Spot Diagnosis

Cough and Hurried Breathing for 5 days

Raghavendra H Gobbur, Keerthi darshini
Department of Pediatrics, Bijapur Lingayat District Education Deemed to be University, Shri B M Patil Medical College, Vijayapur, India

Address for Correspondence: Dr Raghavendra H Gobbur, H.NO.110, K.H.B. Colony, Solapur Road, Vijayapur 586103, India.
Question :
An 18 months old boy presented with cough and hurried breathing for 5 days. His symptoms had not been alleviated by over the counter cough remedies. There was no history of sudden choking while eating or holding an object in the mouth. There was history of pica. On examination, he had tachypnea, nasal flaring, intercostal and subcostal retractions, rales and air entry was diminished over left side of the chest as compared to the right side. Investigations showed hemoglobin 7.1g/dl, white cell count (WBC) 42430cells/cumm (82% polymorphs), platelets of 834000/cumm and mean corpuscular volume (MCV) of 52.7fl. Peripheral smear showed microcytic hypochromic anemia. Chest x-ray is depicted in Figure 1.

What is the diagnosis?

Discussion :
Chest X-ray showed a foreign body. Rigid bronchoscopy showed a foreign body in the left bronchus of 0.5cm in diameter which was successfully removed from the left main bronchus.
Foreign body aspiration (FBA) is a life threatening emergency and requires prompt removal. Although FBA is diagnosed based on history of choking episodes, sometimes it may remain undetected due to an atypical history or misleading clinical and radiological findings. (1,2) In our patient too, the diagnosis was delayed because the parents were unaware of such choking episode in their child.
Although aspirated foreign bodies are most commonly found in the right main bronchus in the adults, the distribution of aspirated foreign bodies in the children may vary in location. Van Looij et al reported that aspirated foreign bodies were equally distributed between the left and right main bronchi in children upto 3 years of age. (3) In our patient, the foreign body was in left main bronchus.
Pica is the compulsive eating of non-nutritive substances and it may have a serious medical complications. Low iron level may be the possible cause of pica. Microcytic anemia frequently occurs as a result of iron deficiency. (4) Physicians should be aware of behavioural alterations seen in the children with iron deficiency. (5) They may swallow and aspirate whatever they find in their environment. Sometimes this can result in a life threatening emergency. In our patient too, there was a history of pica which may have lead to stone aspiration.

References :
  1. Ciftci AO, Bingol-Kologlu M, Senocak ME, Tanyel FC, Duyukpamukcu N. Bronchoscopy for evaluation of foreign body aspiration in children. J Pediatr Surg. 2003; 38:1170-1176.
  2. Tokar B, Ozkan R, Ilhan H. Tracheobronchial foreign bodies in children: Importance of accurate history and plain chest radiography in delayed presentation. Clin Radiol. 2004; 59: 609-615.
  3. Van Looij MAJ, Rood PPM, Hoeve LJ, Borgstein LJ. Aspirated foreign bodies in children: Why are they more commonly found on the left? Clin Otolaryngol 2003; 28: 364-367.
  4. Singhi S, Ravishanker R, Singhi P, Nath R. Low plasma zinc and iron in pica. Indian J Pediatr. 2003; 70: 139-143.
  5. Buchanan GR: The tragedy of iron deficiency during infancy and early childhood. J Pediatr 1999; 135: 413-415.

Correct Answers : yes  13%

Last Shown : Jul 2018
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