This is a two-year old Caucasian male with a chief 
complaint of cough and fever.  He has had fevers up to 
38.5 degrees and "wet" coughs intermittently for the 
past two months.  He has also had episodes of emesis 
and decreased activity.  His initial diagnosis had been 
"bronchitis," which was empirically treated with an oral 
cephalosporin.  His symptoms improved somewhat, but 
later recurred.  At that time, a chest radiograph (CXR) 
revealed a right lower lobe infiltrate, and he was then 
treated with erythromycin/sulfamethoxazole.  Again, his 
symptoms initially improved but recurred within two 
days.
     After being ill for one month, he was hospitalized for 
recurrent and persistent pneumonia with a suspected 
foreign body in the right mainstem bronchus on CXR.  
In retrospect, his mother recalls the child choking on 
almonds prior to the initial onset of symptoms.  A 
bronchoscopy was performed which resulted in removal 
of granulation tissue, after which he was treated with 
cephalosporins for seven days with improvement.
     One week later, he again developed  mild 
respiratory symptoms and was started empirically on a 
different cephalosporin, but his symptoms actually 
worsened over the next day.  Tuberculin skin testing 
and sweat chloride tests were negative.  Neonatal 
and developmental histories are unremarkable.
     Exam VS T39.4 (oral), P164, R36, BP 127/96, 
oxygen saturation 98% in room air.  He is awake, alert, 
consolable, and in no acute distress.  HEENT and neck 
exams are normal.  Heart regular without murmurs.  
Lung exam reveals diffuse coarse rhonchi and slightly 
diminished breath sounds in the right base, but 
otherwise no retractions, wheezing, or rales. The 
remainder of his exam is unremarkable.
     Another CXR is obtained.

View CXR PA view.


Lateral view.

     There is moderate subsegmental atelectasis versus 
an infiltrate in the right lower lobe.  This is best seen 
on the lateral view as a linear density in the posterior 
lower lung.  It is also seen faintly on the PA view in the 
right lower lung field, but the scanner was not able to 
capture it very well.  What would you do at this point?  
He has had several pneumonias following a history of 
choking on almonds, but a previous bronchoscopy was 
negative.  
     Remember the "principle" discussed in Case 8 of 
Volume 1, Foreign Body Aspiration in a Child:

     Nuts  +  Choking  =  Bronchoscopy

     Despite the negative previous bronchoscopy, a 
different surgeon is called for bronchoscopy under 
general anesthesia.  Initial laryngoscopic exam reveals 
an erythematous and mildly edematous epiglottis.  The 
remainder of the procedure is then performed via 
bronchoscopy, which reveals an erythematous trachea 
with an injected mucosa.  There is also moderate 
edema in both mainstem bronchi, and marked edema in 
the subsegmental bronchi on the right side.  The lower 
lobe bronchus contains granulation tissue that is friable, 
and upon retracting the granulation tissue, a foreign 
body is visualized and removed.  Histologic exam 
reveals vegetable matter consistent with a nut.

Teaching Points and Discussion
     Although foreign body aspiration may not be the 
most common cause of recurrent pneumonia, it is not 
uncommon especially in this age group which varies 
from six month olds to three year olds with a peak 
incidence at two years of age and a ninety percent 
incidence before five years of age (1,2).  It is, therefore, 
imperative to maintain a high index of suspicion even if 
there is no definite history of a choking episode, which 
is usually the case in about half the cases, but up to 
70% of the time in one study (3).
     Most commonly, patients may present with localized 
wheezing, diminished air movement, and rhonchi on 
auscultation of the lungs.  However, these findings may 
not always be present and certainly may seem diffuse 
over both lung fields due to transmission of those 
sounds through the bronchi.  Pneumonia may also be a 
concomitant finding in up to 20% of the cases.  
Recurrent pneumonia may develop secondary to a 
foreign body that is obstructing the normal mucociliary 
clearance mechanism (4).  In fact, there have been 
cases of months to even years where an aspirated 
foreign body had been the cause of recurrent 
pneumonia (5).
     More common types of aspirated objects include 
peanuts (up to 50% of total cases), raisins, sunflower 
seeds, popcorn, teeth, and toys. Foreign body 
aspiration should always be considered in a child with 
unexplained pulmonary problems.
     Evaluation for a foreign body aspiration should 
include inspiratory and expiratory CXR's (or bilateral 
decubitus CXR's for infants and toddlers who cannot 
follow commands) looking for asymmetric air-trapping 
secondary to bronchial obstruction.  CXR under 
fluoroscopy may also aid in detecting diminished 
lung/diaphragm movement.  A single CXR may detect 
the foreign body, but one study demonstrated only four 
percent of pulmonary foreign bodies to be radiopaque 
(6).  Even if all radiographic studies are negative, 
clinical suspicion should lead one to consider 
bronchoscopy since negative radiographic studies are 
not able to totally rule out foreign bodies.
     The treatment of choice is bronchoscopy for removal 
of the foreign body. Without such removal, 
complications may arise such as recurrent pneumonia 
(even migratory), pulmonary abscess and/or cyst 
development, bronchospasm, pneumothorax and 
bronchopleural fistula (5,7).
     The differential diagnosis for recurrent pneumonia 
can be extensive with the most common etiologies 
being reactive airway disease, various 
immunodeficiencies, tuberculosis, cystic fibrosis, and 
anatomical anomalies (8).  In this case, a "choking" 
episode while eating nuts was eventually elicited by 
history, and repeated pulmonary infiltrates on CXR as 
well as localized lung findings on exam suggested a 
retained pulmonary foreign body, after which the 
appropriate therapy was performed, and the patient's 
symptoms eventually resolved.

References
     1. Wiseman NE.  The Diagnosis of Foreign Body 
Aspiration.  J Ped Surg 1984;19:531-535.
     2. Oski FA (ed).  Principles and Practice of 
Pediatrics, 2nd Edition.  Philadelphia, J.B. Lippincott 
Co., 1994, pp. 822, 1475-1477.
     3. Moazam F.  Foreign Bodies in the Pediatric 
Tracheobronchial Tree.  Clin Pediatr 1983;22:148.
     4. Rubin BK.  The Evaluation of the Child with 
Recurrent Chest Infections.  Pediatr Inf Dis 
1985;4(1):88-98.
     5. Ben-Dov I.  Foreign Body Aspiration in the Adult: 
An Occult Cause of Chronic Pulmonary Symptoms.  
Postgrad Med J 1989;65(763):299-301.
     6. Blazer S.  Foreign Body in the Airway:  A Review 
of 200 Cases.  Am J Dis Child 1980;134:68.
     7. Barlett JG.   The Triple Threat of Aspiration 
Pneumonia.  Chest 1975;68:560-566.
     8. Stockman JA (ed).  Difficult Diagnosis in 
Pediatrics.  Philadelphia, W.B. Saunders Co., 1990,
pp. 375-382.