Divisions of *Thoracic Surgery and Interventional Pulmonary
†Anatomic Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
Disclosure: There is no conflict of interest or other disclosures.
Reprints: Erik Folch, MD, MSc, Division of Thoracic Surgery and Interventional Pulmonary, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Street, Deac 201, Boston, MA 02215 (e-mail: firstname.lastname@example.org).
Received May 16, 2013
Accepted February 12, 2014
Tracheobronchial foreign body aspiration (FBA) is a major cause of morbidity and mortality in children younger than 4 years of age, resulting in >150,000 emergency department visits in 2010.1 The incidence of FBA decreases significantly with increasing age, resulting in atypical presentations in adults.2 A high index of suspicion is required in adults presenting with respiratory symptoms. Elderly patients with neurological disorders, cognitive impairment, or a history of alcohol and sedative abuse represent a subgroup of patients highly predisposed to fatal FBA events.3
We present a rare case of a foreign body (pill) aspiration in an elderly female mimicking an obstructing endobronchial lesion.
A 74-year-old woman with severe schizophrenia was transferred to our institution for evaluation of a left main stem endobronchial lesion, resulting in severe hypoxemia.
The patient initially presented to an outside hospital with frequent falls and failure to thrive. She was found to have a non-ST elevation myocardial infarction, with the highest troponin level of 4.1, which was managed conservatively with aspirin, clopidogrel, and intravenous heparin. During this hospitalization, she became progressively short of breath, with increasing leukocytosis, fever, and oxygen requirements. Chest radiograph revealed a complete opacification of the left lung as well as a right-sided lung mass. Given her age and a prolonged history of smoking, concern for a malignant endobronchial obstruction with subsequent postobstructive pneumonia was raised. The patient underwent a bronchoscopic evaluation at the outside hospital, which revealed friable obstructing mass in the left main bronchus and was transferred for further care and management.
At presentation, she was requiring oxygen at 100% FiO2 by facemask to maintain her oxygen saturation above 90%. She underwent a computed tomography scan of the chest, which revealed collapse of the left lung with associated ipsilateral pleural effusion and several enlarged hilar lymph nodes (Fig. 1).
The patient underwent a rigid bronchoscopy (Dumon-Bryan Corporation, Woburn, MA) which revealed a white lesion in the left main stem bronchus with overlying granulation tissue. After intubation of the left main stem bronchus, a flexible bronchoscope (BF type XT 160; Olympus Tokyo, Japan) was introduced, and using a flexible cryoprobe (ERBE, Tübingen, Germany) the suspicious lesion was frozen and removed (Fig. 2). Thick copious secretions were aspirated after relief of the obstruction. The distal airways were then carefully examined, revealing minimal inflammation and no infiltrating lesions.
The endobronchial material was sent for pathologic analysis, revealing mucous with entrapped neutrophils coating the surface of relatively well-delineated aggregates of polarizable crystalline and nonpolarizable amorphous foreign material, compatible with the tablet filler components microcrystalline cellulose and crospovidone (poly[N-vinyl-2-pyrrolidone]), respectively (Fig. 3). Careful medication review demonstrated polypharmacy with 17 different oral medications, supporting the likelihood of pill aspiration.
Subsequent speech and swallow evaluation revealed moderate oral and mild pharyngeal dysmotility. She also had compulsive ingestion of large quantities of food at once. The patient was discharged with a possible management of her right lung lesion at a latter setting.
Tracheobronchial FBA is a common, potentially fatal presentation in the emergency department. Approximately 80% of the cases occur in patients younger than 15 years of age.4 In 2010, >200,000 cases of FBA in children younger than 9 years of age were evaluated in the emergency departments across the United States.1 The incidence of FBA is considerably rare in adults. Bimodal distribution of the mortality rate is observed with the highest risk seen in infants and elderly adults.5 In the year 2010 alone, around 3400 deaths were attributed to unintentional suffocation in adults older than 65 years of age.
The diagnosis of FBA is challenging in adults especially in the elderly population. As in our case, these patients have a history of cognitive impairment or use of substance causing impairment of consciousness.6 Adult patients do not always volunteer or recall a history of choking, making it highly likely to miss this diagnosis unless a typical choking episode is reported or a radioopaque object is highlighted on a radiograph.2,7–11
The elderly population also has an increased incidence of dentition problems, or neurological disorders such as Parkinsonism, which predisposes them to aspiration events.7,12–14 Compounded with the polypharmacy prevalent in this population, aspiration of medications is an all too real possibility as highlighted in the presented case.
Medication aspiration has been associated with severe local bronchial inflammation and pneumonitis. The exact response is dependent on the properties of the medication; its composition, internal properties, such as pH and solubility as well as the pharmaceutical packaging with plastic or enteric coating.15
Various effects of medication aspiration have been described. Most commonly reported are the effect of iron sulfate tablet aspiration, which has been associated with bronchial necrosis, fatal pneumonia, chronic fibrosing granulomatous reaction, bronchial stenosis, and hemoptysis.16–19 Iron sulfate is locally corrosive, with histologic appearance of the mucosal injury mimicking “iron pill” gastritis.15,20,21
Individual case reports have described effects of other medication aspiration syndromes, including aspirin associated with cardiorespiratory arrests probably secondary to laryngeal spasm associated with the irritant nature of the medication22; miliary granulomatous reactions associated with aspiration of medications like cholestyramine, phenobarbital, and phenytoin23; giant-cell foreign body reaction seen with aspiration of bismuth subgallate,24 Pepto-Bismol, and kaopectate25; and severe airway inflammation associated with nortriptyline.26 Care is warranted while removing such toxic substances from the airways. Serious complications of bronchoscopic removal include accidental dislodgement into the normal airway resulting in loss of ventilation or breakage of the foreign body with subsequent migration into the distal airways. Bronchoscopic removal in such cases is difficult and leaving the toxic foreign body has potential severe consequences.3
Fewer complications have been noted with plastic or enteric-coated capsules as the airways lack the proteolytic enzymes present in the gastrointestinal tract, thereby retarding the release of potentially inflammatory pharmacologic components. A minimal inflammatory response has also been described in previous reports of calcium carbonate tablet aspiration,27 most likely due to the inert, noncaustic nature of the compound itself.28 Of note for this case, the patient’s daily pill regimen included an enteric-coated calcium carbonate supplement, which grossly had a similar appearance to the recovered chalky-white endobronchial lesion.
Our case highlights the difficulty in the diagnosis of FBA in an elderly patient with cognitive difficulties. The presence of a focal wheeze, recurrent or nonresolving pneumonia should prompt a detailed bronchoscopic evaluation. Occasionally, initial bronchoscopic evaluation of the airways may reveal granulation tissue which mimics a friable malignant tumor as in our case and is imperative that tracheobronchial FBA is considered in the differential diagnosis in high-risk adults. This rare but fatal disease is readily treatable if recognized in a timely manner.
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