Pulmonary destruction due to retained bronchial foreign body in a 13‐year‐old boy

To the editor, Bronchial foreign bodies represent common pediatric emergencies that can be life-threatening. Early diagnosis and prompt removal of the foreign body are crucial for reducing complications and lowering mortality rates. In this report, we present a rare case involving a of 3 year's duration bronchial foreign body that caused significant damage to the left lung. Despite attempts with bronchoscopy, the foreign body could not be removed, necessitating surgical intervention. This case underscores the potential severe consequences of retained bronchial foreign bodies. A 13-year-old Chinese boy presented with a persistent cough for 2 weeks and chest pain for 1 week. Over the past 3 years, he experienced 2−3 episodes of fever and cough annually, which were alleviated with oral antibiotics prescribed by a local clinic, without undergoing chest imaging examinations. On physical examination, decreased breath sounds were noted over the left lung, while the rest of the examination was unremarkable. Chest computed tomography (CT) revealed consolidation of the left lung with bronchiectasis in the upper lobe and localized necrosis in the lower lobe. Additionally, a high-density circular shadow was observed in the basal segment of the left lower lobe (Figure 1A). Further evaluation included a combined examination using rigid and flexible bronchoscopy. During the procedure, a significant amount of purulent secretions was found within the left main bronchus and its branches. The opening of the left lower lobe bronchus was obstructed by granulation tissue, which was removed to reveal a foreign body at the distal end of the basal segment bronchus. The surrounding mucosa exhibited congestion, erosion, and necrosis. Despite multiple attempts, the foreign body could not be extracted. Upon further questioning, the patient recalled a history of accidentally inhaling a pen cap 3 years ago. At that time, he experienced severe coughing, but the symptoms quickly resolved, and he did not seek medical attention. Due to multiple unsuccessful endoscopic removal attempts, he subsequently underwent a left lower lobectomy, along with a repair procedure for the left upper lobe. During the surgery, both the upper and lower lobes of the left lung were found to be consolidated and significantly reduced in volume. The lower lobe lung tissue exhibited multiple abscess formations, and within the basal segment, a pen cap was discovered (Figure 2). Postoperatively, the lung tissue pathology demonstrated a solid, granular appearance with bronchial dilation in the left lower lobe, along with a granuloma associated with confluent abscesses. The patient had a satisfactory recovery after surgery. Chest CT examination at 6-month follow-up showed a reduced left lung volume and significant resolution of the lesion in the upper lobe. Furthermore, there was improvement in bronchiectasis (Figure 1B). This patient remained asymptomatic during the 1-year follow-up. The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Children's Hospital Affiliated to Zhengzhou University (Approval no. 2024-k-094). In addition, written consent from the patient's parents was obtained for the publication of this case report. In China, foreign body aspiration accounts for 7.9%−18.1% of unintentional injuries in children aged 0−14 years. Approximately 80% of affected children fall within the age range of 1−3 years,1 while adolescents and adults are relatively less commonly affected. The diagnosis of bronchial foreign body in children primarily relies on a history of foreign body inhalation (often associated with choking episodes), typical symptoms, physical signs, and imaging studies.1 However, in the pediatric population, the history of choking is often absent. Our patient, after inhaling a pen cap, initially presented with coughing but subsequently became asymptomatic as the foreign body slid down and lodged within the bronchus. Unfortunately, the lack of symptoms led to delayed diagnosis and treatment. Therefore, it is essential to conduct appropriate health education campaigns targeting caregivers and schools, emphasizing the importance of effective supervision for children. Additionally, promptly addressing cough-related symptoms can prevent irreversible lung destruction caused by prolonged foreign body retention. The ability to detect foreign bodies depends on their radiopacity. For nonradiopaque foreign bodies, chest imaging can easily confirm their presence. However, for radiopaque foreign bodies, chest imaging may still reveal indirect signs such as mediastinal shift, obstructive emphysema, lung atelectasis, and localized bronchial dilation.1 The initial recommended imaging includes a chest X-ray in both the inspiratory and expiratory phases. In cases of suspected foreign body aspiration, these radiographs can help identify air trapping, further localizing the suspected foreign body. However, it's important to note that up to 25−36%2, 3 of airway foreign bodies may appear normal on X-rays. In infants, this proportion can even reach 48%.4 For more accurate diagnosis, chest CT is superior to plain X-rays. CT provides better visualization and can determine whether bronchoscopy is necessary. In cases where there is a clear history of choking, even if the lung imaging appears atypical, further evaluation with bronchoscopy is warranted to definitively exclude foreign bodies aspiration. Timely intervention of airway foreign bodies is crucial to prevent complications. Delayed treatment, defined as seeking medical attention more than 3 days after foreign body aspiration, poses significant risks for both intraoperative and postoperative complications. Of note, these risks are not determined by the patient's age or the type and location of the foreign body.5 Approximately 40% of cases involving delayed diagnosis of airway foreign bodies occur when the aspiration remains undetected for more than 24 h. Among these cases, 15% can lead to severe complications.6 In children, delayed treatment of bronchial foreign bodies can result in serious consequences such as lung atelectasis, bronchiectasis, and even pulmonary destruction.1 Surgical intervention becomes unavoidable for such patients. Sersar et al.7 reported on seven cases where foreign bodies caused lung infections and irreversible structural damage, necessitating lung resection. Duan et al.8 documented 23 cases of surgically managed bronchial foreign bodies with delayed diagnosis. Among these cases, 17 patients required lung resection due to severe respiratory complications. The decision for surgical intervention was based on factors such as failed broncoscopic retrieval, persistent bronchial dilation lasting over a year, or recurrent infections.1, 9, 10 In our case, the foreign body had been retained for more than 3 years, with its wider end oriented upward. Over time, the foreign body migrated distally within the airway and eventually became impacted in the branch of left lower bronchus. Chronic irritation from the foreign body led to extensive granulation tissue formation and adhesions, making bronchoscopic retrieval unsuccessful. Given the irreversible lung destruction and the potential risks associated with forceful endoscopic removal, the decision to perform a lobectomy was appropriate. In conclusion, this report describes rare case of a 13-year-old Chinese boy with a 3 year's duration bronchial foreign body that caused significant damage to the left lung. Chronic irritation from the foreign body led to extensive granulation tissue formation and adhesions, making bronchoscopic retrieval unsuccessful. Given the irreversible lung destruction and the potential risks associated with forceful endoscopic removal, the decision to perform a lobectomy was deemed necessary. Qianqian He: Writing—original draft; writing—review and editing; conceptualization; investigation. Han Huang: Conceptualization; visualization. Haiming Yang: Funding acquisition; visualization; supervision. Yuelin Shen: Writing—review and editing; writing—original draft; funding acquisition; supervision. The authors do deeply appreciate the patient's parents for permission to publish this case. This work was supported by Natural Science Foundation of Xinjiang Uygur Autonomous Region (2022D01D55), and National Regional Medical Center Opening Project (NRMC0107). The authors declare no conflict of interest. The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Children's Hospital Affiliated to Zhengzhou University (Approval no. 2024-k-094). In addition, written consent from the patient's parents was obtained for the publication of this case report. Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.