INTRODUCTION
Foreign body aspiration (FBA) into the airway is a significant health concern, particularly in children, and can become a life-threatening emergency if not diagnosed and managed promptly. Quick removal of the foreign body (FB) typically leads to rapid recovery, but in many cases, the history of FBA is unclear, making diagnosis challenging. Symptoms such as chronic cough, shortness of breath, and even hemoptysis may persist for extended periods if the FB is not properly identified and addressed. In fact, delayed diagnosis of FBA can result in severe complications, including granuloma formation, recurrent pneumonia, atelectasis, and bronchial scarring with narrowing.[1] This highlights the importance of early detection and intervention.
Trauma, alcohol abuse, and certain medical conditions have been identified as factors that increase the risk of FBA.[1] The complications that arise from delayed or misdiagnosed FBA are wide ranging, with granuloma formation being observed in 76.5% of cases, obstructive pneumonia in 22.0%, bleeding in 14.5%, atelectasis in 10.0%, and bronchial stenosis or scarring in 8.0%.[2] These figures emphasize the need for clinicians to remain vigilant, particularly in pediatric populations, where the tendency to explore objects orally may put children at higher risk for FBA.
The timing of FB removal plays a critical role in the severity of symptoms. Studies have shown that when foreign bodies are removed within 3 days of aspiration, the incidence of associated symptoms is 31.8%. However, this figure rises significantly when removal is delayed beyond this time frame, with the incidence of symptoms increasing to between 62.5% and 89.7%.[3] This underscores the importance of prompt medical intervention to prevent the escalation of complications.
Furthermore, in some cases, the symptoms of FBA may remain mild or even absent for months or years, which can lead to misdiagnosis. Chronic cases that present with radiographic findings such as lobar or segmental atelectasis, pulmonary consolidation, or recurrent inflammation at the same site are often mistaken for other diseases, including lung cancer, tuberculosis (TB), obstructive pneumonia, or chronic obstructive pulmonary disease (COPD).[4] In addition, the auscultatory findings in cases of FB obstruction, such as a dry, crackling sound, can sometimes be misinterpreted as bronchial asthma or localized pneumonia, further complicating the diagnosis.
The challenge in diagnosing FBA becomes especially evident when the clinical and radiological findings closely resemble other respiratory diseases, such as TB. This is particularly true in regions with a high incidence of TB, where healthcare providers may initially lean toward a TB diagnosis based on radiographic findings and family history, without considering the possibility of a FB.[5-11]
TB in children is primarily classified into two types: primary TB and secondary TB. Primary TB typically occurs in children under the age of 5 years and presents as an initial infection in the lungs or other organs. This type is often asymptomatic but may manifest with mild symptoms such as low-grade fever and cough. In contrast, secondary TB occurs following a previous infection or reactivation of the bacteria and can present more severely, with symptoms such as persistent cough, weight loss, and night sweats. Early diagnosis and appropriate treatment of this disease in children are crucial to prevent serious complications.[12,13]
Therefore, a high index of suspicion, thorough clinical evaluation, and the use of appropriate diagnostic tools are essential for accurately diagnosing and managing FBA in pediatric patients. This report highlights the diagnostic challenges posed by FBA in children and the importance of comprehensive clinical evaluation to avoid misdiagnosis.
CASE REPORT
An 8-year-old male child presented approximately 18 months ago with productive cough and shortness of breath following multiple blows to the chest during a traumatic incident. Due to the lack of improvement and the presence of fever, the child sought medical attention.
At the time of the initial visit to a previous hospital, pharmacologic treatment had already been initiated. The patient had been receiving medication for 6 months with salbutamol inhalant, salmeterol/fluticasone spray, levofloxacin and montelukast tablet, nebulization with ipratropium bromide, but the lack of improvement prompted him to seek further care. On admission, the following vital signs were recorded: SpO2 95%, pulse rate 60 bpm, and temperature (T) 37°C. The patient presented with complaints of cough, sputum production, shortness of breath, and urinary burning. Laboratory results are shown in Table 1.
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Table 1: Laboratory test results for the patient
In the ultrasound of the inguinal area, bilateral oval-shaped reactive lymph nodes were observed with a maximum short-axis diameter of 2 mm. In addition, the ultrasound of the lymph nodes and testes was normal. An echocardiogram was performed, which was normal, and the alpha-fetoprotein test was negative.
First, several axial computed tomography (CT) sections were taken through the chest with IV contrast administration. In addition, reformatted sagittal and coronal images were also obtained.
Air space consolidation was noted in the right middle and lower lobes. There was right and lower middle lobe pneumonia. There was also mucoid impaction in the right lower lobe. There was an abnormal vessel originating from the descending aorta which drains through the left inferior pulmonary vein into the left atrium causing an arteriovenous fistula/shunt. The left lung bronchial system was normal. The left atrium was slightly prominent. Pulmonary trunk and pulmonary arteries were unremarkable. Pericardial thickness was normal with no effusion. No evidence of pneumothorax on either side. No hilar or mediastinal lymphadenopathy was noted. Visualized bones appear grossly unremarkable.
The second time was the procedure performed with IV contrast, where the reconstructed 3 mm images from the scan performed on the CT 128 slice on the workstation were examined in several planes using different window settings and levels. There were patchy subsegmental consolidation and alveolar opacities with air bronchogram in the posterior segment of the right upper lobe and right middle and lower lobe. The left lung shows tubular opacity in perihilar region, which could be vessels. There was no cavitation, bronchiectasis, or honeycombing normal trachea and main stem bronchi. There were no large mediastinal lymph nodes. Heart and mediastinal vessels were grossly unremarkable. No pericardial effusion was seen. No pleural effusion was seen.
