B46-25 Thumbtack Aspiration in an Adult With Autism and Intellectual Disability Complicated by Airway Fibrosis

Background Foreign body aspiration is commonly seen in children; however, adults with swallowing difficulties and intellectual disabilities are at risk. Chronic aspiration can lead to chronic inflammation, fibrosis, and post obstructive pneumonia (1, 2). Organic substances are the most frequently aspirated (47%); whereas inorganic foreign bodies are seen in younger adults and account for 41% of the cases. (3) Case Presentation A 39-year-old male with intellectual disability and autism presented after one episode of vomitus followed by persistent cough. Chest Xray showed foreign body in right lower lung. CT chest showed a metallic linear structure along the right lower lobe bronchus with mild-to-moderate tracheal narrowing, representing tracheomalacia. Opacification of the right middle lobe and bilateral lower lobes was noted, suggestive of bilateral aspiration pneumonia. The patient underwent fiberoptic bronchoscopy, where a metallic foreign body surrounded by extensive fibrosis was visualized in the right lower lobe. While initial removal using forceps failed, a subsequent attempt using snare was successful. The plastic component of the foreign body was maneuvered out towards the airway lumen, and the sharp end was oriented inwards. Repositioning allowed for safe extraction of the sharp object without trauma to surrounding airway structures. The object was found later to be a blue thumbtack. The right lower lobe was completely obstructed by fibrosis; argon plasma coagulation (APC) with recanalization was performed followed by 4 rounds of balloon dilatation, 30 seconds each. Good canalization with adequate diameter was achieved; bronchoalveolar lavage (BAL) was done with good fluid return and cultures were negative. The patient was clinically stable and discharged the next day on Clindamycin. Discussion The right main bronchus and lower lobe bronchi are the most common sites for foreign body aspiration due to anatomical orientation. Bronchoscopy remains the gold standard for diagnosis and treatment. (1) Although rigid bronchoscopy is preferred in pediatrics, flexible bronchoscopy is safe in adults, with a success rate of up to 90%. Forceps are commonly used for extraction; whereas snares are used for friable and larger objects. (4) Thumbtack aspiration is rare and mostly reported in pediatrics, several cases documented aspiration of turban pins in young Muslim females (5). Thumbtack removal is difficult due to its sharp edge increasing the risk of mucosal and airway injury. Conclusion Thumbtack aspiration is uncommon among adults, and extraction can be challenging and requires special maneuvering to prevent mucosal and airway injury. Chronic aspiration leads to airway fibrosis complicating management. This abstract is funded by: None