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Allergy and Airway |

Cough and Hemoptysis - The Hidden Culprit in Bronchus

Amrut Sindhu Sanikop, MBBS; Narasimhan Raghupathi, MD
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Apollo Hospitals, Chennai, India


Chest. 2013;144(4_MeetingAbstracts):40A. doi:10.1378/chest.1701020
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Abstract

SESSION TITLE: Bronchology Global Case Reports

SESSION TYPE: Global Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Although foreign body (FB) aspiration is frequently suspected in children with acute or recurrent respiratory symptoms, it is rarely considered in adults with sub-acute or chronic respiratory symptoms, unless a clear history of an aspiration event is obtained. Aspiration of large foreign bodies or food particles can obstruct the trachea to cause immediate asphyxiation and death. However smaller foreign bodies pass distally after aspiration and cause bronchial obstruction. Here we report a case of incidentally detected FB, in an elderly presenting with cough and hemoptysis.

CASE PRESENTATION: A 70 year old non smoker, teetotaller businessman from West Bengal came to the respiratory outpatient with complaints of cough and left side chest pain since 3 months and one episode of moderate hemoptysis 2 month ago. He denied weight loss or any other constitutional symptoms. He was known diabetic and hypertensive on oral medications. Auscultation revealed coarse crackles in left base. Lab investigations were normal except for an elevated ESR of 49 mm/hr. CXR done showed bronchiectatic changes in left lower lobe (LLL). CT chest showed bronchiectasis in LLL, a small area of calcified spot was seen near the division of LLL. On enquiring the patient about history of FB aspiration, he denied any such episodes. Suspecting a FB aspiration, bronchoscopic examination was done which showed a small, long, hard foreign body embedded in the lateral wall of LLL at the entrance, extending upto the opposite bronchial wall. The base was surrounded by granulation tissue and thick purulent secretions were seen distally. An attempt was made to remove FB with a forceps but as it was embedded in the bronchial wall, a small fragment could be removed. On subjecting to histopathological examination it was refractile and crystalline. He was advised for lobectomy as it was embedded in the bronchial wall and there was infected ectasis distal to it.

DISCUSSION: Foreign body aspiration in adults is more common in the setting of advanced age, underlying neurological disorder, poor dentition, alcohol consumption and sedative use where the normal laryngeal reflex which prevents aspiration is impaired. In absence of any of these, children are more prone for aspiration than adults. But our patient did not have any such predisposing factors. The clinical and radiological manifestation of FB aspiration depends on the size of the aspirated material. In our case the chest radiograph did not show any evidence of FB aspiration. Chest radiography of FB aspirations manifests with air trapping, atelectasis, bronchiectasis or pneumonia distal to the obstruction in case of smaller foreign bodies. CXR show a radio opaque FB only in 5 - 15% of the cases. Most common location being right lower lobe (RLL) (28%), 17% in LMB. In our case it was in LLL which is rare.

CONCLUSIONS: This case demonstrates the possible risk of silent aspiration of foreign bodies and in our case presenting as a persistent cough and hemoptysis probably months after aspiration. Bronchoscopic evaluation should be carried out in the differential diagnosis of persistent or recurrent pulmonary symptoms. Time to diagnosis of foreign bodies in adults has been longer when compared to children. Occult foreign body in adults may remain undetected for years, leading to erroneous diagnosis of asthma, bronchitis or pneumonia.

Reference #1: Armstrong P, Hansell D M, Lynch D A, McAdams H P. Imaging of diseases of the chest.4th edition.2005,Elsevier Mosby:474-75.

Reference #2: Rafanan AL, Mehta AC. Adult airway foreign body removal. What's new? . Clin Chest Med. 2001;22(2):319.

Reference #3: Rahulan V, Patel M, Sy E, Menon L. Foreign body aspiration in elderly: an occult cause of chronic pulmonary symptoms and persistent infiltrates. Clin Geriatr 2003;11:41-3.

DISCLOSURE: The following authors have nothing to disclose: Amrut Sindhu Sanikop, Narasimhan Raghupathi

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