CASE REPORT

Niger J Paed 2013; 40 (4): 434 – 437

Oloyede IP

Ekpe E

Okorie OO

Bronchial foreign body

misdiagnosed as pulmonary

tuberculosis

DOI:http://dx.doi.org/10.4314/njp.v40i4,19

Accepted: 20th February 2013

`

Abstract Retained and neglected

case of left bronchial foreign body

foreign bodies in the respiratory tract

in children are a common occurrence.

Undiagnosed foreign bodies can

cause mechanical effects or chemical

reactions and may present as chronic

pulmonary infection, bronchiectasis,

asthma, and lung collapse or lung

abscess. Delay in diagnosis, appears

to result from a failure to give serious

consideration to the diagnosis, normal

chest roentgenographic findings, and

negative bronchoscopic findings. A

aspiration is herein reported to illus-

trate the causes and complications of

the delayed diagnosis. It is hoped that

this will help sensitize the medical

practitioner of the need for a high in-

dex of suspicion in children presenting

with symptoms suggestive of foreign

body aspiration. This study will also

serve as advocacy for the provision of

adequate bronchoscopic equipments

for paediatric practice in our health

facilities.

Oloyede IP⁽

Okorie OO

)

Department of Paediatrics,

University of Uyo Teaching Hospital,

PMB 1136, Uyo, Akwa Ibom State,

Nigeria

E-mail: isooloyede@yahoo.com

Tel +2348068889226

Ekpe E

Cardiothoracic unit,

Department of Surgery,

University of Uyo Teaching Hospital

PMB 1136, Uyo, Akwa Ibom State,

Nigeria

Case report

included dyspnoea, vesicular breath sounds with bilat-

eral crepitations and rhonchi. He was placed on intrave-

nous (IV) Ceftriazone 1g daily for five days, intramus-

cular (IM) arthemether 60mg b.d for six days and IV

hydrocortisone 100mg dly for three days. Clinical fea-

tures of lower respiratory tract infection later resolved

and he was discharged on the seventh day of admission

on oral cefuroxime 250mg b.d for five days and told to

come for a repeat bronchoscopy a week later. The repeat

rigid bronchoscopy was done two weeks after the first

one and no foreign body was visualized. He was thereaf-

ter discharged home on caps Ampiclox 500mg 6hrly

after an initial 24 hours of Ampiclox through the intra-

venous route.

An 11 year old male presented with a four years history

of recurrent wheezing and cough and a two years history

of difficulty in breathing, recurrent fever and weight

loss. The child had earlier presented to the Ear, Nose

and Throat Department of the University of Uyo Teach-

ing Hospital four years earlier with the complaints of

wheezing which the mother noticed after he inhaled a

balloon component, while blowing a whistle with a bal-

loon attached to it. There was associated discomfort in

the throat when he tried to cough. He was not a known

asthmatic and he had completed his immunizations ac-

cording to the National Programme for Immunization

(

NPI) schedule.

He was the last of five children two males and three

females, elder siblings are alive and well. Mother is a

With persistence of symptoms he presented at the Uni-

versity of Calabar Teaching hospital where another

bronchoscopy was done and no foreign body was visual-

ized. During the period he had two episodes of haemop-

tysis and was seen in a health centre and placed on six

months of anti-tuberculous medications, after sputum

Acid and Alcohol Fast Bacilli (AAFB) was tested for,

though mother was not aware of the test results, but

symptoms persisted and hereafter the mother resorted to

herbal medications and prayers in the church.

3

9year old civil servant with secondary level of educa-

tion, while father had died of an unknown illness. There

was no contact with an adult with chronic cough.

Examination findings revealed a respiratory rate of

2

0breaths/minute, vesicular breath sounds with transmit-

ted sounds and localized rhonchi on the left hemithorax.

He was admitted in the paediatric ward after a diagnosis

of foreign body in the left bronchus was made. An ur-

gent chest radiograph done was normal, his haemoglo-

bin concentration was 10g/dl and his Human Immuno-

deficiency Virus (HIV) serology screening was negative.

He had an urgent rigid bronchoscopy which was unsuc-

cessful because of inappropriate equipments.

