A two-year old Caucasian male with a chief complaint of cough and fever. He has had fevers up to 38.5 degrees and “wet” coughs intermittently for the past two months. He has also had episodes of emesis and decreased activity.
His initial diagnosis had been “bronchitis,” which was empirically treated with an oral cephalosporin. His symptoms improved somewhat, but later recurred. At that time, a chest radiograph (CXR) revealed a right lower lobe infiltrate, and he was then treated with erythromycin/sulfamethoxazole.
Again, his symptoms initially improved but recurred within two days. After being ill for one month, he was hospitalized for recurrent and persistent pneumonia with a suspected foreign body in the right mainstem bronchus on CXR.
In retrospect, his mother recalls the child choking on almonds prior to the initial onset of symptoms. A bronchoscopy was performed which resulted in removal of granulation tissue, after which he was treated with cephalosporins for seven days with improvement.
One week later, he again developed mild respiratory symptoms and was started empirically on a different cephalosporin, but his symptoms actually worsened over the next day.
Tuberculin skin testing and sweat chloride tests were negative. Neonatal and developmental histories are unremarkable.
T39.4 (oral), P164, R36, BP 127/96, oxygen saturation 98% in room air.
He is awake, alert, consolable, and in no acute distress. HEENT and neck exams are normal. Heart regular without murmurs. Lung exam reveals diffuse coarse rhonchi and slightly diminished breath sounds in the right base, but otherwise no retractions, wheezing, or rales.
The remainder of his exam is unremarkable.
Another CXR is obtained.
There is moderate subsegmental atelectasis versus an infiltrate in the right lower lobe. This is best seen on the lateral view as a linear density in the posterior lower lung. It is also seen faintly on the PA view in the right lower lung field, but the scanner was not able to capture it very well.
What would you do at this point?
He has had several pneumonias following a history of choking on almonds, but a previous bronchoscopy was negative.
Remember the “principle” discussed in our Foreign Body Aspiration case: Nuts + Choking = Bronchoscopy
Despite the negative previous bronchoscopy, a different surgeon is called for bronchoscopy under general anesthesia. Initial laryngoscopic exam reveals an erythematous and mildly edematous epiglottis. The remainder of the procedure is then performed via bronchoscopy, which reveals an erythematous trachea with an injected mucosa.
There is also moderate edema in both mainstem bronchi, and marked edema in the subsegmental bronchi on the right side. The lower lobe bronchus contains granulation tissue that is friable, and upon retracting the granulation tissue, a foreign body is visualized and removed.
Histologic exam reveals vegetable matter consistent with a nut.
Teaching Points and Discussion
- Although foreign body aspiration may not be the most common cause of recurrent pneumonia, it is not uncommon especially in this age group which varies from six month old to three year old with a peak incidence at two years of age and a 90% incidence before five years of age (1,2). It is, therefore, imperative to maintain a high index of suspicion even if there is no definite history of a choking episode, which is usually the case in about half the cases, but up to 70% of the time in one study (3).
- Most commonly, patients may present with localized wheezing, diminished air movement, and rhonchi on auscultation of the lungs. However, these findings may not always be present and certainly may seem diffuse over both lung fields due to transmission of those sounds through the bronchi. Pneumonia may also be a concomitant finding in up to 20% of the cases. Recurrent pneumonia may develop secondary to a foreign body that is obstructing the normal mucociliary clearance mechanism (4). In fact, there have been cases of months to even years where an aspirated foreign body had been the cause of recurrent pneumonia (5).
- More common types of aspirated objects include peanuts (up to 50% of total cases), raisins, sunflower seeds, popcorn, teeth, and toys. Foreign body aspiration should always be considered in a child with unexplained pulmonary problems.
- Evaluation for a foreign body aspiration should include inspiratory and expiratory CXR’s (or bilateral decubitus CXR’s for infants and toddlers who cannot follow commands) looking for asymmetric air-trapping secondary to bronchial obstruction. CXR under fluoroscopy may also aid in detecting diminished lung/diaphragm movement. A single CXR may detect the foreign body, but one study demonstrated only four percent of pulmonary foreign bodies to be radiopaque (6). Even if all radiographic studies are negative, clinical suspicion should lead one to consider bronchoscopy since negative radiographic studies are not able to totally rule out foreign bodies.
- The treatment of choice is bronchoscopy for removal of the foreign body. Without such removal, complications may arise such as recurrent pneumonia (even migratory), pulmonary abscess and/or cyst development, bronchospasm, pneumothorax and bronchopleural fistula (5,7).
- The differential diagnosis for recurrent pneumonia can be extensive with the most common etiologies being reactive airway disease, various immunodeficiencies, tuberculosis, cystic fibrosis, and anatomical anomalies (8). In this case, a “choking” episode while eating nuts was eventually elicited by history, and repeated pulmonary infiltrates on CXR as well as localized lung findings on exam suggested a retained pulmonary foreign body, after which the appropriate therapy was performed, and the patient’s symptoms eventually resolved.
1. Wiseman NE. The Diagnosis of Foreign Body Aspiration. J Ped Surg 1984;19:531-535.
2. Oski FA (ed). Principles and Practice of Pediatrics, 2nd Edition. Philadelphia, J.B. Lippincott Co., 1994, pp. 822, 1475-1477.
3. Moazam F. Foreign Bodies in the Pediatric Tracheobronchial Tree. Clin Pediatr 1983;22:148.
4. Rubin BK. The Evaluation of the Child with Recurrent Chest Infections. Pediatr Inf Dis 1985;4(1):88-98.
5. Ben-Dov I. Foreign Body Aspiration in the Adult: An Occult Cause of Chronic Pulmonary Symptoms. Postgrad Med J 1989;65(763):299-301.
6. Blazer S. Foreign Body in the Airway: A Review of 200 Cases. Am J Dis Child 1980;134:68.
7. Barlett JG. The Triple Threat of Aspiration Pneumonia. Chest 1975;68:560-566.
8. Stockman JA (ed). Difficult Diagnosis in Pediatrics. Philadelphia, W.B. Saunders Co., 1990, pp. 375-382.