the left
hemidiaphragm and to extend into the apex of the LUL. Approximately 10
cm of tubing was situated below the diaphragm. A curative LUL lobectomy
We describe a unique case of an intraparenchymal pulmonary foreign
body causing prolonged symptoms and progressive cavitatory lung
The foreign body was a stiff smooth plastic tube, 25 cm in length and 4
mm in diameter, that extended below the left hemidiaphragm and up into
the LUL (Fig 3
). A retrospective review
showed that it had been present on all her previous radiographs,
including those taken in Sudan. The patient was questioned after the
surgery to try and ascertain its origin.
In Africa, she had spent years as a refugee and had been a prisoner of
war. In Ethiopia, when she was 13 years old, a TOP was performed. A
second pregnancy several years later was carried to full term. No
history of any other surgical procedures or trauma could be elicited
that may have explained the origins of the tube.
The length and stiffness of the tube and the normal bronchoscopy would
exclude a transtracheal route. There was no history to suggest
introduction through the thoracic or abdominal wall. The only apparent
explanation is that the tube had been introduced via the uterus at time
of undergoing an obstetric procedure.
The consensus opinion of a number of senior gynecologists surveyed was
that the TOP had been performed using either a minisuction technique or
the installation of irritant intrauterine fluid. It is postulated that
the tube had perforated the uterus and inadvertently been left in
Uterine perforation is an uncommon complication of TOP. In a study of
US national data from 67,175 abortions, the rate of perforation was 9
in 10,000 cases.2However, a review of 144 cases in
Nigeria showed a much higher incidence of perforation.3–
Damage to pelvic and abdominal organs, especially bladder and bowel, is
well recognized in this context.4 There is no description
of pulmonary trauma in the literature.
Migration of foreign bodies from the abdomen or pelvis to the lung is a
rare but well-described entity. There have been descriptions of
bullets, diagnostic catheters, and venous shunts in this
context,5–7 although they all appear to have migrated
hematogenously. Sharp foreign bodies have been previously described
migrating through tissue planes. Examples include small bones that have
perforated through the esophagus and been located in the muscles of the
neck,8and Kirschner wires, used in orthopedic procedures
to stabilize the clavicle, have been found in the
mediastinum.9 The mechanism of how this occurs has not
How the tube ended up in the lung is a matter of speculation. Taking
into account its length and the small size of the patient, it would
appear likely that when the termination was performed, the superior end
of the tube was lodged near the diaphragm. It may have then migrated
upwards spontaneously or been pushed cephalad by the subsequent
Abbreviations: LUL = left upper lobe;
TOP = termination of pregnancy
We thank the Department of Obstetrics & Gynaecology
at Monash Medical Center for their advice.
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