Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 15  |  Issue : 2  |  Page : 159-161

Esophageal foreign body in a child mimicking a primary respiratory disease


Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University Kano, Kano, Nigeria

Date of Web Publication24-Dec-2013

Correspondence Address:
Ibrahim Aliyu
Department of Paediatrics, Aminu Kano Teaching Hospital/Bayero University, Kano
Nigeria
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2276-7096.123618

Rights and Permissions
  Abstract 

Foreign body aspiration or ingestion is common in young children. They may be asymptomatic and pass unnoticed if unwitnessed or may manifest with digestive, respiratory or behavioural problems. Some could be life threatening, therefore in unwitnessed cases, a high index of suspicion should be entertained when young children present with complains suggestive of its occurrence.
Key words: Child, foreign body, ingestion, witness

Keywords: Child, foreign body, ingestion, witness


How to cite this article:
Aliyu I. Esophageal foreign body in a child mimicking a primary respiratory disease. J Med Trop 2013;15:159-61

How to cite this URL:
Aliyu I. Esophageal foreign body in a child mimicking a primary respiratory disease. J Med Trop [serial online] 2013 [cited 2019 Jul 17];15:159-61. Available from: http://www.jmedtropics.org/text.asp?2013/15/2/159/123618


  Introduction Top


Foreign body ingestion is a potential serious problem that peaks in children aged 6 months to 3 years; [1] children of this age group have that tendency to put objects in their mouth as they explore their environment; which puts them at risk of foreign body aspiration or impaction. Faced with developmental limitations of incompletely formed posterior dentition, poor coordination of swallowing, the risk of food related and foreign body impaction is further heightened. [2] An estimated 40-50% of foreign body ingestion in children is unwitnessed, and in many cases the child is symptomatic. [3] Common objects ingested are coins, pins, disk batteries, toys and food related like bones and meat balls. [4] Such objects could lodge in any part of the gastrointestinal tract. Patients with objects lodged in the esophagus may be asymptomatic or may present with symptoms varying from vomiting, refractory wheezing to irritability and behavioral disturbances. [3],[5] Longstanding esophageal foreign bodies may result in esophageal perforation, failure to thrive or recurrent aspiration pneumonia. We present an 11-month-old infant with a neglected esophageal disk battery impaction misdiagnosed as pulmonary tuberculosis.


  Case Report Top


An 11-month-old girl presented with 1 month history of cough, fever and weight loss. Cough was non-paroxysmal worsened by feeding and associated with choking. No known relieving factor; 2 days to presentation she developed difficulty in breathing but no history of darkening of the mucous membranes or lips. There was associated hoarseness, poor appetite, progressive weight loss, but no history of stridor. There was no history of contact with chronic coughing patient suggestive of tuberculosis. She was seen severally in a general hospital where she had several antibiotics without significant improvement. She was fully immunized for age but no Bacillus Calmette-Guérin (BCG) scar was seen. She had attained normal developmental milestones before onset of the illness but had lost ability to crawl. She was the only child of her parents. She was in respiratory distress evidenced by flaring of ala nasi and intercostal recession, her oxygen saturation at room air was 95%, respiratory rate was 54 breaths/ min, she had resonant percussion note with widespread coarse crepitations but no rhonchi. The abdominal examination revealed non-tender hepatomegaly. The ear, nose and throat examination was unremarkable. She had normal gag reflex, but reduced muscle bulk and tone. The white blood cell count showed leukocytosis with relative lymphocytosis (WBC = 7.0 × 10 9 /L, lymphocyte count = 3.9 × 10 9 /L) and erythrocyte sedimentation rate of 30 mm/hr. Mantoux test of 4 mm was not significant and the retroviral screen was non-reactive. She was commenced on anti-tuberculosis therapy from the referring centre. We made a tentative diagnosis of tuberculous pneumonia, to rule out upper gastrointestinal tract foreign body obstruction. Thorough review of the chest radiograph showed diffuse patchy opacities in both lung fields mimicking miliary shadows and a radiopaque coin-like object at the upper esophagus [Figure 1] and [Figure 2]. The diagnosis of esophageal foreign body impaction with aspiration pneumonia was finally made. She was referred to the otorhinolaryngologist where she had esophagoscopy and a disc battery [Figure 3] was removed from the esophagus 8 cm from the upper central incisors.
Figure 1: X-ray view of the chest and the upper neck (AP), revealing a radiopaque coin-like object lodged in the neck region

Click here to view
Figure 2: X-ray lateral view of the upper neck showing a coin-like object in the esophagus

Click here to view
Figure 3: A disc battery extracted from the upper esophagus

Click here to view



  Discussion Top


Aerodigestive foreign body aspiration and ingestion is common in young children often as they start exploring their environment. The esophagus is a common site of foreign body impaction. [6],[7] The anatomy of the esophagus has three areas of physiologic narrowing where obstruction can occur; the first area of narrowing is the cricopharyngeal junction which is at the junction of the striated and smooth muscles, where the propulsive force is weak; the second area is at the area of impingement of the aortic arch on the anterolateral wall of the esophagus; while the third area is at the gastroesophageal junction. [8] Gastro-intestinal foreign body ingestion may be asymptomatic in about 90% [9] of cases and unwitnessed by the caregiver in 40-50% of cases, [4] but in symptomatic cases the complaints often depend on the site of impaction, the nature and size of the object involved and also the duration of ingestion. [3] Symptoms may point to the respiratory system as it occurred in our patient; they may present with cough, hoarseness, wheezing, and difficulty in breathing resulting in misdiagnosis of a primary respiratory disease as in our patient.

