Esophageal Obstruction due to Foreign Body Ingestion Presenting as Ataxia

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Purpose: Introduction: Patients with foreign body ingestion (FBI) can present with varied symptoms including dysphagia, odynophagia, choking, coughing, gagging, drooling, wheezing, decrease in appetite and refusal to eat. Patients with developmental disabilities (DD) and mental retardation (MR) are particularly challenging, not only because of the higher risk of FBI, but also due to the delay in diagnosis as the classical symptoms may be lacking and their inability to communicate may mask FBI. Here we describe a case of 46-year old woman with MR who had FBI and presented subacutely with ataxia. Case Report: A 46 y/o Caucasian woman with MR secondary to childhood encephalitis and seizure disorder was brought to the emergency room by her mother for increased agitation and ataxia for one week. She was afebrile and hemodynamically stable with no evidence of inspiratory stridor or respiratory compromise. Her chest X-ray and computed tomographic scan of the head showed no acute abnormality. Electroencephalogram showed no seizure activity. Esophagoscopy was performed as the patient had history of swallowing foreign objects and had notably hoarse voice, kept trying to gag herself and repeatedly rubbing her chest, suggestive of some chest discomfort. She was found to have a 16 oz soda bottle cap in the mid-esophagus as the etiology for her symptoms which was successfully removed using rigid esophagoscope and a curved Coda balloon catheter after the initial failure to remove it with the flexible scope. Patient was started on proton pump inhibitors and her ataxia and agitation improved. She was discharged the next day of procedure. Discussion: This is the first case report of esophageal obstruction due to FBI presenting as ataxia. This case illustrates the difficulty in diagnosing FBI in non-verbal patients with MR who have impaired cognitive skills. A very high index of suspicion is needed in these patients as FBI in these patients can have varied presentations. They not only have a higher predisposition to FBI but the usual protective mechanism like gagging episodes occur more frequently and hence a sudden episode may not provoke additional anxiety in the caregiver. FBI should be considered early in the differential diagnosis of sudden behavioral change and altered mental status. Patients with suspected FBI should have prompt esophagoscopy, as it can not only confirm the diagnosis but also can help in removal of the foreign body. Conclusion: This case illustrates that patients with MR may not have a classical presentation associated with FBI. They can even present as ataxia and a high index of suspicion is needed to make a prompt diagnosis to avoid potentially lethal complications.