|Year : 2013 | Volume
| 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 Publication||24-Dec-2013|
Department of Paediatrics, Aminu Kano Teaching Hospital/Bayero University, Kano
Source of Support: None, Conflict of Interest: None
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
| Introduction|| |
Foreign body ingestion is a potential serious problem that peaks in children aged 6 months to 3 years;  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.  An estimated 40-50% of foreign body ingestion in children is unwitnessed, and in many cases the child is symptomatic.  Common objects ingested are coins, pins, disk batteries, toys and food related like bones and meat balls.  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. , 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|| |
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|
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|Figure 2: X-ray lateral view of the upper neck showing a coin-like object in the esophagus|
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| Discussion|| |
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. , 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.  Gastro-intestinal foreign body ingestion may be asymptomatic in about 90%  of cases and unwitnessed by the caregiver in 40-50% of cases,  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.  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.  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.  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.  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%),  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.  The mechanisms of injury from battery ingestion include electrical discharge, pressure necrosis, and leakage of battery contents  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|| |
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.
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[Figure 1], [Figure 2], [Figure 3]