Foreign body aspiration (FBA) in adults is uncommon but may present as a diagnostic dilemma. The clinical picture may vary from chronic nonspecific symptoms mimicking other lung diseases to severe obstructive pneumonitis. We present a case series of FBA occurring in three adults who shared similar symptomatology and risk factors but were mistakenly treated for chronic bronchitis.
Case #1: A 47-year-old man with a 40-pack-year smoking history presented with a long history of multiple hospitalizations for dyspnea, halitosis, productive cough, and wheezing. Ten months earlier, he had undergone a right inguinal hernia repair performed under general anesthesia, associated with a difficult intubation. Postoperatively, the respiratory symptoms persisted despite inhaled bronchodilators, broad-spectrum antibiotics, corticosteroids, and smoking cessation. Multiple chest radiographs were normal. On the current hospitalization, chest CT revealed an intraluminal linear density involving the trachea and right mainstem bronchus (RMB). Fiberoptic bronchoscopy (FOB) retrieved a 4.1 x 2.0 x 0.1 cm piece of wooden tongue depressor. The patient’s symptoms subsequently resolved. Case #2: A 42-year-old man with a 45-pack-year smoking history and several years of alcohol use was evaluated at his physician’s office for a 4-month history of cough and wheezing. He was treated with inhaled bronchodilators, oral antibiotics, and advised to stop smoking and drinking alcohol; however, his symptoms worsened. A chest radiograph revealed a coin shadow in the RMB. FOB retrieved a penny from the RMB following which his symptoms subsequently resolved. Case #3: A 57-year-old man with a 100-pack-year smoking history and major depression (well controlled with medication) presented with a one-year history of dyspnea, cough, wheezing, dysphonia, and a choking sensation. Chest radiograph demonstrated infiltrates in the right middle and lower lobes. FOB retrieved a gauze-like object from the right bronchus intermedius; pathologic exam confirmed the object to be vegetable matter.
Although rare, tracheobronchial FBA in adults can occur in various clinical settings. The most common presenting feature is a history of aspiration. When this history is absent, diagnosis is sometimes delayed by hours or even years. Food products such as vegetable matter, meat, and bones are the most common aspirated foreign bodies in adults. Up to 80% of patients have normal radiographs. In our 3 patients, the major risk factor was an altered mental state which precluded any recall of aspiration. In case #1, the aspiration occurred most likely during the difficult intubation when a tongue depressor (used for better visualization of the airways) may have broken into pieces. The second patient was involved in the so-called “drinking quarters” game in the weeks preceding the initial symptoms. In this game, patrons at the bar drink glasses of alcoholic beverages when coins bouncing on the bar table fall directly into their drinking glasses. It is customary for the patrons to spit the coin out of their mouths, but inebriety may have predisposed our second patient to aspiration. Finally, despite good compliance to the antidepressants, aspiration may have occurred in the third patient at an earlier period when the depression may not have been well-controlled. All three patients presented with dyspnea, wheezing, cough, and right-sided FBA. Because of the smoking history, all were mistakenly diagnosed with bronchitis. The first two cases were diagnosed by chest imaging and the third by FOB. All 3 foreign bodies were retrieved by FOB. Symptomatic improvement was reported by all patients after extraction of the foreign bodies.
In adult smokers, FBA can easily be mistaken for chronic bronchitis, causing unnecessary delay in diagnosis and initiation of therapy.
Mohamed Bakry, None.