A 26-Year Secret: An Unusual Culprit Behind Massive Hemoptysis: A Case Report

Abstract

Foreign body aspiration is frequently encountered in children but can also occur in adults, where it often remains undiagnosed for years. Forgotten foreign bodies within the bronchial tree may later manifest with either vague symptoms or life-threatening complications, such as massive hemoptysis. Contrast-enhanced computed tomography of the thorax is the preferred initial diagnostic modality and can suggest the presence of a foreign body. We present a case involving an adult who remained undiagnosed until adulthood, when he was ultimately found to have a foreign body embedded in the lung parenchyma.

Case report

A 33-year-old man initially received conservative management by a pulmonologist after presenting with massive hemoptysis. Contrast-enhanced computed tomography (CT) of the thorax revealed bronchiectatic changes in the left lower lobe, with small blood-filled cavitary regions. An arteriovenous malformation was suspected (Fig. 1). The patient underwent selective bronchial artery embolization for immediate symptom control. However, dense neovascularization in the affected segment prevented complete isolation of eroded vessels, resulting in recurrent hemoptysis. He was then referred to our institution for further care.

Fig. 1.

Contrast computed tomography of the chest shows a blood-filled cavity lesion marked with a long red arrow, and the lower lobe bronchial tree is marked with a short red arrow (A), fibrocaviaory lesions in the left lower lobe (B), confluent opacity in lower lobe parenchyma marked with a red arrow (C), and single pulmonary venous trunk marked with a red arrow (D).

A multidisciplinary team consisting of an interventional radiologist, a pulmonologist, and a thoracic surgeon reviewed the case. Given the failure of embolization and recurrent bleeding, surgical intervention was advised.

The patient was scheduled for thoracoscopic left lower lobectomy under general anesthesia. Intraoperative fiberoptic bronchoscopy showed normal anatomy up to the segmental bronchial openings. Thoracoscopy revealed ecchymosis around the perivascular adventitia of the descending thoracic aorta, and a single pulmonary venous trunk was observed draining both lobes of the left lung. Owing to dense inflammatory adhesions between the pulmonary vein and the lung parenchyma, the procedure was converted from video-assisted thoracoscopic surgery (VATS) to open thoracotomy. The pulmonary vessels and lower lobe bronchus were divided with an endoscopic stapler.

Intraoperative examination of the resected specimen revealed an area of unusual thickening within the parenchyma. Dissection of this area uncovered a pen cap (Fig. 2)—an unexpected finding. The patient expressed surprise equal to that of the surgical team when informed postoperatively. On reviewing his medical history, he vaguely recalled aspirating a pen cap at age 7. This case potentially represents one of the longest-documented instances in India of a retained intrapulmonary foreign body—approximately 26 years. After securing informed consent in accordance with the journal’s guidelines, we elected to share the patient’s clinical data, including preoperative CT images and intraoperative photographs, for this report.

Fig. 2.

Operative photographs showing the resected left lower lobe containing the pen cap (A, arrow) and the extracted pen cap displayed on the specimen table (B).

Discussion

Foreign body aspiration is the leading cause of accidental death in infants and ranks as the fourth most common cause among preschool-aged children, typically presenting with catastrophic symptoms in early childhood [1]. Non- life-threatening events, however, may go undetected at the time of aspiration. Forgotten foreign bodies (FFBs) within the tracheobronchial tree may remain asymptomatic for years, only becoming clinically relevant in adulthood. Presentations most commonly include cough, recurrent pneumonia, lung abscess, bronchial stenosis, and hemoptysis [2,3]. Frequently aspirated objects include small organic objects and plastic items such as caps and whistles [4].

Chest radiography generally has low sensitivity for direct foreign body detection—especially for organic material—but may reveal indirect signs like compensatory emphysema, pneumonia, or bronchiectasis [5]. Chronic cough following a choking episode is the most consistent symptom associated with an aspirated foreign body [6], but absence of such symptoms does not exclude the diagnosis.

Our case underscores the unusual retention of an inorganic foreign body within the lung parenchyma for over 2 decades, complicating both preoperative evaluation and intraoperative management. The foreign body likely eroded from the bronchial tree into the pulmonary parenchyma, eliciting a dense inflammatory response with pronounced neovascularization. This process closely mimicked an arteriovenous malformation on preoperative chest CT imaging. Anticipating technical challenges due to the complexity of the case, we expected difficulty with port placement for VATS. Intraoperatively, extensive adhesions were encountered, making port creation more difficult, but not impossible. Once access was achieved, pneumothorax was induced using CO₂ insufflation to facilitate visualization and manipulation of the affected lobe. Despite this, the combination of dense adhesions and an unexpected pulmonary venous anomaly ultimately surpassed the limitations of VATS, necessitating conversion to open thoracotomy.

As this case illustrates, non-specific symptoms and the absence of a clear etiology can obscure clinical judgment. Despite a thorough preoperative evaluation, the history of aspiration was not elicited until postoperatively, when the intraoperative findings prompted direct questioning of the patient.

Although chest CT revealed localized bronchiectatic changes in the left lower lobe—most likely due to the retained foreign body—the patient had remained asymptomatic throughout childhood. He did seek medical attention at age 7 after aspirating a pen cap, but a chest radiograph at that time was unremarkable. In the absence of ongoing respiratory symptoms, the event was presumed to be ingestion rather than aspiration. There were no recurrent respiratory infections or hospitalizations until his current presentation. This remarkably prolonged asymptomatic period, despite the presence of an occlusive bronchial foreign body, is highly unusual and remains perplexing. One possible explanation is recall bias. Another consideration is the composition of the foreign body itself. Organic materials are known to provoke a more robust inflammatory response than plastic or other inorganic substances [7,8], which may have contributed to the absence of symptoms for more than 26 years.

Chest radiographs are often insensitive for detecting FFBs, yet can reveal secondary effects of chronic retention, such as atelectasis, compensatory emphysematous changes, pneumonia, or bronchiectasis [5].

Foreign body aspiration usually occurs on the right side owing to the anatomy of the bronchial tree. It remains unclear why, in this case, the object lodged deep within the left lower lobe, as no anatomical anomaly was identified. Smaller foreign bodies have a greater likelihood of traveling distally into segmental bronchi [2]. With the object lodged in the left lower lobe bronchus instead of the right, our patient evaded clinical suspicion of a foreign body aspiration, only for it to be discovered as a surprising finding on the operation table.

In conclusion, although rare in adults, foreign body aspiration should remain part of the differential diagnosis when patients present with unexplained, nonspecific symptoms and no clear etiology, even in the absence of a suggestive clinical history. CT of the thorax can provide critical clues to an FFB, but even advanced imaging may fail to definitively identify these cases.