The Case of the Coughing Obstetrician
THE CASE: An 81-year-old retired obstetrician who had never smoked tobacco presented with a 6-week history of cough with clear sputum, fever, chills, and a 30-lb weight loss. He noted dyspnea on exertion and right-sided pleuritic chest pain. His medical history included stable congestive heart failure, coronary artery disease, type 2 diabetes mellitus, chronic kidney disease (stage 3), and bi-ventricular pace-maker/automated implantable cardioverter-defibrillator placement for atrial fibrillation and cardiomyopathy. He denied any alcohol or sedative intake and did not recall any previous episodes of dysphagia, choking, aspiration, seizures, or loss of consciousness.
Physical examination. Blood pressure was 120/65 mm Hg; heart rate, 72 beats per minute; temperature, 36.5°C (97.7°F); and oxyhemoglobin saturation was 98% on room air. He was alert and fully oriented to person, place, and time. No finger clubbing was seen, and jugular venous distension was within normal limits. Cardiovascular examination revealed a regular heart rhythm and normal heart sounds without murmurs. Examination of the respiratory system was notable for dullness to percussion, egophony, and bronchial breath sounds, over the right upper lung zone posteriorly. No abnormal neurological signs were elicited.
Laboratory and imaging studies. White blood cell count was 9800/μL; hemoglobin level, 13.7 g/dL; and platelet count, 166,000/μL. A chemistry blood panel showed a glucose level of 117 mg/dL and a creatinine level of 1.3 mg/dL. An ECG revealed normal sinus rhythm and chronic right bundle branch block. A chest radiograph (shown here) revealed right hilar fullness associated with right upper lobe (RUL) consolidation. Subsequently, the results of a chest CT scan confirmed mediastinal, pretracheal, and precarinal lymphadenopathy together with RUL consolidation that extended into the right middle lobe.
To what diagnosis do the radiographic and clinical findings point?
Outcome of this case. These findings suggested a post-obstructive pneumonia from a possible endobronchial lesion. The patient was treated with a course of doxycycline without complete resolution. Flexible bronchoscopy revealed a yellowish endobronchial mass causing 65% obstruction of the RUL. It was surrounded by friable granulation tissue. Cytology brushings showed reactive bronchial mucosal cells with inflammation, and a rare fragment of atypical squamous metaplastic cells.
Repeat flexible bronchoscopy was performed 4 weeks later, after clopidogrel had been discontinued. Endobronchial biopsies revealed degenerating vegetable matter. A prolonged course of moxifloxacin resulted in resolution of symptoms with radiographic improvement.
Figure 3 – the right upper lobe endobronchial foreign body is displayed here after removal.
Figure 2 – the right upper lobe orifice is 100% patent after an interventional bronchoscopic procedure.
Ten months later, the patient presented with fatigue and body aches. He was treated with intravenous antibiotics for a RUL pneumonia. Flexible bronchoscopy revealed 90% obstruction of the RUL by an endobronchial mass (Figure 1). Repeated endobronchial biopsies yielded vegetable material with surrounding chronic granulation tissue without malignancy.
A subsequent interventional bronchoscopic procedure using a neodymium:yttrium-aluminum-garnet (Nd:YAG) laser together with cryotherapy resulted in 100% recanalization of the RUL orifice (Figure 2) after complete removal of the endobronchial foreign body (Figure 3). Significant abatement in his cough and sputum production had occurred with resolution of his fevers and chills during outpatient follow-up 6 weeks later. Concurrent radiological improvement was also documented on a chest radiograph (Figure 4).
Discussion. Aspiration of a foreign body with resultant airway obstruction can cause significant morbidity and mortality.1-3 Symptoms and signs may be immediate and life-threatening,2 or chronic.3 Baharloo and colleagues2 retrospectively found foreign body aspiration was rarer in adults than in children: 75% to 85% of cases occurred in children under the age of 15, with most under the age of 3.
A retrospective analysis by Mise and associates4 showed that foreign bodies were found in only 86 (0.33%) of 26,124 adult patients who had undergone flexible bronchoscopy. Fifty-eight percent of all patients with foreign body aspiration had neurologic or neuromuscular disease; stroke (30%) was the most common disorder. The investigators found that cough, dyspnea, and chest pain were the predominant symptoms, much in keeping with the presentation of our patient. Although a choking episode can be helpful in making the diagnosis, such a history was absent in about 50% of cases.3 Our patient had no history of choking.
