ENDOBRONCHIAL FOREIGN BODY ASPIRATION MIMICKING AN ENDOBRONCHIAL TUMOR

Abstract

TOPIC: Procedures TYPE: Fellow Case Reports INTRODUCTION: Aspiration of foreign body (FB) into the airways may have an indolent presentation in adults. Although the majority of FB aspiration cases can be diagnosed easily and accurately by radiography and bronchoscopy, some patients are misdiagnosed as having endobronchial tumors. We describe an interesting case of bronchus intermedius FB that mimicked an endobronchial tumor. CASE PRESENTATION: A 61-year-old, male long-time heavy smoker with history of excessive alcohol use and stroke with residual left-sided hemiparesis presented with a 3-month history of worsening dry cough, hemoptysis and dyspnea. Chest computed tomography revealed occlusion of the bronchus intermedius with an enhancing lesion highly suspicious for an obstructing bronchial mass, along with moderate pleural effusion and enlarged subcarinal lymphadenopathy. Thoracentesis of the pleural effusion showed exudative fluid with predominantly neutrophilic cells that was negative for malignancy on cytology twice. Flexible bronchoscopy a firm, endobronchial lesion causing near total occlusion of the bronchus intermedius. Forceps endobronchial biopsy of the lesion and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) of a subcarinal lymph node revealed no malignant cells. The patient then underwent flexible bronchoscopy with removal of the occluding lesion using cryoablation. The obstructing mass appeared to be freely movable when the cryoprobe was attached to it. A basket was used to retrieve the entire resected mass, which appeared to be an aspirated pill surrounded by granulation tissue on gross examination. Histopathology of the specimen showed no evidence of malignancy but was consistent with FB aspiration. DISCUSSION: Symptoms of FB aspiration in adults may be absent and often delayed, in some reports for up to 26 months. Dysphagia and impaired cough reflex are the main mechanisms for FB aspiration. This was likely the case in our patient with a history of stroke and excessive alcohol use. In case of such an indolent presentation and invisibility of the FB on chest imaging due to formation of granulation tissue, FB aspiration may be overlooked in adults. In our patient, this was further cofounded by the presence of pleural effusion and mediastinal lymphadenopathy, which were concerning lymphadenopathy, but were likely due to post-obstructive pneumonia. Bronchoscopic cryotherapy, which resulted in the correct diagnosis in this patient, has been described in the diagnosis of benign and malignant lesions of the airways and for recanalization. CONCLUSIONS: This case highlights the importance of suspecting FB aspiration when evaluating airway lesions. Choice of a noninvasive method, such as bronchoscopic cryotherapy, for removing an endobronchial lesion, may preclude the need for thoracotomy. REFERENCE #1: 1- Alharthi BJ, et al. Occult foreign body in the lung mimicking bronchogenic carcinoma. BMJ Case Rep. 2014;2014:bcr2014207438. Published 2014 Dec 17. doi:10.1136/bcr-2014-207438 REFERENCE #2: 2- Hewlett JC, et al. Foreign body aspiration in adult airways: therapeutic approach. J Thorac Dis. 2017 Sep;9(9):3398-3409. doi: 10.21037/jtd.2017.06.137. PMID: 29221325; PMCID: PMC5708401. REFERENCE #3: 3- Sehgal IS, et al. Use of cryoprobe for removal of a large tracheobronchial foreign body during flexible bronchoscopy. Lung India. 2016 Sep-Oct;33(5):543-5. doi: 10.4103/0970-2113.188978. PMID: 27625452; PMCID: PMC5006338. DISCLOSURES: No relevant relationships by Omar Abdulfattah, source=Web Response No relevant relationships by Muath Alsharif, source=Web Response No relevant relationships by Traves Crabtree, source=Web Response no disclosure on file for Keivan Shalileh