Diagnostic difficulties in chronic obstructive pulmonary disease exacerbations: A case report

doi:10.4236/crcm.2013.26099

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Vol.2, No.6, 370-374 (2013) Case Reports in Clinical Medicine

http://dx.doi.org/10.4236/crcm.2013.26099

Diagnostic difficulties in chronic obstructive

pulmonary disease exacerbations: A case report

Simona Stefania Bucsa1*, Petre Iacob Calistru2

1Department of Pneumology, “Dr Victor Babes” Diagnosis and Treatment Center, Bucharest, Romania;

*Corresponding Author: [email protected]

2Department of Infectious Diseases, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania

Received 16 May 2013; revised 10 June 2013; accepted 30 June 2013

mons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work

is properly cited.

ABSTRACT

Exacerbations of COPD (chronic obstructive pul-

monary disease) influence, by their frequency

and severity, the life prognosis of patients with

COPD. Most exacerbations are caused by res-

piratory infections with negative impact on pa-

tient quality of life. The impact of frequent ex-

acerbation in COPD is manifested by the rapid

decline of lung function, decreased quality of life

increased airway inflamation and high mortality.

Bronchial obstruction by foreign bodies meets

frequently during childhood but can occur in

adults under certain conditions of loss of con-

sciousness (sleep, administration of tranquili-

zers, after anesthesia, intoxicated). The long-

standing intrabronchial foreign body presents

problems of diagnosis and treatment which are

very different from those associated with the

recently inhaled foreign body. W e herein repor t a

77-year-old male, smoker (40 pack-year) pre-

sented to the clinic with severe dyspnoea, fever

and cough with purulent sputum for about 6

months. Persistent symptoms require repeated

hospitalizations for receiving different regi-

mens of antibiotics, but they have not helped.

Chest radiography showed extensive consoli-

dation of the right lower lobe, intensity rib, he-

terogeneous and Chest CT scan showed me-

tallic foreign body in right lower lobar bronchus

with secondary pneumonic process in the lower

right lobe. Emergency was performed broncho-

scopy and extracted dental crown consists of

three teeth and then the patient received com-

bined antibiotic therapy for 14 days, in asso-

ciation with anti-inflammatory, mucolytics and

bronchodilators. After 2 weeks he was overall

in very good condition and all other complaints

disappeared and C hest X-ray control sho wed ful l

resorption of pneumonia opacity, without dis-

abling signs. In this particular case, only minor

symptoms are seen at the beginning and the

aspirated foreign body was forgotten until later

symptoms (inflammation, infection) were devel-

oped and developing clinically manifest. The

diagnosis was delayed due to lack of radiogra-

phic view which may be aspirated foreign body

embedded in granulation tissue formed around.

Keywords: Retrostenotica Secondary Pneumonia;

Metallic Foreign Body Aspirated Intrabronsic

1. INTRODUCTION

Bronchial obstruction by foreign bodies (FB) meets

frequently during childhood, and commonly after the age

of 1 year to 45 years. The highest incidence occurs be-

tween the age of 1 - 3 years that is 77% [1] and it is rare

in adults. Aspiration of FB is multifactorial in their aeti-

ology, in their broad spectrum of different resolutions for

the same FB and in the response of each patient to the

treatment.

In aspiration of foreign body symptoms are three clini-

cal phases: initial stage (first stage or impaction or FB)

showing choking, gagging and paroxysms of coughing,

obstruction of the airway (AW), occurring at the time of

aspiration. These signs calm down when the FB lodges

and the reflexes grow weary (second stage or asympto-

matic phase).

Complications occur in the third stag e (also defined as

the complication phase), when the obstruction, erosion or

infection cause pneumonia, atelectasis, abscess or fever.

The first symptoms to receive medical care may actually

represent a complication of impaction of FB [2]. Early

S. S. Bucsa, P. I. Calistru / Case Reports in Clinical Medicine 2 (2013) 370-374 371

diagnosis and treatment is imperative to prevent mor-

tality as well as complications.

