B47-13 Radiographically Occult Foreign Body Aspiration Presenting as Chronic Cough and Cavitary Actinomycosis Pneumonia

Abstract Tracheobronchial foreign body aspiration (FBA) can range from asymptomatic to life-threatening. Radiography is the initial diagnostic tool, but radiolucent foreign bodies pose a challenge. We present a case of chronic cough and cavitary actinomycosis pneumonia from foreign body aspiration with resolution after extraction and antibiotic therapy. A 72-year-old male with asthma and COPD was seen for routine follow-up. His wife was concerned about his chronic cough for years, previously unreported. CT chest revealed a hollow tubular density embedded in his right mainstem bronchus measuring 9 mm x 9.2 mm x 9.8 mm. Further history revealed he inhaled a small plastic wheel while installing a closet door 9 years ago. At that time, evaluations for FBA, including neck and chest radiographs and EGD, were unrevealing. Following the CT finding, the patient was referred to interventional pulmonology for foreign body removal, which significantly improved his cough. Repeat bronchoscopy showed persistence of the granulation tissue treated with cryotherapy. 2 months later, repeat imaging showed a 4.5 cm spiculated, cavitating right upper lobe pulmonary mass. Diagnostic bronchoscopy with biopsy revealed organizing pneumonia with cultures growing Actinomyces spp. and Streptococcus mitis-oralis. Because of penicillin allergy, he was referred to Infectious Diseases and was started on intravenous ertapenem for 6 weeks followed by oral doxycycline to complete for 6 months. FBA in adults often presents insidiously, masquerading as chronic pulmonary disease, which delays recognition. Chest radiography remains the initial imaging modality; however, studies demonstrate that 17.6% of adult FBAs are diagnosed late (Kara, 2024), with radiolucent foreign bodies detected in only 6.7% of standard posteroanterior films but 65% of chest CT scans. Bronchoscopy remains the diagnostic and therapeutic gold standard, allowing direct visualization and removal. Sehgal et al. reported successful flexible bronchoscopic removal in 91.8% of adult cases without major complications. Pulmonary actinomycosis is a rare, chronic suppurative infection caused by Actinomyces spp., typically resulting from oropharyngeal aspiration. In this case, the retained plastic wheel served as a nidus for infection. Only two prior reports of FBA-induced pulmonary actinomycosis exist, both associated with aspirated food bones. While prolonged penicillin is first-line, alternatives include cephalosporins, macrolides, doxycycline, or carbapenems in penicillin-allergic patients. This case underscores the importance of meticulous history-taking, particularly regarding remote aspiration events, and the limitations of radiography in detecting radiolucent foreign bodies. Early bronchoscopy should be considered when clinical suspicion persists, even in the absence of overt imaging findings, to prevent chronic infectious complications. This abstract is funded by: None