Two years later the patient represented to the children

emergency unit of UUTH, with complaints of cough and

difficulty in breathing of two months duration, with fe-

ver and weight loss of one month duration. The cough

was insidious in onset and initially productive of frothy

sputum, which later became purulent, there was no

haemoptysis and no history of contact with persons with

Two days into admission he developed high grade fever

with laboured breathing. Chest examination findings,

4

35

chronic cough. Difficulty in breathing was progressive,

initially on exertion but later occurred also at rest, it was

worsened by bouts of cough. Chest pain was present

especially over the left hemi thorax, stabbing, worse on

coughing or movement and relieved by rest. There was

associated orthopnoea and paroxysmal nocturnal dysp-

noea. Fever began a month later, insidious in onset, high

grade and intermittent and transiently relieved by tablet

paracetamol. Weight loss was progressive with a poor

appetite. For the above he was taken to general hospital

Abak where purulent fluid was aspirated from the left

side of the chest using a syringe and needle and he was

referred to UUTH for expert management.

Packed Cell Count (PCV) was 29%, Mantoux test was

10mm, a tuberculous score was 10/15 and child was

referred to the DOTS unit where he was recommenced

on anti-tuberculous medication for six months as a case

of treatment failure but mother declined the drugs. He

was discharged after spending four weeks on admission

Four years after the first presentation child was seen

with similar complaints of cough, difficulty in breathing,

chest pain and inability to lie flat. The general physical

examination showed a chronically ill looking child, in

0

respiratory distress, afebrile (36 C), grade III finger

clubbing, no peripheral lymphadenopathy, with a weight

of 26kg(80% of expected). The child was tachypneic

and dyspneic with a respiratory rate of 48cy/min. The

trachea was deviated to the right, with reduced chest

expansion and tactile fremitus on the left mid/lower lung

zones. The percussion notes were stony dull in the left

mid/lower lung zones while they were resonant on the

right.

Air entry was reduced in the left upper lung zone and

absent in the mid/lower zones while there was good air

entry on the right. Breath sounds were bronchial on the

left upper lung zone, absent in the left mid/lower lung

zones and vesicular on the right hemithorax. There were

no crepitations.

Physical examination revealed an acute on chronic ill

0

looking child, febrile with a temperature of 38.7 C,

wasted with prominent ribs and scapulae, moderately

pale, dyspneic and tachypneic, acyanosed, grade 2 fin-

ger clubbing, nil peripheral lymphadenopathy and nil

pedal edema. The body weight was 26kg (81% of ex-

pected). Respiratory system examination revealed a

tachypneic (RR=48cy/min) and dyspneic child with

intercostal and subcostal recession. The trachea was

central with a bulging and tender left anterior chest wall.

There was reduced chest expansion, reduced tactile fre-

mitus and stony dull percussion notes over the left

hemithorax. Breath sounds were bronchial in the upper

left lung zone. Air entry in the left hemithorax was

decreased in the mid and absent in left lower zone.

There was no evidence of cardiomegaly or cardiac fail-

ure and examination of other systems was essentially

normal. A diagnosis of bronchiectasis with left lung

collapse and left empyema thoracis to R/O Left Tuber-

culous empyema and left lung collapse was made. An

urgent close tube thoracotomy drainage, (CTTD) under

local anaesthesia was productive of thick purulent fluid

which later on became seropurulent, because of the vis-

cosity of the fluid the CTTD was not very effective. A

review chest x-ray showed interval improvement with

appearance of lung substance close to the left lateral

chest wall with mediastinal shift to the left and left lung

collapse.(Fig 1) He was thereafter commenced on IV

Ceftriazone 1g 12hrly and Gentamicin 40mg 8hrly.

Diagnostic thoracocentasis yielded free flowing offen-

sive rice water like aspirate with the impression of

thickened parietal pleura. Other systems were essentially

normal. A diagnosis of bronchiectasis with left lung

collapse and empyema thoracis was made. A

pre-intubation x-ray showed homogenous opacity of the

left hemithorax with minimal apical sparing with oblit-

eration of the costophrenic and cardiophrenic angles and

air-fluid levels, mediastinal shift to the right with apical

cavitatory lesions on the left lung and right hilar opaci-

ties. (Fig 2)An urgent PCV was 24% while a repeat

mantoux test had no wheal. The sputum AAFB was

negative while sputum culture and sensitivity grew

Klebsiella species which was sensitive to ofloxacin and

levofloxacin. The HIV serology was negative.

