Airway obstruction from proximal tracheobronchial lesions is well-described, but for a projectile to obstruct a main bronchus is almost unheard of.
A 30-year-old man presented to the pulmonary clinic with dyspnea on exertion, stridor, and intermittent wheezing. He had a past history of gunshot wound to the chest ten months prior associated with tracheostomy and mechanical ventilation. He had cough intermittently productive of purulent sputum without systemic symptoms.Physical examination revealed a tracheal scar, inspiratory stridor, and expiratory wheezing heard mostly over the anterior chest. Spirometry with lung volumes revealed mixed restrictive and obstructive physiology, with FEV1 35% predicted and TLC 69% of predicted. The FEV1 increased 35% after bronchodilators. Chest x-ray (Graphic 1) demonstrated a mediastinal bullet.The clinical diagnosis was asthma and unexplained restriction. He underwent flexible fiberoptic bronchoscopy to rule out tracheal stenosis. Bronchoscopy revealed a bullet causing 95% obstruction of the left mainstem bronchus (Graphic 2). Follow-up CT scan revealed left mainstem location of the bullet with left volume loss and hypoperfusion on the left. The patient was referred to surgery for sleeve resection.DISCUSSION: Broncholiths are now rare. Aspiration of foreign bodies is relatively common, but to our knowledge this is the first reported case of a foreign body traversing the thorax to lodge in the bronchial tree. In this case, near-complete left bronchial obstruction appears to have caused hypoventilation of the left lung, hypoperfusion, and volume loss on that side. This resulted in restrictive physiology. The most plausible explanation for the bronchodilator response is concomitant asthma.
The implausible can occur. This is an unusual and interesting case of proximal airway obstruction and its possible physiologic profile.
Z.C. Boujaoude, None.