Foreign body in lung: a case report

Abstract

Introduction:

The presence of a metal foreign body (FB) in the lungs can be a major contributor to pulmonary embolism. FB pulmonary embolism is a rare condition and difficult to diagnose due to its variable clinical presentations.

Case Presentation:

This article presents a case of a 34-year-old male presented to our emergency department after getting injured with a FB fragment entering the upper right thigh. Plain X-ray proved the presence of the FB and patient was admitted to surgical extraction. However, the FB disappeared with the first attempt to reposition the patient. Then, the patient underwent a chest computed tomography (CT) without contrast that revealed the presence of the FB in the heart with a characteristic finding of a starburst appearance. Then the patient was transferred to the Catheter lab. But cardiologists did not find the FB inside the heart. Another chest CT scan was done that showed the FB in the right lower pulmonary artery. Then patient was transferred to the cardio-thoracic surgery department that decided not to remove the FB and just follow-up.

Discussion:

There are many cases of metal FB lodged in the vascular system. In this case, CT scan had been performed to the FB helped to take the appropriate decision before the FB causes damage to any vital organ.

Conclusion:

FB traveling through the vascular system can cause a pulmonary embolism. In our case, the time the FB took to reach the pulmonary arteries was merely few hours. However, appropriate management could help steer the patient away from danger.

Introduction

Highlights

• Foreign body pulmonary embolism is a rare condition but it has a high incidence of danger.

• Patient may present without symptoms at emergency room.

• Foreign body pulmonary embolism needs a high level of suspicion and appropriate management as soon as possible.

The presence of a metal foreign body (FB) in the lungs can be a major contributor to pulmonary embolism. Pulmonary embolism is a blood clot that travels through the bloodstream and result in a sudden block in pulmonary arteries. FB pulmonary embolism is a rare condition, and once it occurs it is difficult to diagnose due to its variable clinical presentations, the nature of the embolized material and dubious radiological findings. At presentation patients are asymptomatic; however, most of them eventually develop symptoms¹. Controversy persists regarding the management of intracardiac missile emboli. Fritz et al. advocate for leaving retained cardiac missiles based on their experiment involving the implantation of small metal objects in dog hearts. In this study, all implanted objects were encapsulated in fibrous tissue with minimal complications within 8 weeks². This case will describe a patient who came to the ER with a metal FB in his right lower limb that resulted in a metal FB embolism traveling from his right femoral vein to the heart and eventually settled in the right lower pulmonary artery. This case report has been submitted in accordance with the Surgical CAse REport (SCARE) guideline criteria 2023³.

Case presentation

A 34-year-old male presented to our emergency department after getting injured with a FB fragment entering his right thigh at the upper third at the antero-medial aspect in the sub sartorial canal. Plain X-ray proved the presence of the FB and laboratory investigations were done, and patient was admitted to the general surgery ward and was prepared for surgical extraction for the FB aided with the help of an intraoperative X-Ray (C arm) under spinal anesthesia (Fig. 1). However, the FB disappeared on the X-Ray (C arm) with the first attempt to reposition the patient. After that, a full limb scan was done using the C arm, which did not show the FB in the distal part of lower limb. Hence, a distal pulmonary embolism was suspected, and the patient was transferred to radiology department for further assessment using chest CT without contrast that revealed the presence of the FB in the right atrium of the heart with a characteristic finding of a starburst appearance (Fig. 2). Multidisciplinary meeting was done, and then the patient was transferred to the Catheter lab. But the cardiologists did not find the FB inside the heart at that moment. Another chest CT scan was done that showed the FB in the terminal branch of the right lower pulmonary artery (Fig. 3). Another multidisciplinary meeting was held with involvement of cardio-thoracic surgery department that decided not to remove the FB and just follow-up after a month and then after 6 months. A chest CT scan was done after 6 months showed fibrous tissue surrounding the FB without any further complications.

Figure 1.

X-Ray shows the metal Reich in the middle third of the right thigh.

Figure 2.

Uncontrasted CT showing characteristic starburst of the foreign body in the right atrium of the heart.

Figure 3.

Uncontrasted CT showing characteristic starburst of the foreign body in the right atrium of the heart.

Discussion

There are much more cases of metal or bullet foreign bodies lodged in the vascular system compared to fewer cases reported a pulmonary embolus from a fragmented medical catheter⁴. There is a dilemma of weighing decisions made for metal FB pulmonary embolism management. In this case, conservative treatment and appropriate investigations had been performed to the FB that reached the pulmonary arteries from the femoral vein. Surgical removal of FB pulmonary embolism has no agreed definitive strategy when the patient is asymptomatic, hence the treatment varies according to the case presented. However, it has been suggested that any FB with a diameter of >5 mm or length of 10 cm must be surgically removed^1,4. Follow-up for asymptomatic patients is recommended as an operation might be required if any complication develop. History of patient trauma should be taken into consideration. For any penetrating injuries with a metal FB that enters the vascular system, an X-Ray radiography should be performed first to locate the metal foreign bodies. Furthermore, Chest CT without contrast must be performed early in the presentation to detect if the embolism reached the heart or lungs. The use of CT scan would help take the appropriate decision as early as possible before the FB causes more damage to lung or any other vital organ. MRI must be avoided as it may trigger the migration of the FB. Moreover, Lu K, et al.² mentioned that in asymptomatic patients with FB in right heart and pulmonary arteries observations and medical managements are enough. We recommend that more research be done to determine the benefit of surgical removal versus conservative treatment in cases of metal emboli.

Conclusion

FB traveling through the vascular system can easily cause huge damage so it must be managed as early as possible to prevent a pulmonary embolism or worse. In our case, the time the FB took to reach the pulmonary arteries was merely few hours. But, with high level of suspicion and the help of proper investigations and appropriate management in the presence of competent multidisciplinary team could help steer the patient away from danger.

Ethical approval

Not applicable.

Informed consent

Written informed consent was obtained from the patient 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.

Sources of funding

Financial support and sponsorship: none.

Author contribution

A.M., M.A.T., and Y.Z.F.: wrote the manuscript; J.A.S.: held the patient clinical presentation and investigations.

Conflicts of interest disclosure

There are no conflicts of interest to disclose.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Mohamed A. Tolba. E-mail: mohamed.atolba@must.edu.eg.

Data availability statement

Not applicable.

Provenance and peer review

Not commissioned, externally peer-reviewed.