TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Foreign body aspiration can be a life-threatening event. Aspiration of iron pill can cause significant bronchial destruction via necrosis. Iron pill quickly disintegrates in the airway, inducing deep mucosal necrosis responsible for severe complications if not diagnosed promptly. We report a case of iron pill aspiration with asthma like presentation leading to severe bronchial stenosis. CASE PRESENTATION: A 50-year-old nonsmoking female, with past medical history of hypertension and arthropathy was referred to pulmonology for wheezing and shortness of breath that started after she had accidentally aspirated an iron pill. Examination was significant for expiratory wheezing. X-ray of the chest was normal. Bronchoscopy performed for the removal of the iron pill revealed complete obstruction of the right lower lobe (RLL) bronchus with thick mucoid secretions coated in iron and granulation tissue. Follow up bronchoscopy showed similar findings which included severe persistent airway inflammation. Cultures obtained grew cryptococcus neoformans. For which patient was she was treated with oral Diflucan for 1 year. Pulmonary function test showed no evidence of restriction or obstruction Once the infection was fully treated patient underwent endobronchial ultrasound (EBUS) which was performed as a therapeutic intervention for the RLL lesion as patient still had persistent symptoms of wheezing. EBUS showed severe stenosis of the RLL which was relieved following CRE balloon-tipped catheter insertion into the stenotic segment of the lower trachea followed by local intralesional steroid injection. On follow up three months later patient reported significant improvement in her symptoms. DISCUSSION: Iron pill aspiration syndrome is a relatively rare cause of severe bronchial inflammation leading to endobronchial stenosis [1,2]. The diagnosis is made by the presence of history of aspiration, airway inflammation and iron deposition as noted on histopathology. Oxidation of iron pill can cause bronchial mucosal inflammation, ulceration and necrosis which progresses to bronchial narrowing and possibly irreversible stenosis [3]. Early diagnosis with bronchoscopy and treatment plays a crucial role in overall prognosis. Our case represents a remarkable recovery with balloon dilation and intralesional steroid injection resulting in relief of stenosis. CONCLUSIONS: •Physicians should be very prudent with prescribing iron pills in individuals who are at high risk of aspiration in order to avoid serious bronchial complications. •Prompt bronchoscopic intervention and management is required to prevent progression to serious complications. •Physicians should consider balloon dilation with intralesional steroid injection for patients with refractory symptoms after removal of the foreign object. REFERENCE #1: Caterino U., Battistoni P., Batzella S., Iacono R. Dello, Lucantoni G., Galluccio G. Syndrome of iron pill inhalation in four patients with accidental tablet aspiration: severe airway complications are described. Respir. Med. Case Rep. 2015, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4501451/ REFERENCE #2: Management of Iron Pill Aspiration Syndrome: Advanced Bronchoscopic InterventionMonali Patil MD* Arjun Mohan MD; and Kassem Harris MD University at Buffalo, Buffalo, NY, https://journal.chestnet.org/article/S0012-3692(16)57346-2/pdf REFERENCE #3: The Iron Lung: When Iron Pill Aspiration Results in an Immediate Bronchoscopy. A Successful Medical Therapy to a Serious ConditionSarah Abuseif, Mohamed Elsawaf, Gustavo De La Luz, https://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2017.195.1_MeetingAbstracts.A5565 DISCLOSURES: No relevant relationships by Camelia Chirculescu, source=Web Response No relevant relationships by Adel El Abbassi, source=Web Response No relevant relationships by Saman Saeed, source=Web Response No relevant relationships by Haniya Saeed, source=Web Response No relevant relationships by Dima Youssef, source=Web Response