Abstract
SESSION TITLE: Medical Student/Resident Procedures SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Pill aspiration is a major cause of morbidity and mortality in elderly patients in whom an aspiration event may not be evident. Chest imaging has limited utilization as most pills are radiolucent. During surveillance bronchoscopy, a foreign body may not be seen, as pills can dissolve in the tracheobronchial tree causing obstruction, inflammation, fibrosis and airway stenosis. A high index of suspicion is required in adults presenting with respiratory symptoms. CASE PRESENTATION: A 73 year old woman presented to the hospital with non productive cough and shortness of breath for a few days. Her past medical history was significant for stroke with left-sided hemiplegia and seizure disorder on treatment. She had no associated symptoms including fever, chills, night sweats or weight loss. On physical examination, she was tachypneic and had diminished left lung breath sounds. Laboratory work-up revealed a normal white blood count without bandemia. Chest X-Ray was consistent with complete left lung opacification. The patient was intubated due to worsening hypoxemia. Computed Tomography (CT) of Chest revealed extensive obstruction of the left main stem bronchus with concern for endobronchial lesions. She underwent an emergent bronchoscopy; revealing complete obstruction of the left main stem bronchus; mass like dense granulation tissue was noted with intense airway reaction. A biopsy forceps was used initially to remove the granulation tissue. Subsequently, Argon plasma coagulation was used for mechanical debridement, debulking and restoration of the airway. Histopathology of the evacuated specimen revealed fragments of crystalline and calcified material with intense inflammatory changes. Further history revealed that patient had been taking Calcium acetate pills orally and asking her caregiver to "throw the pill” into her mouth. Her presentation was then explained by a medication aspiration event, and subsequent intense foreign body reaction. The patient was extubated after the procedure, improved clinically and was discharged. DISCUSSION: The clinical presentation of airway obstruction due to medications varies, from dyspnea and focal wheezing to severe inflammation, fibrosis and respiratory failure. The exact response depends upon the properties of the pill ingested. Calcium acetate is known to cause granulation tissue formation following aspiration. A diagnosis may be established by endobronchial surveillance with bronchoscopy along with biopsy or bronchoalveolar lavage. This may also identify the extent of injury and guide interventions to maintain airway patency. CONCLUSIONS: The presence of a focal wheeze, recurrent or non-resolving pneumonia or a new endobronchial lesion in an elderly patient should prompt an early detailed bronchoscopic evaluation. Fatal complications from aspiration can be avoided and treated if recognized in a timely manner. Reference #1: Kupeli, E., et al. (2015). ""Pills” and the air passages: a continuum.” Chest 147(1): 242-250 Reference #2: Kinsey, C. M., et al. (2013). "Evaluation and management of pill aspiration: case discussion and review of the literature.” Chest 143(6): 1791-1795 Reference #3: Mehta AC, Khemasuwan D. A foreign body of a different kind: Pill aspiration. Annals of Thoracic Medicine. 2014;9(1):1-2. https://doi.org/10.4103/1817-1737.124404 DISCLOSURES: no disclosure on file for Toler Doug; No relevant relationships by Mohsin Ijaz, source=Web Response No relevant relationships by Amir Khan, source=Web Response No relevant relationships by Kamran Manzoor, source=Web Response No relevant relationships by DOUGLAS TOLER, source=Web Response No relevant relationships by Fatima Zeba, source=Web Response
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