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Bronchoscopic Removal of a Long-standing Aspirated Iron Pill

Somalaraju, Sandeep R. MD*; Patil, Katherine MD; Campagna, Anthony C. MD

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Journal of Bronchology & Interventional Pulmonology: April 2017 - Volume 24 - Issue 2 - p 163-165
doi: 10.1097/LBR.0000000000000252
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Abstract

Pill aspiration can be a common occurrence in the elderly population, due to abnormal swallowing reflexes, dysphagia, and comorbidities such as stroke and cancer.1 Most pills disintegrate over time depending on their type and make. Iron pills in particular have been known to cause destructive effects from oxidative stress. The “syndrome of iron pill aspiration” has been proposed by the triad of aspiration, airway inflammation, and iron deposits on biopsy even in the absence of the pill on bronchoscopy.2

We report a long-standing case of iron pill aspiration with symptoms of chronic cough and removal of the foreign body a year after aspiration.

CASE REPORT

An 80-year-old man with coronary disease, peripheral vascular disease, hypertension, and gastrointestinal bleed of unknown etiology was on oral iron supplementation for iron deficiency anemia. For 5 days he experienced progressive cough and shortness of breath with low-grade fevers and decreased appetite. Physical exam demonstrated decreased breath sounds and a faint unilateral wheeze on the right mid-lung zone. He was diagnosed with a right mid-lobe pneumonia confirmed by chest x-ray (CXR) (Fig. 1A). He had improved clinically on antibiotics and was discharged home after 4 days.

FIGURE 1
FIGURE 1:
A, Chest x-ray demonstrating right middle lobe pneumonia. B, Chest x-ray taken a year ago. The arrows in (A) and (B) were misinterpreted as an end-on appearance of a blood vessel. C, Chest x-ray 4 weeks after bronchoscopy with resolution of “end-on appearance.”

A repeat CXR and subsequent CT scan at 4 and 6 weeks later (Figs. 2A, B) demonstrated a slowly resolving pneumonia with the emergence of a radioopacity in the right middle lobe, not previously noted given the dense pneumonia. With a persistent cough, unilateral wheeze, and findings of a radioopacity, he underwent a bronchoscopy.

FIGURE 2
FIGURE 2:
Computed tomography image with (A) right middle lobe infiltrate, noted at week 4 and (B) foreign body noted in the right middle lobe bronchus (arrow), noted at week 6.

A gray foreign body was seen impacted with mucous, obstructing the right middle lobe (Fig. 3A). The left main bronchus was entirely normal. Pigmented submucosal tissue was visualized in the right main stem bronchus at the pill site. A flexible curette and basket were used to extract the object (Fig. 3B). Residual granulation tissue remained. Pathologic and chemical analysis confirmed the foreign body to be an iron sulfate tablet.

FIGURE 3
FIGURE 3:
A, Bronchoscopic view of right main stem bronchus with foreign body. B, Iron pill extracted wire basket.

Subsequent swallowing studies showed a delay in the laryngopharyngeal phase, making him prone to aspiration. He denied any irksome episodes of choking but had trouble swallowing recently and reported to aspirating a pill about a year earlier. On retrospective review of prior CXRs a year from this episode, it appeared that this pill was present in the right main bronchus and may have been interpreted as a blood vessel (Fig. 1B).

On follow-up, the patient’s cough and pneumonia had completely resolved. CXR performed within 4 weeks after bronchoscopy had no further radiographic evidence of the “end-on appearance” near the right hilum, as shown in Figure 1C. Several outpatient reevaluations in 2 years did not reveal worsening airway defects.

DISCUSSION

Iron pill aspiration does not typically have any clinically significant sequelae due to its ability to dissolve as the pill disintegrates when it comes in contact with lung secretions. Despite the common scenario, it is important to recognize that some pills and tablets may not dissolve and may be a source of airway obstruction.3

Virtually all cases of iron pill aspiration are suggested by airway inflammation and residual iron deposits on bronchoscopy. Bronchial wall injury may occur due to oxidative and free radicular damage from its acidic pH (<3) leading to caustic necrosis as evidenced by bronchial biopsy.4–7 This can further manifest as scarring and development of granulation tissue from fibroblastic proliferation.4,8,9 The resulting gamut of pathology comprises findings of bronchitis, recurrent pneumonias, bronchiectasis, bronchial stenosis, or bronchial necrosis.2,5,10,11 The severity of symptoms can range from persistent cough to massive hemoptysis. In cases of bronchial scarring with recurrent pulmonary symptoms, balloon bronchoplasty has been beneficial. To limit inflammation and scarring, the use of topical chemotherapy such as mitomycin C has shown to reduce restenosis but this needs further review.2 Bronchotomy or lobectomy may be indicated in severe cases of necrosis or failure of recurrent bronchoplasty.

Capsules and tablets have different coatings that may facilitate or delay their dissolvability. Iron pills are typically large “horse pills” that are more prone to getting caught in proximal segmental airways if they are aspirated. If identified, early pill removal may potentially reduce free-radical damage preventing late complications.

Our patient had signs of bronchial inflammation with airway obstruction causing pneumonia. From the history and radiographic findings, this pill was present for almost a year on the right side, causing a chronic cough. As clinicians, the suspicion of pill aspiration should be raised especially with recurrent symptoms and findings of a unilateral wheeze, although patients may often not recollect an episode of aspiration.12 The importance of following x-rays to document resolution of pneumonia may unmask such etiologies. This case illustrates that iron pills can remain as a persistent foreign body and can be a reason for recurrent pneumonia or chronic cough.

REFERENCES

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12. Mise K, Jurcev Savicevic A, Pavlov N, et al. Removal of tracheobronchial foreign bodies in adults using flexible bronchoscopy: experience 1995-2006. Surg Endosc. 2009;23:1360–1364.
Keywords:

iron pill; aspiration; bronchoscopy

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