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Iron Pill Aspiration and Bronchial Stenosis

Lee, Pyng MD; Culver, Daniel A. DO; Saad, Cynthia MD; Mehta, Atul C. MD

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From the Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, Ohio, USA (Drs. Lee, Culver, Saad, and Mehta).

Reprints: Dr. Atul C. Mehta, Department of Pulmonary and Critical Care Medicine, A90, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA; (e-mail: mehtaa1@ccf.org).

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CASE REPORT

A 69-year-old woman with hypothyroidism, hypertension, multiple previous strokes, and partial gastrectomy had been taking daily ferrous sulfate tablets. She remembered aspirating an iron pill when she experienced choking, wheezing, and cough. Chest radiograph was normal. Two months later she was hospitalized with pneumonia and required assisted ventilation. Bronchoscopy at that time revealed extensive inflammation of the truncus intermedius (TI) and left lower lobe bronchus (LLLB). No foreign body was detected but the TI was lined with greenish brown necrotic material (Fig. 1).

FIGURE 1.

FIGURE 1.

Since she remained symptomatic, repeat bronchoscopy was performed 3 months later, revealing 90% and 70% stenosis of the TI and LLLB respectively. Near-total patency of the bronchi was established by balloon bronchoplasty followed by an endobronchial injection of submucosal DepoMedrol.

Stenoses of the affected bronchi recurred. Endobronchial biopsies of the TI a year after the episode of aspiration revealed ferric iron in the subepithelial connective tissue with foci of granulation tissue and fibrosis, confirming the patient's history of iron pill aspiration. With informed consent, she underwent a second balloon bronchoplasty followed by topical application of 0.2 mg mitomycin-c via flexible bronchoscopy. Six weeks following the procedure, good patency of the TI and LLLB was demonstrated on bronchoscopy.

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DISCUSSION

Tracheobronchial stenosis, as a result of granulomatous diseases 1,2 and mechanical causes such as prolonged endotracheal intubation or cuffed tube tracheostomy, 3 has been well documented in the literature. Bronchial stenosis due to iron pill aspiration has been observed only in a few reported cases. 4–6 It is often irreversible and may necessitate lobectomy in severe cases. Unlike most foreign bodies, which remain intact in the tracheobronchial tree, the iron pill disintegrates in the airway and cannot be detected via bronchoscopy. However, bronchial biopsy and lung tissue may reveal iron deposits with airway inflammation months after the episode of aspiration. 7 In our patient, diagnosis of iron pill aspiration was established by positive endobronchial biopsies for iron staining with endobronchial findings of intense airway inflammation and stenosis even in the absence of the actual foreign body. 6

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REFERENCES

1. Daum TE, Specks U, Colby TV, et al. Tracheobronchial involvement in Wegener's granulomatosis. Am J Respir Crit Care Med. 1995; 151:522–526.
2. Chung HS, Lee JH. Bronchoscopic assessment of the evolution of endobronchial tuberculosis. Chest. 2000; 117:385–392.
3. Andrews MJ, Pearson FG. Incidence and pathogenesis of tracheal stricture following cuffed tube tracheostomy with assisted ventilation. Ann Surg. 1971; 173:249–263.
4. Tarkka M, Anttila S, Sutinen S. Bronchial stenosis after aspiration of an iron tablet. Chest. 1988; 93:439–441.
5. Mizuki M, Onizuka O, Aoki T, et al. A case of remarkable bronchial stenosis due to aspiration of delayed release iron table [in Japanese]. Nihon Kyobu Shikkan Gakkai Zasshi. 1989; 27:234–239.
6. Lee P, Culver DA, Farver C, et al. Syndrome of iron pill aspiration. Chest. 2002; 121:1355–1357.
7. Godden DJ, Kerr KM, Watt SJ, et al. Iron lung: bronchoscopic and pathological consequences of aspiration of ferrous sulphate. Thorax. 1991; 46:142–143.
© 2003 Lippincott Williams & Wilkins, Inc.