Diagnosis of pulmonary tuberculosis is often difficult in children because young aged children often do not expectorate sputum and the yield of gastric lavage may be poor coupled with our inability to routinely culture the organism. Often a low threshold for the diagnosis of tuberculosis is observed in most developing countries with high disease burden. [10] Furthermore, the Mantoux test maybe insignificant in most children who are severely malnourished or with overwhelming infection. These factors often result in over diagnosis of tuberculosis especially when the tuberculosis score is applied. [11] Our patient could pass for a case of miliary tuberculosis if the history of choking when fed was not highly recognized, and the presence of the radio-opaque coin-like shadow which made the diagnosis easier. However, in about 64% of cases the objects involved may be radiolucent. [4] Therefore, a high index of suspicion of foreign body-related illnesses should be entertained when dealing with children especially toddlers and when they present with an atypical clinical history. Though coins are the most common object ingested by children in Kano (79.3%), [12] our patient swallowed a lithium disc battery of approximately 12 mm. Disc battery ingestion is considered a medical emergency because of its associated complications such as esophageal perforation, esophago-pleural fistula formation, and heavy metal poisoning. [13] The mechanisms of injury from battery ingestion include electrical discharge, pressure necrosis, and leakage of battery contents [4] which results in corrosive damage when the battery lies in contact with a mucosal surface for a long period; among these, electrical discharge is the important mechanism involved in most cases. Though our patient did not have any marked structural damage despite having symptoms for four weeks, probably it might had been a discharged battery with little or no current. Clinicians should therefore explore all possible clinical differentials when evaluating young children; furthermore, investigations should be thoroughly reviewed when dealing with atypical clinical presentations so that unnecessary mis-diagnosis is avoided.


  Conclusion Top


Esophageal foreign body could present with respiratory complaints, and a detailed evaluation of the clinical history and investigations results especially a chest x-ray is important in order to avoid mis-diagnosis.

 
  References Top

1.Alexander W, Kadish JA, Dunbar JS. Ingested foreign bodies in children. In: Kaufmann HJ, editors. Progress in Pediatric Radiology, 2 nd ed. Chicago: Yearbook Medical Publishers; 1969.  Back to cited text no. 1
    
2.Koirala K, Rai S, Chettri S, Shah R. Foreign body in the esophagus- comparison between adult and paediatric population. Nepal J Med Sci 2012;1:42-4.  Back to cited text no. 2
    
3.Dahshan A. Management of ingested foreign bodies in children. J Okla State Med Assoc 2001;94:183-6.  Back to cited text no. 3
[PUBMED]    
4.Arana A, Hauser B, Hachimi-Idrissi S, Vandenplas Y. Management of ingested foreign bodies in childhood and review of the literature. Eur J Pediatr 2001;160:468-72.  Back to cited text no. 4
[PUBMED]    
5.Eisen GM, Baron TH, Dominitz JA, Faigel DO, Goldstein JL, Johanson JF, et al. Guideline for the management of ingested foreign bodies. Gastrointest Endosc 2002;55:802-6.  Back to cited text no. 5
[PUBMED]    
6.Onotai LO, Ebong EJ. Impacted fishing hook in the upper cervical esophagus of two Nigerians: Case reports. J Med Med Sci 2012;3:365-70.  Back to cited text no. 6
    
7.Ahmad BM, Dogo D, Abubakar Y. Pharyngo-oesophageal foreign bodies in Maiduguri. Niger J Surg Res 2001;3:62-5.  Back to cited text no. 7
    
8.Ratcliff KM. Esophageal foreign bodies. Am Fam Physician 1991;44:824-31.  Back to cited text no. 8
[PUBMED]    
9.Chan YL, Chang SS, Kao KL, Liao HC, Liaw SJ, Chiu TF, et al. Button battery ingestion: An analysis of 25 cases. Chang Gung Med J 2002;25:169-74.  Back to cited text no. 9
[PUBMED]    
10.Osinusi K. Childhood tuberculosis. In: Azubuike JC, Nkanginieme KE, editors. Paediatrics and child health in a tropical region. 1 st ed. Owerri, Nigeria: African Educational Services; 1999.  Back to cited text no. 10
    
11.Hesseling AC, Schaaf HS, Gie RP, Starke JR, Beyers N. A critical review of diagnostic approaches used in the diagnosis of childhood tuberculosis. Int J Tuberc Lung Dis 2002;6:1038-45.  Back to cited text no. 11
[PUBMED]    
12.Salisu AD. Metallic foreign body in esophagus: Are multiple radiographs necessary? Ann Afr Med 2010;9:73-6.  Back to cited text no. 12
[PUBMED]  Medknow Journal  
13.Chen MK, Beierle EA. Gastrointestinal foreign bodies. Pediatr Ann 2001;30:736-42.  Back to cited text no. 13
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case Report
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed2075    
    Printed44    
    Emailed0    
    PDF Downloaded104    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]