The long-standing intrabronchial foreignbody presents

problems of diagnosis and treatment which are very

different from those associated with the recently inhaled

foreign body. There may be no history to suggest the

original incident; the clinical picture is usually clouded

by superadded pathological changes-atelectasis, pneu-

monitis, bronchiectasis, or lung bscess-and the broncho-

scopic appearances are often misleading. The symptoms

of aspiration of FB can simulate different diseases such

as asthma, croup or pneumonia, delaying the correct

diagnosis [2]. The delay in the removal of FB is po-

tentially harmful. Even when correctly diagnosed, the

choice of treatment is not always easy. The treatment of

choice for AW is endoscopic removal [2].

Bronchoscopy may be necessary to make a definitive

diagnosis and to remove the object. Prevention remains

the best treatment, but in case of complications anti-

biotics and resp iratory therapy techniques may b e used if

infection develops. Sometimes, for the removal of highly

difficult and high risk tracheobronchial foreign bodies,

preoperative analysis and discussion should be sufficient,

appropriate surgical skill and surgical instruments may

improve the success rate of the surgery and prevent the

operation complications [3].

2. CASE REPORT

A 77-year-old male, smoker (40 pack-year), living in

villages, presented to the clinic with severe dyspnoea,

fever and cough with purulent sputum for about 6

months. He has a history of Chronic Obstructive Pulmo-

nary Disease (COPD) 5 years ago, with two exacerba-

tions in the past year, diabetes mellitus with oral treat-

ment and chronic use of ethanol. Current disease onset

was 6 months ago with cough with purulent sputum,

intermitent fever and chills, shortness of breath. He was

hospitalized in the village with diagnosis of COPD ex-

acerbations, community acquired pneumonia and receiv-

ed antibiotic treatment with Amoxicilin-Clavulanat and

Gentamicin, then Ceftriaxon, with temporary improve-

ment. Then recurrence the simptoms determined repeated

hospitalizations for which he received different antibiotic

regimens, but they have not helped. A few days before

presenting to hospital , the symptoms worsened, the pa-

tient presenting malaise, severe dyspnoea with weezing,

fever and cough with purulent sputum. Physical exami-

nation on admission: General appearance: underweight;

Respirator stetacustic. prolonged expiration, weezing,

bronchial rales crackles in lower right lung, SaO2 = 91%

- 93%; Febrile, T = 38 .5˚C; Vital signs: in normal limits;

No other significant signs revealed. Blood tests showed:

leucocytes 17.800/mm3, with neutrophils 9.900/mm3;

VSH = 68/105 mm/h/2h; CRP = 8.68 mg/dl; Fibrinogen

= 785 mg/dl; TGP, TGO, Glycemia, BUN within normal

ranges; specific tumor markers-negative. Chest radiog-

raphy showed extensive consolidation of the right lower

lung lobe,intensity rib, heterogeneous (Figure 1). Spiro-

metry: severe mixed ventilatory dysfunction with reduc-

ed FEV1 with 73% (FEV1 = 27%, FVC= 63%, Tiffeneau

Index = 34.6) (Figure 2). Abdominal ultrasound, cardiac

ultrasound, all in normal limits. We performed a Chest

CT scan contrast enhanced which showed metallic for-

eign body in right lower lobar bronchus with secondary

pneumonic process in the lower right lobe (Figures 3(a)

and (b)).

The diagnosis is: Intrabron chial foreign body with air-

way obstruction secondary pneumonia, COPD group D.

Emergency bronchoscopy was performed. Bronchoscopy

showed that the mucosa of the right lower lobe was

hyperaemic, granular, much pus and extracted a dental

crown made of three teeth. Than we started antibiotics

treatment with Amoxicilin-Clavulanat 1 g three times a

day and Metronidazol 1 g twice a day for 14 days in

association with anti-inflammatory, mucolyti cs and bron-

chodilators (Corticosteroid inhaled with Long action β

agonist fixed combinations). With tratment and postural

drainage, he became afebrile in three days, general con-

dition improved and than the cough and dyspnoea im-

proved.

Treated, after 2 weeks he was overall very good

condition and all other complaints disappeared. Control

Chest X-ray showed complete resolution of pneumonia

opacity without other signs added (Figure 4).

