Migrating airway foreign body

Case contributed by Dr Ammar Ashraf

Presentation

Progressive shortness of breath, productive cough, and recurrent fever for 1 week. No history of contact with COVID-19 patient.

Patient Data

Age: 60 years
Gender: Female
X-ray

Day 1

Reduced volume right lung with extensive changes of collapse/consolidation with mild right sided mediastinal shift. Mildly hyperinflated left lung.

CT

Day 2

Extensive consolidative changes with air bronchograms are noted in the right middle and lower lobes. Extensive tree in bud appearance suggestive of endobronchial spread of active infective process is also noted in the right lung. A foreign body measuring 7 x 10 mm having an average density of 377 HU is noted in the right main bronchus just distal to the carina. Small right pleural effusion. No pneumothorax or pneumomediastinum is noted. An enhancing pretracheal lymph node measuring 17 mm in short axis is noted. Left lung is unremarkable. Mild cardiomegaly.  Large hiatus hernia.

X-ray

Day 4 (after bronchoscopy)

Interval development of a right-sided tension pneumothorax with mediastinal shift to the contralateral side.

X-ray

Day 4

Interval insertion of right sided chest tube with near complete resolution of the previously noted pneumothorax and mediastinal shift.

CT

Day 15

Small foreign body noted in the right main bronchus on previous CT scan is now visualized within the distal left main bronchus. No associated lobar collapse is appreciated within the left lung. An interval improvement is noted in the right lung consolidative changes; however, tree-in-bud pattern, suggestive of endobronchial spread of active infective process is still appreciable. Minimal right-sided pneumothorax. No significant pleural / pericardial effusion or lymphadenopathy is seen. Large hiatal hernia

Photo

2nd Bronchoscopy

A foreign body (chicken vertebra) was seen in the distal left main bronchus, which was retrieved easily with a grasper. No complications noted.

Case Discussion

Initial workup showed elevated inflammatory markers (CRP, WBC, LDH, ferritin, lactic acid) respiratory alkalosis and hypoxia. A clinical diagnosis of acute respiratory failure was made and the patient was admitted in the ICU. Negative work up of COVID-19 and pulmonary tuberculosis. Bronchoscopy (after the initial CT chest) showed a foreign body in the proximal right main bronchus; however, it could not be retrieved due to copious thick secretions in the airways. Patient’s general condition further deteriorated during the procedure and post-bronchoscopy chest x-ray showed a right-sided tension pneumothorax which was managed with a chest tube.  

2nd CT chest was done after significant improvement in the clinical condition of the patient which showed the migration of the foreign body from the right main bronchus to the left main bronchus. Bronchoscopy was done which showed a chicken vertebra in the distal left main bronchus which was successfully removed. No complications were noted and the patient was discharged the next day in a stable condition.

The patient did not remember the event of aspiration exactly.     

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Case information

rID: 83928
Published: 18th Nov 2020
Last edited: 20th Nov 2020
System: Chest
Inclusion in quiz mode: Included
Institution: Ministry of national guard health affairs