Foreign Body Aspiration masquerading as Pneumonia

Case

Two and a half year old boy presented to the ER with a seizure. Mother gave h/o cough cold, fever for the past one week and the child also had history of a choking spell one week back. Background h/o reactive airway disease (RAD) was positive.

O/E: Dehydrated , Comatose, Gasping

HR 60bpm, RR 50bpm , SpO2 60% RA, Temp 103F and bilateral silent chest .Vitals improved with BMV and he was treated on the lines of infective exacerbation of reactive airway disease. 

CXR on arrival

Eventually he was intubated following which SpO2 improved to 94%. CXR was suggestive of left consolidation /collapse. He was shifted to the ICU where due to a lack of response to treatment, he underwent bronchoscopy that revealed a peanut that caused collapse of the left lung and secondary infective exacerbation of RAD.

CXR after 2 days

Discussion

Foreign Body Aspiration (FBA) occurs commonly in children and it is frequently encountered by paediatric EM practitioners. It is more common in boys and frequently seen in kids less than 3 years of age. With classic acute and dramatic presentations, FBA is usually frequently diagnosed promptly but the diagnoses can get delayed with subtle of atypical presentations if a high index of suspicion is not maintained. 

Classic history comes as choking, coughing and cyanosis. Examination may reveal respiratory distress, asymmetrical chest expansion, localised wheeze or decreased breath sounds. If the size of the FB is small in relation to the airway, it can lead to partial airway obstruction and presentation may be delayed for days or weeks ultimately presenting as pneumonia. Majority of the FB aspirated are organic materials typically peanuts which can gradually absorb water and swell up over a period of time leading to complete obstruction. Inorganic FB like batteries, coins, toys are rare (unfortunately, the rare ones are easily seen on a CXR). 

Even with a FBA, CXR can be completely normal or it may show air trapping, infiltrates, consolidation. A later CXR may help in differentiating between airway and oesophageal FB. CT scans and bronchoscopy can further accurately localise the FB and aid removal . Whenever there is a high suspicion (based on history or poor response to treatment), further work up must be done. Rigid Bronchoscopy is used for the definitive management with occasional use of flexible bronchoscopes to reach sub segmental FBs. 

Take Home:

Aspirated foreign body is an important differential diagnosis for Asthma/Reactive Airway Disease and should also be considered in the child who has an exacerbation that does not respond to standard treatment. 

Further Reading

1. Rizk H, Rassi S. Foreign body inhalation in the pediatric population: lessons learned from 106 cases. Eur Ann Otorhinolaryngol Head Neck Dis 2011;128(4):169-174.

2. Asif M, Shah SA, Khan F, Ghani R. Analysis of tracheobronchial foreign bodies with respect to sex, age, type and presentation. J Ayub Med Coll Abbottabad 2007;19(1):13-15.

3. Saki N, Nikakhlagh S, Rahim F, Abshirini H. Foreign body aspirations in infancy: a 20-year experience. Int J Med Sci 2009 14;6(6):322- 328.

4. Fraga Ade M, Reis MC, Zambon MP, Toro IC, Ribeiro JD, Baracat EC. Foreign body aspiration in children: clinical aspects, radio- logical aspects and bronchoscopic treatment. J Bras Pneumol 2008;34(2):74-82.

5. Orji FT, Akpeh JO. Tracheobronchial foreign body aspiration in children: how reliable are clinical and radiological signs in the diagnosis? Clin Otolaryngol 2010;35(6):479-485.

6. Jung SY, Pae SY, Chung SM, Kim HS. Three-dimensional CT with vir- tual bronchoscopy: a useful modality for bronchial foreign bodies in pediatric patients. Eur Arch Otorhinolaryngol 2011;16. (Epub ahead of print)

7. Passàli D, Lauriello M, Bellussi L, Passali GC, Passali FM, Gregori D. Foreign body inhalation in children: an update. Acta Otorhinolaryn- gol Ital 2010;30(1):27-32.

8. Wu CT, Wang CJ. Alternate lung collapse in a 9-year-old boy with peanut aspiration. Pediatr Radiol 2006;36(12):1327. 

9. Zaupa, Paola, et al. "Management strategies in foreign-body aspiration." The Indian Journal of Pediatrics 76.2 (2009): 157-161.

10. Cohen, Shlomo, et al. "Suspected foreign body inhalation in children: what are the indications for bronchoscopy?." The Journal of pediatrics 155.2 (2009): 276-280.

Case contributed by Dr. Azharullah Khan, MRCEM (@Khan123Azhar)