Medical Image of the Month: An Unexpected Cause of Chronic Cough

Figure 1. Axial image from a contrast-enhanced CT demonstrates a hollow, calcified structure in the bronchus intermedius with thickening suggesting inflammation in the surrounding bronchial wall (arrow).

 

Figure 2. Photograph of chicken bone fragment retrieved from bronchus intermedius during flexible bronchoscopy (A).  In retrospect, this fragment of bone is visible on the topogram from the chest CT (B) and is circled. Note the prominent notch that is visible on CT and on the actual bone fragment (arrowheads).

Sometimes it is as simple as it looks!  A previously healthy nonsmoking 40 years old man presented with a 7-month history of dry cough which was misdiagnosed as asthma. He had persistent cough despite appropriate asthma treatment including empiric PPIs. This patient had undergone extensive lab work up and evaluation; from negative viral and fungal panel, repeated pulmonary function tests which were within normal limits, chest x-rays, and CT scans which had shown small local calcification in the bronchus intermedius with significant thickening of the surrounding bronchial wall (Figure 1). The decision was made to proceed with flexible bronchoscopy, which yielded a chicken bone fragment with surrounding granulation tissue as shown in Figure 2A. In retrospect the bone is visible within the  bronchus intermedius on the topogram from the CT scan, see Figure 2B.

Foreign body aspiration in adults reported in low rates (0.66 per 100 000) (1). Despite being uncommon, neurological disorders, alcohol abuse, advanced age and altered level of consciousness all found to be the main underlying cause of foreign body aspiration in adults (2). Still, 10% of adult patients with foreign body aspiration have no known risk factors (3). Usually, diagnosis of foreign body aspiration in adults is straightforward only if the patient’s history involves aspiration or choking event. But, if the initial event goes unnoticed, the clinical picture maybe similar to obstructive lung diseases such as COPD or asthma.

Yazan Khair ¹, Hussam Al-Jawaldeh², Ayah AL Mufleh³ , Maxim Abu Joudeh⁴, Emad Hammode⁵  

¹Pulmonary department, Royal Medical Services (RMS), Amman, Jordan

²Internal Medicine Resident, Canyon Vista Medical Center, Sierra Vista, AZ USA                

³Internal Medicine transitional program, King Hussein Cancer Center, Amman, Jordan

⁴Internal Medicine Resident, Canyon Vista Medical Center, Sierra Vista, AZ USA

⁵Program Director of Canyon Vista Medical Center Internal Medicine program, Sierra Vista, AZ USA

References

1. Lund, ME. Foreign body removal in: Ernst A, Herth, FJF eds. Principles and Practice of Interventional Pulmonolgy. New York, NY: Springer; 2013:477-488.
2. Singh A, Kaur M. Recurrent pneumonitis due to tracheobronchial foreign body in an adult. JIACM, 2007:8:242-44.
3. Mise K, Jurcev Savicevic A, Pavlov N, Jankovic S. Removal of tracheobronchial foreign bodies in adults using flexible bronchoscopy: experience 1995-2006. Surg Endosc. 2009 Jun;23(6):1360-4. [CrossRef] [PubMed]

Cite as: Khair Y, Al-Jawaldeh H, Mufleh A, Joudeh M, Hammode E. Medical Image of the Month: An Unexpected Cause of Chronic Cough. Southwest J Pulm, Crit Care & Sleep. 2022;25(2):23-24. doi: https://doi.org/10.13175/swjpccs032-22 PDF 

August 2022 Imaging Case of the Month: It’s All About Location

Michael B. Gotway MD

Department of Radiology

Mayo Clinic, Arizona

5777 East Mayo Boulevard

Phoenix, Arizona 85054

A 78–year–old man with a history of hyperlipidemia, hypertension, paroxysmal atrial fibrillation, and transcatheter aortic valve replacement on anticoagulation presented to the Emergency Room with a 2-month history of cough and exertional shortness of breath. He denied fever, chills, nausea, and chest pain. The patient had undergone three COVID-19 vaccines, the most recent 3 months earlier. He had noted some recent bruising, but denied any recent trauma.

The patient’s past medical history also included a history of prostate carcinoma 10 years earlier treated with radiation therapy. The patient’s past surgical history was remarkable for remote vasectomy, endoscopic sinus surgery and percutaneous aortic valve replacement. He was a former smoker and reported no allergies or illicit drug use; alcohol use was at most moderate, consisting of an occasional beer. The patient’s medications included a statin, warfarin, and metoprolol.

The patient’s physical examination showed normal vital signs and was remarkable only for some decreased breath sounds over the left lower thorax. The patient was afebrile. Bruising was noted involving the right hand and right abdominal wall, but without limitations in range of motion or associated pain.

A complete blood count showed a hemoglobin and hematocrit value of 7.7 gm/dL (normal, 13.2-16.6 gm/dL) and 23.9% (normal, 38.3–48.6%) and a platelet count of <2 x x10⁹/L (normal, 135-317 x10⁹/L). The white blood cell count was minimally abnormal at 9.7 x10⁹/L (normal, 3.4-9.6 x10⁹/L), with a mild left shift with a neutrophil level of 7.11 x10⁹/L (normal, 1.56-6.45 x10⁹/L). The eosinophil count was normal, but reticulocytes were elevated at 4.06% (normal, 0.60-2.71%). The INR was elevated at 2.3, with a prolonged prothrombin time of 25.8 sec (normal, 9.4-12.5 sec). Fibrinogen was also mildly abnormally elevated. Serum chemistries were largely within normal limits, with a mild elevation in lactate dehydrogenase at 273 U/L (normal, 122–222 U/L). Serum iron values were low at 30 mg/dL (normal, 50-150 mg/dL), with the total iron binding capacity abnormally decreased also. An ECG was unremarkable. A serum NT-Pro BNP value was elevated at 1174 pg/mL (normal, ≤122 pg/mL). Liver and renal function were within normal limits.

Frontal and lateral chest radiography (Figure 1) was performed.

Figure 1. Frontal (A) and lateral (B) chest.

Which of the following represents an appropriate interpretation of the frontal chest and lateral radiograph? (Click on the correct answer to be directed to the second of twelve pages)

1. Frontal chest radiography shows a large left pleural effusion
2. Frontal chest radiograph shows focal right lung opacity
3. Frontal chest radiography shows pleural calcification
4. Frontal chest radiography shows right peribronchial lymph node enlargement
5. More than one of the above

Cite as: Gotway MB. August 2022 Imaging Case of the Month: It’s All About Location. Southwest J Pulm Crit Care Sleep. 2022;25(2):15-22. doi: https://doi.org/10.13175/swjpccs034-22 PDF