Late migration of an aspirated foreign body from the lung to the bowel: A plausible explanation or a medical mystery. A case report

Abstract

Introduction and importance

Foreign body (FB) aspiration is a common preventable cause of death among children between ages 1–3 years. A rare case of an aspirated sharp metallic object in a 4-year-old boy that migrated from the left lung to the GIT after a year is presented after bronchoscopy and thoracotomy failed to retrieve it.

Presentation of case

A 4-year-old boy presented with cough a year after aspirating a sewing machine needle. He was stable with normal chest findings. Previous bronchoscopy attempts failed to retrieve the needle. A thoracotomy was done after a chest CT revealed the foreign body in the left lower lobe. FB could not be palpated nor visualized intraoperatively. Flexible bronchoscopy could also not visualize the needle in the airway. A postoperative x-ray done revealed the needle was no longer in the chest but in the bowel.

Clinical discussion

Bronchoscopy is the standard treatment for FB aspiration but in our case, it failed on two occasions to retrieve the sharp object. Our literature search revealed only reported cases of migrating FB from one bronchus to the other, and from the bronchus to the gastrointestinal tract (GIT) but not from the lung into the GIT.

Conclusion

FB migration from the lung to the GIT after a year without signs of perforation is possible. While we brainstorm the plausible explanations for this migration, one may wonder if this is just a medical mystery.

Highlights

• •Removal of foreign body aspiration can be challenging.
• •Thoracotomy was indicated after foreign body was seen in the lung.
• •Although possible, the mechanism of migration of needle after one year from the lung into bowel can be a dilemma.

1. Introduction

Foreign body (FB) aspiration is a common life-threatening emergency among children [1]. It is a preventable cause of death in children. About 300 children die in a year in the United States of America due to asphyxiation from foreign body aspiration [2]. The prevalence rate is reported to be 0.37 % with a peak incidence among children aged 1–3 years [3]. Peanut is the commonest cause followed closely by metallic objects [3]^, [4]^, [5]. Patients with FB aspiration will typically present with difficulty in breathing, drooling and coughing [1]. Radiology plays a crucial role in the diagnosis of FB aspiration [6]. Bronchoscopy is regarded as the best diagnostic and therapeutic modality [7].

Migration of FB is uncommon, albeit few case have been reported. Our literature review found reported cases of migrating FB from the one bronchus to the other, or from the bronchus to the gastrointestinal tract (GIT) and vice versa [8]^, [9]^, [10]. To the best our knowledge, there has been no reported case of aspirated FB migration from the lung parenchyma to the GIT. In this study, we report a rare case of an aspirated sharp metallic object in a 4-year-old boy that migrated from the left lung to the GIT after one year. We also brainstormed on the plausible ways by which the sharp metallic object moved from lung to the large bowel.

Reporting of this case was is in line with the SCARE criteria [11].

2. Presentation of case

A 4-year-old boy had an episode of haemoptysis after he aspirated a sewing machine needle whiles playing. He was immediately taken to a nearby facility where he was subsequently referred to a tertiary hospital for further management. An initial rigid bronchoscopy failed to retrieve the needle and patient was managed conservatively. Patient who was now stable withno haemoptysis was discharged to be followed up on outpatient basis for elective removal.

The relatives after visiting the outpatient clinic without removal of the FB attempted to threat the condition with herbal medication and hence was lost to follow up for a year. He then reported to the Ear Nose and Throat unit of our facility with non-productive cough where a rigid bronchoscopy failed to retrieve the needle. A thoracic surgery consult was sought when a chest x-ray showed a radiopaque object in the left lower lung zone (Fig. 1). A chest CT was requested to confirm the specific location of the foreign body before a decision for surgical removal was planned. The chest CT scan revealed a radiopaque foreign object in the left lower lobe posterior basal segment (Fig. 2). Physical examination and laboratory findings were essentially normal. Based on this, a diagnosis of FB in left lung was made. Due to financial constraints and lack of resources a decision to perform a left mini thoracotomy instead of using video assisted thoracoscopic surgery (VATS) for extraction or wedge resection was made.

Fig. 1.