Most foreign bodies are aspirated into the right bronchial tree (67% to 75.6% of patients) and into both bronchial trees in 1% to 5.8%.2,4,5 The RUL was involved in only one patient in Lan’s review,3 but this was due to a broncholith.
The anatomic location of our patient’s foreign body is unusual. We speculate that the patient aspirated the organic foreign body, likely a peanut, in either a prone position or lying on his right side. This positioning may have enhanced its deposition in the RUL.6 Alternatively, the foreign body may have been aspirated into the right lower lobe, and the patient’s cough reflex may have caused it to subsequently wedge in the RUL. The vegetable material found on endobronchial biopsy together with surrounding granulation tissue that suggests chronicity is consistent with the commonest type of foreign body material reported (29%) in Limper and Prakash’s7 retrospective analysis of 60 consecutive patients who were evaluated for foreign body aspiration.
Although a chest radiograph is diagnostic in only about 14% of patients because of the radiopaque nature of a minority of foreign bodies,5 radiologic changes consistent with a post-obstructive pneumonia and/or atelectasis can be present in up to 74% of patients.3,5 However, these latter findings on a chest radiograph are often nonspecific. Nevertheless, recurrent pneumonias at the same radiologic site as had occurred in our patient, delay in resolution of the pneumonia, localized bronchiectasis, and wheezing ought to suggest at least the possibility of an endobronchial lesion.3,5 The fact that our patient had never smoked also reduced the likelihood that his endobronchial tumor was malignant.
We were successful in the complete removal of the foreign body using flexible bronchoscopy and the Nd:YAG laser together with cryotherapy. The success of flexible bronchoscopy in removing foreign bodies varies between 60% and 91%.3,4,7 In contrast, Limper and Prakash7 used rigid bronchoscopy to successfully remove foreign bodies from 43 of 44 patients, including 6 of 7 patients in whom previous flexible bronchoscopy had failed. Lesions in the RUL may be difficult to access with the rigid bronchoscope. Therefore, both modalities are likely complementary,5 allowing both central and more peripheral endobronchial lesions to be treated.8 We used the Nd:YAG laser to vaporize the surrounding granulation tissue in the RUL, and then utilized the cryoprobe to help remove the foreign body itself. This method has been previously described.9,10
Take-home message. The occasional and often subtle presentation of non-asphyxiating foreign body aspiration in adults behooves clinicians to develop a high index of suspicion. Successful removal of the foreign body is definitive treatment. Such interventional bronchoscopic treatments should, however, be performed in centers of excellence where appropriate skills and experience exist to achieve such satisfactory outcomes.
1. Boyd M, Chatterjee A, Chiles C, et al. Tracheobronchial foreign body aspiration in adults. South Med J. 2009;102:171-174.
2. Baharloo F, Veyckemans F, Francis C, et al. Tracheobronchial foreign bodies: presentation and management in children and adults. Chest. 1999;115:1357-1362. 3. Lan RS. Non-asphyxiating tracheobronchial foreign bodies in adults. Eur Respir J. 1994;7:510-514.
4. Mise K, Savicevic J, Pavlov N, et al. Removal of tracheobronchial foreign bodies in adults using flexible bronchoscopy: experience 1995-2006. Surg Endosc. 2009;23: 1360-1362.
5. Debeljak A, Sorli J, Music E, et al. Bronchoscopic removal of foreign bodies in adults: experience with 62 patients from 1974-1998. Eur Respir J. 1999;14: 792-795.
6. Dudek RW. Tracheobronchial tree. In: Dudek RW. High-Yield Lung. Baltimore: Lippincott Williams & Wilkins; 2005:25-26.
7. Limper AH, Prakash UB. Tracheobronchial foreign bodies in adults. Ann Intern Med. 1990;112:604-609.
8. Chan AL, Tharratt RS, Siefkin AD, et al. Nd:YAG laser bronchoscopy. Rigid or fiberoptic mode? Chest. 1990;98:271-275.
9. Mehta A, Rafanan, AL. Extraction of airway foreign bodies in adults. J Bronchol. 2001;8:123-131.
10. Tzeng D, Chan AL. An update on advances in interventional bronchology.
J Respir Dis. 2006;27:415-428.