An acute foreign body ingestion presenting as left sided empyema as its removal by novel method

Foreign body aspiration is not very common in adults, clinically, patients either present with acute respiratory failure which require immediate intervention or with recent onset of symptoms, like wheezing, breathlessness, coughing, and expectoration. Occasionally, a forgotten or incidental foreign body may get detected on a chest radiographs which are obtained for unrelated reasons or during bronchoscopy. Identifi cation of occult foreign body aspiration often requires a high index of clinical suspicion, especially in those who present without a history of aspiration. There have been many reports where foreign body present radiologically as collapse, consolidation and in chronic cases may even as bronchiectasis. Here we have 36 year old who had empyema which was later found to be sequelae to incidental foreign body aspiration, and which was removed by innovative method using electrocautery, fogarty and biopsy forceps Case Report An acute foreign body ingestion presenting as left sided empyema as its removal by novel method Ramniwas*, Gopal Chawla, Nishant Kumar Chauhan and Naveen Dutt Department of Pulmonary Medicine, All India Institute of Medical Sciences, Jodhpur, India Received: 19 July, 2019 Accepted: 09 August, 2019 Published: 12 August, 2019 *Corresponding author: Dr. Ramniwas, Department of Pulmonary Medicine, All India Institute of Medical Sciences, Jodhpur, India, Tel: 9999493179; E-mail: https://www.peertechz.com


Introduction
Foreign body aspiration is very commonly seen in children can present acutely in form collapse stridor or respiratory arrest, though in adults FB aspiration is less common as compared to children. Here young male presented with dyspnoea which started after FB aspiartaion and resulted in formation of empyema increasing the respiratory distress

Case Scenario
A 36 year old, non-smoker, occasional betel nut chewer, gold smith by occupation, having background history of Type 1 Diabetes Mellitus for past 6 years and is on anti-depressants for mood disorders for past 4 years, presented to emergency with worsening breathlessness and fever for past 4 days and chest pain for 3 days, he was having chest x ray which was done 3 days back showing blunting of left costophrenic angle.
Patient was admitted and fresh tests were ordered along with chest x ray. On detailed history he told that 6 days back while eating betel nut he started coughing and felt he may have aspirated. Chest x ray showed increase in effusion along with some opacities extending up to middle zone, effusion appears to be loculated. USG chest was done which showed organized effusion, which could not be aspirated even with 18 G needle , so USG guided pigtail (14 fr) was inserted and thick brown pus was drained , which was sent for microbiological analysis. .Side by side fi beroptic bronchoscopy was planned. During FOB fl eshy endobronchial growth was seen in lower lobe post segment, which bleed to touch, mucus was seen coming from side of growth. BAL was taken and sent for microbiological analysis. Patient was planned for repeat FOB for endobronchial biopsy next day after informed consent. Globular fl eshy mass was cauterised partially to take biopsy, but to surprise brown unidentifi ed material was seen below that mass after electrocautery ( Figure 1). Biopsy of that material was taken, histopathologic examination showed fi bro-collagenous tissue infi ltrated with acute on chronic infl ammatory infi ltrate and numerous proliferating blood vessels with adjacent areas of Our patient had initial chest X ray which showed heterogeneous opacity in left lower lobe and next radiology was suggestive of massive pleural effusion which later turned out to be empyema. This is quite unusual as there is no report which shows acute aspiration of betel nut results in empyema.
It may be because our patient was having diabetes which has been shown independent risk factor in diabetes [9].
It is well known that old FB aspiration may cause bronchiectasis, necrotising pneumonia or pleural effusion [10]. Empyema following aspiration of a FB is rare scenario.
One study done over a period of 15 year revealed among 1038 patients with bronchiectasis only eight were found to be due to a long retained FB [9]. It has been proven again and again that removal of FB is suffi cient to revert the lung changes to normal and usually it does not warrant any surgical intervention [10].
In the present case, the acute aspiration of FB in the left lower lobe bronchus as compared to common observation of lodgement in right main bronchus, but few previous studies had shown that FB aspiration into the left main bronchus was also not uncommon. In that study 28 out of 60 ( To conclude FB aspiration should be considered as one of the important differential of chronic intractable cough or unresolved pneumonia. A long-term unrecognised FB aspiration can present with recurrent pneumonia and secondary empyema but in patients with immunosuppression it can present early and should be considered by giving due importance to history and course of illness.