Preoperative chest x-ray showing radiopaque object in the left lower lung zone.

Fig. 2.

Chest CT shows radiopaque foreign body in the left lower lobe posterior basal segment.

Intraoperatively, there was no intrathoracic adhesions and fissure was complete. All segments of the left lung and bronchi were palpated with no sign of the FB. Flexible bronchoscopy was done intraoperative to see if the needle had migrated into the upper airways, but there was no needle in the airways. Our C-arm was not working at that moment and hence we could not use it intraoperatively to locate the FB. The chest was closed anatomically with a plan to use an x-ray to locate the foreign body postoperatively. A chest and abdominopelvic x-rays done on postoperative day 1 showed the FB was no longer in the chest (Fig. 3) but rather in the rectum (Fig. 4). On postoperative day 3 the sewing machine needle was passed out in his stool. The child had an uneventful recovery and was discharged home on postoperative day 6.

Fig. 3.

Postoperative chest x-ray shows normal lung with left chest tube and no sign of the foreign object.

Fig. 4.

Postoperative abdominopelvic x-ray shows radiopaque object in the rectum.

3. Discussion

FB aspiration is a common emergency seen in children. In this case, a 4-year-old boy aspirated a sharp metallic object a year prior to presentation. Previous studies have reported metallic objects to be the second most common cause of FB aspiration with peanut being the commonest [4]^, [5]. Aspiration of inorganic FB do not usually incite acute inflammation and are more likely to be asymptomatic. On the other hand, organic FB absorb bronchial secretions and swell-up to block the airway [9]. This could explain why the child was asymptomatic for a year after his initial haemoptysis. The shape of an aspirated FB also plays a crucial role in its migration. Sharper foreign bodies are more likely to get stuck and fixed to the mucosa and may not easily migrate [9]. In our case however, that convention was defied because the sharp object migrated from the lung to large intestine.

Our literature search revealed a few reported cases of migrating aspirated FB. This is not a common occurrence. What was common among the scarcely reported cases in literature was migration of FB from one bronchus to the other or from one bronchus to the GIT and vice versa [8]^, [9]^, [10]. Our search did not reveal any case of migration of aspirated FB from the lung to the GIT.

The patient underwent two rigid bronchoscopies which were all unsuccessful, this is no surprise since it is sometimes difficult to remove such sharp objects. The migration of this FB came as a surprise to the medical personnel. The most likely explanation was the child ingesting the needle from the airway into the GIT. The period this occurred is difficult to determine. Maybe an immediate x-ray before the thoracotomy would have made it easier to determine. Another plausible explanation could be bouts of cough causing migration of the FB from the lung to the oesophagus and descending the GIT. Abraham and colleagues reported on spontaneous migration of an intrabronchial metallic FB to the GIT as a result of bouts of coughing [12]. While this may be plausible, the child never had any bouts of cough preoperatively, intraoperatively or postoperatively. Another explanation could be the sharp object penetrating the lung, pleura, oesophagus or diaphragm into the bowel. This reason could be a little far-fetched because the child did not experience any form of peritonism through his admission and there was no sign of penetration or perforation from the lung intraoperatively. While we can only speculate, one may wonder if this is just a medical mystery.

4. Conclusion

FB migration from the lung to the GIT after a year without signs of perforation is possible. There is a medical dilemma as to the exact mechanism of migration of a sewing machine needle in a year in a 4-year-old boy after one year of aspiration.

Patient perspective

Throughout the course of his treatment, the parents expressed satisfaction with the care their child received.

Informed consent

Written informed consent was obtained from the patient's parents/legal guardian for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contribution

Adamu Issaka: Conceptualisation, study design, writing of paper, critical revision for intellectual content

Anwar Sadat Seidu: Data collection, writing of paper, critical revision for intellectual content

Theophilus Adjeso: Study design, critical revision for intellectual content

Guarantor

Adamu Issaka is the guarantor of the work and accepts full responsibility.

Conflict of interest statement

Adamu Issaka has no conflict of interest.

Anwar Sadat has no conflict of interest.

Theophilus Adjeso has no conflict of interest.