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| RADIOLOGY QUIZ |
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| Year : 2022 | Volume
: 5
| Issue : 1 | Page : 45-46 |
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Aspirated foreign body - Fish bone
Ajay Narasimhan1, Vignesh Ashokan2
1 Department of Cardiothoracic and Vascular Surgery, Apollo Hospitals, Chennai, Tamil Nadu, India
2 Department of Respiratory Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
| Date of Submission | 12-Jun-2022 |
| Date of Acceptance | 14-Jun-2022 |
| Date of Web Publication | 12-Aug-2022 |
Correspondence Address:
Vignesh Ashokan
Department of Respiratory Medicine, Apollo Hospitals, Greams Road, Chennai, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/japt.japt_18_22
How to cite this article:
Narasimhan A, Ashokan V. Aspirated foreign body - Fish bone. J Assoc Pulmonologist Tamilnadu 2022;5:45-6 |
| Case Description | |  |
A 48-year-old female presented to the outpatient department owing to persistent complaints of (c/o) cough with expectoration for the past 3 years associated with c/o hemoptysis and breathlessness on exertion.
She also had c/o weight loss around 15 kg in the last 1 year and decreased food intake.
She had a past history of hypothyroidism, impaired fasting glucose, dust allergy, snoring, wheezing, and sneezing and uses asthalin inhaler occasionally.
On physical examination, she was obese, afebrile, and maintained optimal saturation with room air and had monophonic wheeze on auscultation in the right infraclavicular and mammary areas. Computed tomography (CT) of the chest [Figure 1], [Figure 2], [Figure 3], [Figure 4] done revealed intraluminal lesion in the right intermediate bronchus with plate-like atelectatic fibrotic strand in the right middle lobe. | Figure 1: Computed tomography chest coronal view showing plate like atelectatic fibrotic strand
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 | Figure 2: Computed tomography chest Axial view showing plate like atelectatic fibrotic strand
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 | Figure 3: Computed tomography chest coronal view showing intraluminal lesion in RIB
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 | Figure 4: Computed tomography chest Axial view showing intraluminal lesion in RIB
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- What is the radiological abnormality?
- What is the bronchoscopic image?
- Discussion.
| What Is the Radiological Abnormality? | | |
CT chest axial view [Figure 2] and [Figure 4] and coronal view [Figure 1] and [Figure 3] show intraluminal lesion in the right intermediate bronchus with plate-like atelectatic fibrotic strand in the right lower lobe.
70%–90% of foreign bodies are mostly organic-like seeds and nuts. Inorganic foreign bodies may include teeth, coins, pins, and pens.
Aspirated foreign bodies have a predilection for the right tracheobronchial tree, due to wider and steeper structure of the right main bronchus.
What Is the Bronchoscopic Image?
- Aspirated foreign body - Fish bone.
Foreign bodies in the airway are rare in adults, usually located in the right main bronchus, because of its more vertical orientation. Aspirated foreign bodies are kept in place for months before being diagnosed and can produce complications, such as infections (pneumonia and abscess), chronic coughing, hemoptysis, bronchial stenosis, and atelectasis. In our case, bronchoscopy was done, and necrotic blackish material of foreign body-aspirated fish bone [Figure 5] and [Figure 6] was retrieved from the right intermediate bronchus using Dormia basket [Figure 7] and sent for Culture and sensitivity (C/S) and Histopathological examination (HPE). | Figure 5: Bronchoscopic image showing necrotic blackish material - foreign body-aspirated fish bone
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Biopsy HPE revealed bronchial mucosa tissue fragments, acute fibrinous exudate, necrotic debris, and bacterial colonies, suggestive of actinomycosis.
| Discussion | | |
The first report of foreign body-induced pulmonary actinomycosis was the Spanish patient case in 1991, which was aspirated chicken bone foreign body. Foreign body associated with endobronchial actinomycosis in our case was attributed to the aspirated fish body. Actinomycosis is an indolent, slowly progressive infectious disease caused by anaerobic or microaerophilic bacteria that normally colonize the mouth, colon, and vagina.[1] Classic features include extension to contiguous structures by crossing natural anatomic boundaries and the formation of fistulas and sinus tracts.[2] Because this infection is commonly confused with a neoplasm, it has been called “the most misdiagnosed disease.” Thoracic actinomycosis is caused by the aspiration of contaminated material from the mouth or oropharynx. Actinomycotic pulmonary infection may follow a characteristic course demonstrating locally invasive disease or, more often, may be manifested by an entirely nonspecific pneumonitis, cough, anorexia, chest pain, and weight loss.[2] The thoracic form accounts for about 20% of the cases. The cervicofacial and abdominal forms account for about 50% and 30%, respectively. The diagnosis of pulmonary actinomycosis is usually based on microscopic examination or culture of the material aspirated from the lesion, anaerobic sputum culture, or histologic examination of the resected specimen as well as from bronchoscopic biopsy.[2] The hallmark of actinomycosis is the formation of yellow sulfur granules. The microorganisms are slender-branching bacilli embedded in the matrix of the granules. In many cases, the diagnosis was based on the finding of only a single sulfur granule in a lesion. The CT scan of pulmonary actinomycosis usually reveals a soft tissue mass with varying degrees of infiltration, abscess formation, and pleural thickening adjacent to the airspace consolidation. The bronchoscope findings are usually not diagnostic and include yellowish, hard, or friable endobronchial mass.[4] Therapeutic measures usually consist of several weeks of high-dose intravenous penicillin, tetracycline, clindamycin, or erythromycin.[3] Abscess and empyema require surgical drainage in addition to antibiotic therapy. The prognosis is usually favorable with early detection and proper management.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Smego RA Jr., Foglia G. Actinomycosis. Clin Infect Dis 1998;26:1255-61.  |
| 2. | Kinnear WJ, MacFarlane JT. A survey of thoracic actinomycosis. Respir Med 1990;84:57-9. |
| 3. | Russo Thomas A. Agents of actinomycosis. In: Principles and Practice of Infectious Disease. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 6 th Edition Edited by Gerald L. Mandell, John E. Bennett, and Raphael Dolin Philadelphia: Elsevier Churchill Livingstone, 2005. 3661 pp; 2000. p. 2645-52. |
| 4. | Mingrone H, Perrone R, La Rosa S, Schtirbu R, Lutzky L. Primary bronchial actinomycosis and foreign body. Medicina (B Aires) 1995;55:337-40. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
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