Fig 2

Fig 1

An urgent CTTD was done with drainage of over

2000mls of offensive purulent fluid. The child was ini-

tially placed on IV Ceftriazone and Genticin but on get-

ting the sensitivity result the drugs were changed to Tab

Ofloxacin 100mg b.d for three weeks and child was

commenced on chest physiotherapy, and reviewed by

the public health physicians who also made a diagnosis

The patient was reviewed by the cardiothoracic unit and

plans were made to do an open thoracotomy with decor-

tication. A post intubation chest radiograph later

showed a central trachea with an area of homogenous

consolidation in the left upper lobe with surrounding

areas of patchy consolidation and left lung collapse. The

4

36

0

of bronchiectasis with recurrent empyema thoracis 2 to

because of the fact that most foreign bodies are radiolu-

cent, the chest radiographs₆_,a₇ re frequently normal as was

seen in the case presented.

foreign body aspiration to R/O pulmonary tuberculosis .

A Computerized Tomography scan showed a radio-

opaque foreign body in the left main bronchus with a

resultant collapse/consolidation of the left lung and di-

lated left bronchioles .(Fig 3) The plan was to attempt

bronchoscopic removal of the foreign body with possi-

ble progression to thoracotomy and bronchotomy if

bronchoscopic removal failed, but due to lack of the

appropriate bronchoscope, the child was referred to the

cardiothoracic unit of university of Nigeria teaching

hospital Enugu for surgery.

Late diagnosis of foreign body has been defined as oc-

curring beyond three days between aspiration of the for-

eign body, or onset of symptoms and the correct diagno-

8

sis. Some causes of late diagnosis that have been identi-

8

fied include, parental negligence, mis_,diagnosis by fel-

9

low professionals and paediatricians, normal chest ro-

7

,10

lack of typical symptoms

entgenographic findings,

and signs, mismanagement, negative bronchoscopic

find₁i₁n_,₁g₂_,s₁₃and lack of appropriate facilities for diagno-

The final diagnosis was Collapse/ consolidation of the

left lung and chronic empyema thoracis 2 to foreign

sis.

In the index case misdiagnosis by fellow pro-

0

fessionals, a normal initial chest radiograph, negative

bronchoscopic findings due to inappropriate equipment

and mismanagement were the identified causes of the

delayed diagnosis. It is well known that antibiotics and

steroids can temporarily subdue a patients reaction to

body in the left main bronchus

Child was seen in the CTSU clinic three months after

the surgery, he was still having cough productive of pu-

rulent sputum but with no fever and was now able to

tolerate exercise (football).

a weight of 30kg

increased), trachea was deviated to the left, decreased

chest expansion on the left, increased tactile fremitus

and vocal resonance on the left hemithorax, dull percus-

sion notes with bronchial breath sound on the left upper

zone and absent breath sounds on the left mid/lower

zone. A diagnosis of persistent atelectatic left lower lobe

was made. He was commenced on tab tinidazole 250mg

bd for two weeks, tab cefuroxime 250mg b.d and syrup

broncholyte 10ml t.d.s for 10 days.

He defaulted from follow up and was seen five months

later in the children outpatient department, when he still

had complaints of productive cough and the examination

findings were basically the same as what was seen in the

previous visit to the CTSU unit

8

,9

foreign body aspiration as was in the index case. Thus

the disappearance of cough, wheezing or the clearing of

a pneumonia may reinforce a faulty diagnosis. On the

other hand, reappearance of symptoms after treatment

should alert one to the possibility of a foreign body aspi-

ration.

Examination findings showed

(

Bronchoscopy has been shown to be an important tool in

both₁t_,h₃_,e₇diagnosis and treatment of foreign body aspira-

tion.

The indication for bronchoscopy include for-

eign body aspiration, or suspicion of aspiration of for-

eign body as well as concomitant symptoms such as

coug₁h₄,_,₁₅difficulty in breathing and rise in tempera-

ture.

