To the Editor:
We read the article “Live fish in the endobronchial tree” by Raju et al1 with great interest. We would like to further extend their observation by reporting a similar case encountered in our practice.
A 40-year-old man with a past medical history of bronchial asthma presented with acute onset breathlessness. On evaluation he was felt to have an acute exacerbation of asthma. He was managed conservatively with nebulized salbutamol, IV aminophylline, and steroids. However, his condition progressively deteriorated. He was transferred to the intensive care unit for monitoring and was managed for asthma exacerbation for 3 days without significant improvement. Although, bronchoscopy in asthma patients has shown to be associated with some risks,2 it was believed that the benefits outweighed the risks in this case. During the procedure, to our surprise, we encountered fragments of bones mixed with blood and mucus. The lumen was cleared of the foreign body fragments and patient was transferred back to the intensive care unit. Medical therapy was continued which resulted in rapid symptomatic improvement. On further interrogation, in light of the foreign body removed, it was revealed that the patient had swallowed a live fish as a treatment for asthma approximately 15 days earlier.
The “live fish prasadam (blessings)” is administered on particular days of the year in Hyderabad, a city in the southern Indian state for Telangana. It involves swallowing a live murrel fish with a mixture of herbs placed in its mouth. It is claimed to cure asthma after 3 consecutive years of treatment. However, the efficacy of the treatment is disputed and it lacks scientific reasoning and proof. On the contrary, it can have complications as reported here. Foreign body aspiration can precipitate an acute attack of exacerbation in asthmatics due to pre-existing airway reactivity. The fact that there is no age bar for this “therapy” is a cause for concern as young children are made to swallow a live fish. There have been at least 4 reported deaths in medical literature as a result of live fish aspiration in different scenarios.1 Knowing that status asthmaticus has a mortality rate of ranging from 3.5% to 8.5%,3 such treatment modalities should be strongly discouraged.
Loose bone fragments in the airway suggests that the aspirated fish was present for long enough time to permit its disintegration. His progressive symptoms culminating in hospitalization lends speculation to the cause of his symptoms. It could have been due to the mere presence of the foreign body in the tracheobronchial tree or as a result of release of antigenic irritants from decomposition. It has been reported that the mean pH of exhaled airway vapour in asthmatics is 5.23±0.21 which correlates with undiluted tracheal secretions.4 This may have contributed to the rapid digestion of the live fish.
With this case we would like to emphasize the role of live foreign body aspiration as a cause of precipitation of an attack in known asthmatics. We suspect that live fish aspiration is more common than reported. Several cases have been reported of aspiration of live fish,1 leech, and even presence of parasites in the airways.5 In certain parts of the world, fishermen are at a higher risk of live fish aspiration due to the practice of holding the fish in their mouth to keep their hands free. The fish may slip into the mouth and lodge in the oropharynx or tracheobronchial tree. It should be considered in differential diagnosis of acute exacerbation of asthma not responding to treatment, in a proper clinical setting in correlation with history.
Retrieval of bone fragments from airway is not uncommon. We believe they can present as 3 scenarios. Witnessed aspiration with acute symptoms that correlates strongly with history and treated with emergent removal of the foreign body lodged in the airway.1 It can also present as granuloma in the airway.6 The history, however, is noninformative about the time of possible aspiration. It can also present subacutely. Here, apart from the evidence on bronchoscopy, the history clearly points to the cause. The role of bronchoscopy in such cases is an indispensable diagnostic and therapeutic tool and removal of foreign body is significant to prevent long-term complications.
We conclude that first; live fish aspiration is more common than reported. Second, people seeking this alternative to medical treatment for this chronic, sometimes self-limiting disease, are at a higher risk of aspiration of live fish with dire consequences. Finally, recovery of bone fragments suggests complete digestion of the fish in the airway. This points toward the physiological changes in the airway secretions in asthmatics.
Syed R. Ali, MBBS*
Ece Albayrak, MD†
Ajendra C. Shah, MD, FCCP‡
*Department of Critical Care Medicine Bombay Hospital, Indore
‡Department of Respiratory Diseases L.T.M.G. Hospital & L.T.M.M. College Sion, Mumbai, India
†School of Medicine, Marmara University Istanbul, Turkey
REFERENCES
1. Raju S, Jhawar P. Live fish in the endobronchial tree. J Bronchology Interv Pulmonol. 2015;22:175–177.
2. Jarjour NN, Peters SP, Djukanovic R, et al. Investigative use of bronchoscopy in asthma. Am J Respir Crit Care Med. 1998;157:692–697.
3. Lugogo NL, Maclntyre NR. Life-threatening asthma: pathophysiology and management. Respir Care. 2008;53:726–735; discussion 735–9.
4. Hunt JF, Fang K, Malik R, et al. Endogenous Airway Acidification. Am J Respir Crit Care Med. 2000;161:694–699.
5. Khemasuwan D, Farver CF, Mehta AC. Parasites of the air passages. Chest. 2014;145:883–895.
6. Takeishi K, Shoji F, Kometani T, et al. Pulmonary granuloma possibly caused by a fish bone material. Kyobu Geka. 2008;61:1114–1117.