It can be concluded that patchy subsegmental consolidation and alveolar opacities were present with air bronchogram in all lobes/right side and were most likely infectious. Furthermore, pleural effusion was not seen in both CT scans [Figure 1].
Figure 1: Computed tomography scan with contrast of the patient
Due to the family history of TB, the initial diagnosis for the patient was TB, and the CT scan was suspicious for TB. However, after performing an ultrasound and considering the typical history, clinical presentation, radiological findings, and blood tests, a diagnosis of FBA was made. The FB, which was a pen cap, was successfully removed via bronchoscopy. After removal, the symptoms resolved, and the patient improved. A medication regimen was started.
For follow-up care, the patient was prescribed co-amoxiclav syrup and pantoprazole tablets, and a request was made for reevaluation tests.
Figure 2 is the chest X-ray (CXR) taken before treatment, and Figure 3 is the CXR of the patient after treatment and bronchoscopy. In Figure 2, the signs of pneumonia have resolved, and the patient is clinically improving.
Figure 2: Chest X-ray of the patient before treatment and removal of the foreign body
Figure 3: Chest X-ray of the patient after bronchoscopy and foreign body removal
DISCUSSION
FBA is more common in children under 3 years old, where curiosity about exploring the world through the oral route, insufficient laryngeal closure reflex, inadequate swallowing reflex, and activity during eating are among the etiological factors.[14] Dyspnea, which is a clinical symptom presented by the patient, may result from the fact that organic materials cause a more intense inflammatory response compared to inorganic materials.[15] Previous studies have found that the most common location for FB impaction is the right bronchus. This is mainly due to the position of the bronchi (the left bronchus forms a steeper angle with the trachea than the right) and also because of the greater size and width of the right bronchus.[16] For the management of this condition, a detailed patient history identifying risk factors, physical examination, and detection of the FB, along with a CXR, can be helpful. In addition, diagnostic bronchoscopy should be performed if a FB is suspected. Otherwise, examination and radiography should be repeated after 24 h.[17]
Baram et al., despite the high sensitivity and specificity of CT scans as a diagnostic tool, avoided using them to minimize exposure to ionizing radiation.[15] According to the study of Guan et al., despite having a chest CT scan and hospital visits, the patient’s persistent cough was mistakenly diagnosed as COPD. Calcification in the right upper lobe was incorrectly attributed to old TB and only during bronchoscopy was the FB in the bronchus discovered.[18]
CONCLUSION
In this case, we present a report on an 8-year-old boy with a FBA. As previously mentioned, the patient exhibited productive cough and shortness of breath as the main clinical symptoms. Initially, several axial CT scans of the chest with IV contrast were performed. In addition, sagittal and coronal images were reprocessed. Airspace consolidation was observed in the right middle and lower lobes. Pneumonia was identified in the right middle and lower lobes, along with mucoid impaction in the right lower lobe. An abnormal vessel originating from the descending aorta was noted, which drained into the left atrium via the left inferior pulmonary vein, causing an arteriovenous fistula/shunt. The left lung bronchial system was normal. In the second CT scan, 3 mm reformatted images from the 128-slice CT scan were examined in multiple planes using different window settings. Patchy subsegmental consolidation and alveolar opacities with air bronchogram were observed in the posterior segment of the right upper lobe and the middle and lower right lobes. The left lung showed tubular opacity in the peripheral region, possibly related to blood vessels. It can be concluded that the patchy subsegmental consolidation and alveolar opacities with air bronchogram seen in all lobes, particularly the right side, were most likely infectious. Due to the family history of TB, the initial diagnosis of TB was considered. However, after performing an ultrasound, the diagnosis of FB was confirmed. The FB, which was a pen cap, was successfully removed via bronchoscopy. Afterward, the symptoms resolved, and the patient improved. Therefore, clinicians should consider FBA in differential diagnoses for children presenting with respiratory distress, particularly in areas with high TB prevalence. Early intervention is crucial to prevent complications such as granuloma formation and recurrent infections.
Rationale of the study
FBA in children can mimic conditions like TB due to overlapping symptoms such as chronic cough and shortness of breath. This study aims to highlight the diagnostic challenge of distinguishing FBA from TB, especially in areas with high TB prevalence. By presenting this case, we emphasize the importance of considering FBA in the differential diagnosis when common treatments fail and demonstrate the value of thorough clinical evaluation to avoid misdiagnosis and complications.
Outcomes of the study
The study successfully identified an FB (a pen cap) in an 8-year-old boy initially diagnosed with TB. After performing bronchoscopy, the FB was removed, and the patient’s symptoms resolved. This case emphasizes the importance of considering FBA in pediatric patients with persistent respiratory symptoms and the effectiveness of bronchoscopy in resolving the condition and improving clinical outcomes.
Limitations of study
This study is based on a single case, limiting the generalizability of its findings. It also does not compare different diagnostic approaches or explore long-term outcomes after the removal of the FB.
Ethical statement
The study was approved by the Ethical Committee of the National Research Institute of Tuberculosis and Lung Diseases (NRITLD) of Shahid Beheshti University of Medical Sciences (IR.SBMU.NRITLD.REC.1403.096). All the steps performed in this study were based on the terms of the Helsinki Convention.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given consent for images and other clinical information to be reported in the journal. The guardian understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
This study was supported financially by the NRITLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
We are grateful to the Pediatrics Pulmonology Department of the NRITLD for providing the opportunity to study this case.
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