Organic foreign body causing lung collapse and bronchopleural fistula with empyema.

To cite: Goussard P, Gie R, Andronikou S, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014204633 DESCRIPTION A 10-month-old infant presented with cough and fever. Treatment with oral antibiotics was initiated but the infant was admitted to hospital 7 days later, severely ill with a high-swinging fever. On clinical examination of the chest there were reduced breath sounds in the area of the right lower lobe. The initial chest X-ray (figure 1A) taken on admission to hospital demonstrated right-sided pleural effusion as well as parenchymal opacities of the right lower lung region. Although the chest X-ray was rotated to the right there was a suggestion that the mediastinum was displaced to the left. In a contrasted CT scan of the chest (figure 2A,B) right lower lobe air-space volume loss with breakdown and cavitation was noted. The parenchymal pathology was complicated by a large pyopneumothorax with loculated pockets of pleural air (with an anterior air–fluid level) indicative of a pleuroparenchymal fistula being present. On careful questioning the father remembered that the child had 3 months previous to admission choked after putting an unidentified object in his mouth while playing in the garden. Since the choking episode the infant had developed a persistent cough. Prior to performing a right-sided lateral thoracotomy to drain the empyema, a fiberoptic bronchoscopy was performed under general anaesthesia. A 2.8 mm video scope with a 1.2 mm working channel was inserted into the airway via a laryngeal mask airway. After lavaging out a large amount of purulent secretions from the right lobe it became apparent that the right lower lobe bronchus was largely destroyed and unusual lung parenchyma could be visualised through the bronchoscope. In one of the subsegmental bronchi a foreign body was visible. The foreign body was removed via the fiberoptic bronchoscope with the aid of biopsy forceps which were introduced via the 1.2 mm working channel. The foreign body was identified to be a 2 cm long twig of a tree. Following the bronchoscopy, the right-sided thoracotomy was performed. On examination of the underlying lung, there was a 0.5 mm tract created by the twig penetrating the lung parenchyma into the pleural cavity, demonstrating the cause of the loculated pyopneumothorax. Post-thoracotomy there was immediate improvement in the infant’s clinical and radiological picture (figure 1B). The improvement was maintained and the infant remains asymptomatic. This case illustrates that foreign body aspiration can occur even in young infants, that foreign body aspiration should be considered in complicated lung infections, and the value of taking a careful history even if the aspiration occurred months previously.