3. DISCUSSION

Although FB aspiration can occur at any stage in life,

it is far more common in children. In adults, FB as-

piration is uncommon and is mostly related to accidental

aspiration of working tools (paper clips, tacks, or nails)

Figure 1. Pretreatment chest X-ray posterior-anterior shows ex-

ensive consolidation in the right lower lung lobe. t

S. S. Bucsa, P. I. Calistru / Case Reports in Clinical Medicine 2 (2013) 370-374

372

Figure 2. Spirometry show severe mixed ventilatory dysfunction with reduced FEV1 with 73% (FEV1 = 27%, FVC = 63%,

Tiffeneau Index = 34.6).

OPEN ACCESS

S. S. Bucsa, P. I. Calistru / Case Reports in Clinical Medicine 2 (2013) 370-374 373

(a) (b)

Figure 3. (a), (b) CHEST CT scan findings metallic foreign body in right lower lobar bronchus with secondary pneumonic

process in the lower right lobe.

Figure 4. After treatment chest X-ray showed complete resolu-

tion of pulmonary opacity without other signs added.

and bone fragments, as well as occurring during uncon-

sciousness (trauma, general anesthesia, sedation, intoxi-

cation, seizures, and neurological disorders) [1].

Clinical onset is sudden, often impressive and some-

times with rapidly fatal evolution. However, in some

cases, only minor symptoms are seen at first, and the

object may be forgotten until later symptoms (inflam-

mation, infection) develop. After overcoming the acute

episode, the patient may remain asymptomatic for a pe-

riod then symptoms debilitating chronic recurrent infec-

tions may delay late foreign body extraction. In the case

of retained foreign bod ies, the p ossibilities o f granu lation

tissue and post-obstruction infection exist. The accurate

diagnosis may be missed even by an experienced clini-

cian because often the initial choking episode is not

witnessed and also the delayed symptoms may mimic

other common conditions like asthma, COPD exacerba-

tions, recurrent pneumonia, upper respiratory infection

and persistent cough. Diagnosis and removal of an in-

haled foreignbody are required as quickly as possible in

order to preven mortality as well as complications.

In the present case, the symptoms did not appear

immediately after bronchial obstruction and were hidden

with antibiotics and physiotherapy symptomatic treat-

ment but were repeated at intervals until th e foreign body

was finally removed. Diagnostic imaging plays a vari-

able role in identifying airways foreign bodies.Most of

the foreign bodies are not radiopaque and small foreign

bodies may cause symptoms but no radiographic signs.

Plain films may be inadequate to document a non radio-

opaque foreign body unless they are obtained in the

expiratory phase. Rodrigues AJ and colleagues showed

in their study that 25% of the chest X-ray findings were

normal, despite a clinical history of FB aspiration [4].

Regardless of the equipment used, bronchosc opy should

be performed in all cases of suspected FB aspiration,

even if the radiological findings are normal [5,6]. Bron-

choscopy remains the gold standard for the diagnosis and

treatment of FB aspiration [7]. Virtually all aspirated FBs

can be extracted by bronchoscopy, with success rates

above 98%. Rigid bronchoscopy remains the standard

procedure for the removal of FB [8] and has various

advantages over flexible bronchoscopy. Rigid broncho-

scopes are larger in diameter than being flexible bron-

choscopes, therefore allowing blood aspiration, thick

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374

secretion aspiration, and patient ventilation.

Although rigid bronchoscopy is considered the gold

standard for the removal of foreign bodies from the air-

ways, exist studys that demonstrated that flexible bron-

choscopy can be safely and effectively used in the dia-

gnosis and treatment of stable adult patients [4].

In the rare instances in which bronchoscopic removal

fails, surgical bronchotomy or segmental resection is

indicated. The presence of chronic bronchial obstruction,

together with bronchiectasis, lung abscess, and paren-

chymal destruction, might be an indication for segmental

or lobar resection [9].

In this particular case, the diagnosis was delayed due

to lack of radiographic visualization of the foreign body

intrabronsic with persistent symptoms of infection des-

pite antibiotic treatment.

4. ACKNOWLEDGEMENTS

This paper is supported by the Sectoral Operational Programme Hu-

man Resources Development (SOP HRD) 2007-2013, financed from

the European Social Fund and by the Romanian Government under the

contract number POSDRU/107/1.5/S/82839.

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