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CASE REPORT
Year : 2021 | Volume
: 70
| Issue : 1 | Page : 150-153
Foreign body aspiration imitating a difficult-to-treat asthma
Mohamed Awad Tag El-Din, Hesham A Abdel Halim
Department of Pulmonary Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
Correspondence Address:
MD Hesham A Abdel Halim
Department of Pulmonary Medicine, Ain Shams University, Cairo, 28C, Opera City Compound, Sheikh Zayed, PO Box 12563, Giza, 12563
Egypt
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ejcdt.ejcdt_155_19
Tracheobronchial foreign body (FB) aspiration is an infrequent but possibly fatal event in adults. Symptoms typically consist of a choking incident followed by cough and dyspnea; however, these findings are conflicting, and symptoms may mimic other chronic pulmonary diseases such as asthma or chronic obstructive pulmonary disease. Chest radiography and computed tomography can offer information with regard to the site and features of the FB and support the diagnosis. Bronchoscopy remains the gold standard for diagnosis and management of FB aspiration. A 38-year-old woman with persistent cough of 4 months’ duration, received several lines of treatment for bronchial asthma. She presented with refractory cough and chest tightness, and high-resolution computed tomography chest showed a small calcified lesion in the bronchus intermedius. Fiberoptic bronchoscopy revealed a chicken bone in the bronchus intermedius which was removed, followed by a complete recovery of symptoms and discontinuation of all asthma treatment.
Keywords: bronchoscopy, chest radiography, difficult asthma, foreign body aspiration
A difficult-to-treat asthma is a challenging health problem for which a meticulous workup is necessary to exclude any other possible differential diagnosis other than asthma. One of these differential diagnoses is a foreign body (FB) aspiration [1].
FB aspiration is an uncommon incident in adults. The symptoms and signs are conflicting and may mimic other chronic pulmonary diseases such as asthma or chronic obstructive pulmonary disease [2].
In this report, we present the case of a woman with unnoticed FB aspiration for 4 months managed as difficult asthma with no response to asthma treatment.
Case reportA 38-year-old woman, living in Cairo, working as a clerk, and having no special habits of medical importance, presented as an outpatient with persistent cough for 4 months. The cough had started 4 months ago with a gradual onset and a progressive course, increasing at night, and associated with expectoration of small amount of whitish, sometimes greenish sputum. She had sought medical advice several times and repeatedly received treatment for bronchial asthma in the form of different types of inhalers (ICS±LABA) and mucolytics, antihistaminics, and antileukotrienes with no improvement of cough.
She was admitted to the hospital for further investigations. All laboratory results were normal, including CBC, ESR, CRP, total IgE, liver, kidney, and coagulation profiles.
ECG was normal, and plain chest radiography (posteroanterior view) was unremarkable.
High-resolution computed tomography chest revealed normal parenchyma, no hilar or mediastinal lymph nodes, no pleural effusion or thickening, normal heart, and mediastinal structures. Only a right bronchus intermedius endobronchial calcified lesion was noticed ([Figure 1]).
Figure 1 (a) An axial cut section of chest computed tomography revealing a calcified radiopaque lesion within the right bronchus intermedius. (b) A coronal cut section of chest computed tomography revealing the same finding.The patient was prepared for fiberoptic bronchoscopy (FOB).
The patient had normal blood pressure, pulse, temperature, and respiratory rate. Oxygen saturation on room air was 98%.
FOB was carried out through an endotracheal tube under general anesthesia and revealed a foreign object (mostly a chicken bone) that was impacted in the bronchus intermedius ([Figure 2]).
Figure 2 A fiberoptic bronchoscopy photo of the foreign body impacted in the bronchus intermedius.The bone was extracted using grasping forceps (CGF-1-240 Caesar Grasping Forceps G25080 Wilson-Cook Medical Inc., Cook, Ireland) ([Figure 3]).
Figure 3 The foreign body (a chicken bone) after retrieval by FOB. FOB, fiberoptic bronchoscopy.After the FB extraction, an inspection of the airways revealed hypertrophied, reddish parts of the mucosa over the wall and the spur between the bronchus intermedius and the upper lobe bronchus ([Figure 4]). Multiple biopsies were taken from these abnormal sites and sent for histopathology.
Figure 4 The airways after removal of the FB showing hypertrophied, inflamed mucosa. FB, foreign body.The patient was free of symptoms starting on the same day after the procedure.
The patient was discharged the next day of the procedure on a home treatment in the form of prednisolone 20 mg daily for 1 week.
On follow-up after 1 week, the patient attended the outpatient department with complete recovery of symptoms.
Histopathology examination shows inflammatory granulation tissue and no abnormal cells.
DiscussionWhen confronted with a patient with asthma that seems to be difficult to control, it is important to consider the reasons that may contribute to a poor response. It is important to verify whether the patient is compliant with therapy. It is also important to check the correct medication technique and to avoid different allergens. All potential worsening factors such as upper airway diseases, gastroesophageal reflux, and drugs such as NSAIDs, Beta-blockers, and angiotensin-converting enzyme inhibitors should be recognized and discontinued. Sometimes, poor response to asthma treatment is due to the wrong diagnosis [3],[4].
One of the possible alternative diagnoses is an FB aspiration. FB aspiration refers to the inhalation of solid and liquid material into the airways. The FB may be embedded into the main bronchi and its branches and may reach the lung. As it is a rare incidence in adults, aspiration of an FB is frequently overlooked [5],[6],[7]. The most common aspirated FBs are typically food particles and broken parts of teeth [8]. Diagnosis of aspiration of FB may be difficult due to the absence of a history of aspiration [9].
Initial presentations of aspiration include choking sensations with an intermittent dry cough. Although choking may raise early suspicion of aspiration, it may not always be apparent with all patients. Inspiratory and expiratory wheezing, dyspnea, and hemoptysis may also be observed in these patients [8]. Chronic complications occur mainly because of the lag in the proper diagnosis of FB aspiration, resulting in improper management. In several occasions, the aspirated FB is unrecognized. Many cases with tracheobronchial aspiration are misdiagnosed as asthma or bronchiolitis and emphysema or atelectasis. Complications include recurrent pneumonia, hemoptysis, bronchiectasis, bronchial strictures, and development of inflammatory polyps at the site of impaction [5],[10].Lodgment of an FB is more common on the right side. The chest radiograph is useful in detecting FB impaction in 70% of patients. As most FBs are not radio-opaque, one must rely on indirect findings suggestive of the presence of a FB, such as mediastinal shift, atelectasis, and hyperinflation [3].
A forgotten episode of an FB aspiration may remain undetected for months or years, as in the case of our female patient who had a chicken bone aspirated 4 months ago and who denied any history of aspiration or choking event. The patient was treated as a case of difficult-to-treat asthma all the while until a high-resolution computed tomography chest was performed seeking for an alternative diagnosis, and, fortunately, a suspected endobronchial small radiopaque shadow was detected in only two axial and coronal cuts, raising the possibility of a calcified endobronchial lesion or an FB. Finally, an FB was directly visualized and successfully retrieved by grasping forceps through an FOB. Short-course oral steroid was given to the patient after the procedure for proper healing of the hypertrophied granulation tissue in the site of the long-standing FB impaction to prevent possible further fibrosis and stenosis.
ConclusionA difficult-to-manage asthma is challenging, and meticulous workup for the exclusion of other possible alternative diagnoses must be carried out. An FB aspiration, although very rare in healthy adults, may be a hidden problem, and its proper diagnosis and management may reduce the incidence of costly and unnecessary complications.
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Conflicts of interest
There are no conflicts of interest.
References
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