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Case Letters
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A forgotten foreign body in bronchus
Sir,
Foreign body aspiration (FBA) is more common in
children than in adults.[1] Hence, it is rarely considered
in adults unless the patient gives a clear history of
aspiration.[2] Depending on the composition of the foreign
body and duration of retention in the tracheobronchial tree,
inflammatory reaction in the tissue, at the site of retention
may vary. Nevertheless, it should be diagnosed early so
that sequelae caused by its retention are prevented.[3] We
report here a case of aspiration of a plastic whistle at the
age of 12 years which was diagnosed on contrast‑enhanced
computed tomography (CECT) thorax 20 years later
when patient presented as postobstructive collapse with
bronchiectasis and secondary infection.
A 32‑year‑old man presented with a history of cough
associated with minimal mucopurulent expectoration for
15 days and left‑sided dull aching chest pain off and on for
2 years. He had a history of recurrent respiratory infections
in the past. He was a nonsmoker and had no history of
exposure to biomass fuel. There was no history of wheezing
episodes in the past. He was an owner of a hardware
shop. On examination, the only positive findings were
the presence of clubbing, impaired note on percussion,
and crepitations on auscultation in the left infrascapular
area. His chest radiograph showed retrocardiac haziness
694 Lung India • Vol 33 • Issue 6 • Nov - Dec 2016
2007;41:1992‑2001.
12. Zaha O, Hirata T, Kinjo F, Saito A, Fukuhara H. Efficacy of ivermectin for
chronic strongyloidiasis: Two single doses given 2 weeks apart. J Infect
Chemother 2002;8:94‑8.
13. Fardet L, Généreau T, Cabane J, Kettaneh A. Severe strongyloidiasis in
corticosteroid‑treated patients. Clin Microbiol Infect 2006;12:945‑7.
This is an open access article distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non-commercially, as long as the
author is credited and the new creations are licensed under the identical terms.
Access this article online
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DOI:
10.4103/0970-2113.192860
How to cite this article: Chand T, Bansal A, Jasuja S, Sagar G.
Pulmonary strongyloidiasis and hyperinfection in a renal transplant
patient. Lung India 2016;33:692-4.
probably due to left lower lobe collapse and secondary
infection. He was advised to get a CECT thorax after a
course of antibiotics. CECT thorax showed the presence of
a foreign body in the left lower lobe bronchus [Figure 1].
There was atelectasis due to fibrosis and bronchiectasis
in the left lower lobe [Figure 2]. On probing, he revealed
history of aspiration of a plastic whistle at the age of
12 years which he had totally forgotten as the episode
had happened 20 years back. He could not recollect any
major respiratory illness prior to that. Three months later,
he underwent flexible bronchoscopy at his native town in
Kerala for its removal which was unsuccessful and was
advised surgery for the same. The patient refused surgery.
Ten months later, following a violent bout of cough,
the whistle got spontaneously expelled out [Figure 3].
Postexpulsion, he felt sense of relief from resistance while
breathing.
Aspiration of a foreign body causes sudden onset of
cough and a sensation of choking. However, once these
acute symptoms subside, episode may be forgotten over
a period of time.[4] It is difficult to diagnose FBA if the
patient does not recollect the history.[5] It may remain
undetected until such time when patient develops either
recurrent secondary infection distal to obstruction or
bronchiectasis or changes of atelectasis which leads to
various investigations in search of underlying etiology.
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Case Letters
Figure 1: Contrast-enhanced computed tomography thorax showed
presence of a foreign body in the left lower lobe bronchus
Figure 2: Computed tomography thorax shows atelectasis of the left
lower lobe
Figure 3: Left lower lobe bronchus after expulsion of aspirated whistle
The longest period of foreign body retention in an adult
recorded in the medical literature is 40 years.[2]
Lung India • Vol 33 • Issue 6 • Nov - Dec 2016 695
Aspiration of foreign bodies in all airway locations have
been reported in literature.[6]
Tissue response to a foreign body varies according to the
duration of its retention and its composition. Longer the
duration of its retention, more will be the granulation
and impaction in the surrounding tissue.[7] Foreign bodies
comprising metal, plastic, etc., being inert will cause less
inflammation of the tissue than of organic nature such as
nuts and grains.[7]
There may be delay in diagnosis due to nonvisualization
of the foreign body on chest radiograph if it is not
radiopaque. When suspected a chest radiograph in
inspiratory and expiratory phase may aid in diagnosis by
demonstrating air trapping beyond obstructed segment.[8]
Computed tomography (CT) thorax shows foreign body as
dense structure within a bronchial lumen. Furthermore,
secondary changes such as volume loss, bronchiectasis, and
hyperluscency due to air trapping are well visualized on CT
thorax.[2] In a study by Davies et al., it has been observed
that in children with FBA on the left side with evidence of
collapse consolidation on the initial chest radiograph, there
are more chances of developing long‑term complications.[9]
In adults, the most common initial diagnostic tool used for
FBA is flexible bronchoscopy. In most cases, it allows for
its successful removal.[1] Flexible bronchoscopy can also be
used in patients who are already intubated at the time of
initial presentation. At the time of bronchoscopy, following
removal of the foreign body, a “second look” should always
be undertaken to identify any additional foreign bodies,
complications of FBA, and iatrogenic injuries.[5]
Spontaneous expulsion of aspirated foreign body is a
rare phenomenon and few cases have been published in
literature.[10]
This case report highlights the fact that an aspirated foreign
body should be diagnosed and removed as early as possible.
If forgotten and left to remain in the tracheobronchial tree for
prolonged period of time, postobstructive sequelae such as
bronchiectasis and recurrent secondary infection are likely to
develop. In this patient, foreign body being of plastic material,
the inflammation at the site of retention must have been less
intense. This might have been one of the reasons for it being
dislodged and eventually expelled out spontaneously.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Sanjivani J Keny, Uday C Kakodkar
Department of Pulmonary Medicine, Goa Medical College,
Caranzalem, Goa
E‑mail: sanjukeny@dataone.in
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Case Letters

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machine needle) from right middle lobe bronchus – A rare case report.
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1. Vachani  A, Haas  AR, Sterman  DH. Bronchoscopy. In: Spiro  SG,
Silvestri GA, Agusti A, editors. Clinical Respiratory Medicine. 4th ed.
Philadelphia: Saunders; 2012. p. 154‑73.
This is an open access article distributed under the terms of the Creative
2. Lerra  S, Raj  R, Aggarwal  S, Saini  VK, Nagarkar  NM. A long standing
Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows
foreign body in bronchus in adult: A  diagnostic dilemma. JK Sci
others to remix, tweak, and build upon the work non-commercially, as long as the
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author is credited and the new creations are licensed under the identical terms.
3. Donato  L, Neus  IJ. Tracheobronchial foreign bodies. Arch Pediatr
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4. Wu TH, Cheng YL, Tzao C, Chang H, Hsieh CM, Lee SC. Longstanding
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8. Koul PA, Wahid A, Bhat TA, Hussain T. Whistle in the bronchus. Ann
Thorac Med 2007;2:124‑5.
9. Davies H, Gordon I, Matthew DJ, Helms P, Kenney IJ, Lutkin JE, et al. How to cite this article: Keny SJ, Kakodkar UC. A forgotten foreign
Long term follow up after inhalation of foreign bodies. Arch Dis Child
body in bronchus. Lung India 2016;33:694-6.
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696 Lung India • Vol 33 • Issue 6 • Nov - Dec 2016