The success of bronchoscopy is dependent on

the appropriateness of the equipment and the expertise

of the professional. In a case of an initial negative bron-

choscopy, a second bronchoscopy should be considered

even more carefully because it is more difficult and dan-

gerous due to the mucosal damage and formation of

7

Discussion

granulation tissue caused by the initial bronchoscopy.

Hence a search for the foreign body should be made jus₈t

below the granulation tissue in a repeat bronchoscopy.

This may have been the reason for failure to visualize

the bronchial foreign body in the subsequent broncho-

scopies in the index case.

Inhalation of foreign bodies is a very serious condition

in childhood and may result in an acute respiratory

distress, chronic and irreversible lung damage or even

death. Early diagnosis and removal of foreign bodies

1

must be achieved to avoid complications. Forty two to

5

between one and three years of age.

5% of patients with foreign bodies_,₂_,i₃n the airways are

Radiology is the primary means of confirming the diag-

nosis. However, it has been seen that most foreign bod-

1

6

The location of a

foreign body is dependent not only on its size and shape

but also on the positi₄o_,₅n taken by child at the time the

aspiration takes place. In 5-60% it is located in the left

bronchus while in 30-40% it is seen in the right bron-

ies are radioluce_,n₇t and so the chest radiographs are fre-

6

quently normal. As a result computerized tomographic

(CT) scan is increasingly being recognised as a more

superior diagnostic tool. CT scan not only shows both

opaque and non-opaque foreign bodies in the bronchial

tree in many cases but also detects subtle air trapping

4

,5

chus and in the trachea in 10-15%. The most common

presentations of bronchial foreign body aspiration in-

clude recurrent cough, wheezing, dyspnoea and de-

creas₁e_,_,d₆ breath sound especially asymmetrical ausculta-

7

not yet present in chest radiograph. In the index case an

earlier resort to CT scan would have prevented the long

term morbidity from the complications of foreign body

aspiration and the unnecessary cost incurred by the care-

givers in the treatment of recurrent pneumonia. The

drawback in the use of CT scan however, is its radiation

hazard and increased cost especially in resource poor

tion.

These were all present in the index case.Early

diagnosis of foreign body in the airway has been hinged

on the tripod of a history of foreign body inhalation,

2

clinical presentation and radiographic findings. This

however has some shortcomings as an acute episode of

inhalation may escape the notice of the caregivers, the

child may not present with the classic symptoms and

6

setting. As presented in the index case it took the care-

giver almost nine months to gather the resources for the

4

37

CT scan before a definitive diagnosis was made. Hence,

although CT scan is a very sensitive test, it is usually

reserved for the₇diagnosis of elusive cases of a foreign

body aspiration.

Conclusion

Aspiration of foreign body should be suspected in all

cases of bronchopulmonary infection with an atypical

course. Early diagnosis and removal may save the

patient chronic illness, an existence as an invalid or pos-

sibly death. Despite the great progress in the methods of

endoscopy and anaesthesia great difficulties and compli-

cations are still present owing to the limitation of

diagnostic procedures.

We therefore recommend that the basic tools needed for

the diagnosis and removal of foreign bodies including

appropriate sized bronchoscopes and CT scan should be

made available in all tertiary health centres. Training of

professionals including otolaryngologist, pulmonologist

and cardiothoracic surgeons should be emphasised as

the diagnosis and treatment of foreign body in the

airway requires a multi-disciplinary approach.

Retained and neglected foreign bodies in the respiratory

tract are fraught with a myriad of complications. Com-

mon complications of undiagnosed foreign bodies in-

clude obstructive emphysema, recurrent pneumonia,

lung abscess, cystic bronchiectasis, atelect₂a_,₇s_,₈is of a lobe,

asthma, lung collapse, bronchial stenosis

and pneu-

3

momediastinum. The index case presented with most of

the outlined complications. As a result of these compli-

cations most cases of retained foreign bodies are usually

misdiagnosed. This was evident in the index case, which

was misdiagnosed as a case of pulmonary tuberculosis,

treated with anti-tuberculous medications for six months

and would have had a second course but for the refusal

by the caregivers. Li et al in his study gave the frequent

misdiagnosis of foreign body aspiration to include pneu-

monia, bronchitis,₉ pulmonary tuberculosis, laryngitis,

and common cold.

Conflict of interest: None

Funding: None

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