Aspirated Foreign Body November 9, 2011

HPI 6 year-old boy previously healthy Referred in 9/2011 for recurrent pneumonia 1st pneumonia in 3/2011 Left-sided Diagnosed clinically and treated with Azithromycin

CXR 6/2011 2nd pneumonia in 6/2011 Fevers and cough Treated with high-dose Amoxicillin Left lower lobe and lingular pneumonia Top edge of pneumonia very sharp – concern for mass vs round pna – should get a follow up CXR

Follow up CXR 7/2011 Interval resolution of left lower lobe pneumonia with residual patchy atelectasis versus scar and pleural thickening

HPI 3rd pneumonia in 9/2011 Fevers and cough Treated with high-dose Amoxicillin Left lower lobe pneumonia and pleural effusion

HPI No history of PNA prior to 3/2011 No history of other infections No history of failure to thrive No history of reactive airways disease or allergies No antecedent choking or aspiration event

PMH Born full-term at BMC NKDA No Medications Family History unremarkable Social History Lives with parents and five older siblings No recent travel, no pets or smoke exposures Parents from Somalia, no sick contacts

MGH Pulm Clinic 9/2011 O2 sat 99%, Wt 18.7kg (15%tile), Ht 115 cm (32%tile) Exam Well-appearing No LAD Decreased breath sounds on left No crackles or wheezes No clubbing of extremities

Chest CT 9/2011 Consolidation and atelectasis involving the lingula and inferior basilar portion of the left lower lobe with bronchiectasis and mild pleural thickening No obstructing airway abnormality Mediastinal and bilateral hilar adenopathy

DDx 6 year old M previously healthy with recurrent LLL PNA and bronchiectasis on chest CT Aspirated foreign body Immunodeficiency TB CF Pulmonary sequestration Post-infectious bronchiectasis ?Previous adenoviral infection Normal newborn screen and growth, location of bronchiectasis 10

Labs PPD negative CBC normal Chem 10 normal Immunoglobulins and subclasses normal Strep pneumo/Hib/Tetanus vaccine titers normal Fungal studies negative

Bronch 9/11 RML RLL Trachea 12

Lingula Foreign material removed via forceps

Lingula

Corn POPS or Popcorn??

Results BAL Negative for Mycobacteria Negative for fungus 42N, 21L, 4M Negative for Mycobacteria Negative for fungus Cultures grew Moraxella and normal oral flora Endobronchial biopsy of lingula No malignant cells on cytology Granulation tissue with xanthogranulomatous infiltrates, multinucleated giant cells and hemosiderin-laden macrophages Patient did well following procedure Signs of inflammation from foreign body 16