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An elusive foreign body

01 January 2010

Three-year-old Thomas was brought in to the Emergency Department (ED) by his mother, with a history of having inhaled or swallowed a little building brick.

They brought a similar piece with them. Thomas was seen by a junior doctor, Dr W, who documented that Thomas appeared well, with no signs of respiratory distress and had a normal auscultation. Dr W arranged for him to have a chest x-ray, which both Dr W and a radiologist considered normal.

Two months later, Thomas became unwell with a cough and a high temperature. His mum brought him to the ED where, following a chest x-ray, he was diagnosed with right lower lobe pneumonia. Mrs Thomas mentioned to Dr W – the junior doctor who saw them – that they had been to the ED not long ago after Thomas "swallowed” a little toy. All this was documented.

During the next two years, Thomas suffered recurrent episodes of pneumonia and attended the local ED five times. He saw a different doctor on every occasion and had five more chest x-rays. All of them were reported as “right lower lobe pneumonia with collapse and some pleural fluid”. There were no indications in the ED cards to suggest that previous cards or x-rays were looked at.

In view of the recurrent chest infections, Thomas’ GP, Dr F, referred him to the paediatric team for further investigations. Paediatric consultant Dr Q saw Thomas in clinic, looked at all the x-rays and became suspicious of the presence of a foreign body. An urgent bronchoscopy was organised and a large piece of plastic removed. Thomas required further surgery; unfortunately, the foreign body had caused fibrosis of the pulmonary parenchyma, which required excision.

Thomas’ mother made a claim against the hospital and all the hospital doctors involved during those two years. The experts commented that “a case of a possible inhaled foreign body has to be followed up closely and even without a clear history of inhalation of a foreign body, this should be considered a possibility in cases of recurrent pneumonia in children with persistent x-ray changes”. The case was found to be indefensible and was settled for a moderate amount.

Further information

Shlomo Cohen, et al, Suspected foreign body inhalation in children: What are the indications for bronchoscopy?, The Journal of Paediatrics, volume 155, pp 276–280 (Aug 2009).

Learning points

  • Taking a good history can save a lot of mishaps in clinical practice; it is important to listen. Digging into the details of what happened to this child could have made it clear whether the foreign body was swallowed or inhaled. The sudden onset of respiratory difficulty, with coughing, stridor or wheezing, needs to be specifically investigated. If inhalation is suspected, careful follow-up is required to determine the need for a bronchoscopy. 
  • Many types of plastic are radiolucent and will not show up on an x-ray. 
  • Asking the radiographers to place an example of a foreign body, if brought in by the parents, next to the patient they are going to x-ray will easily determine whether it is a radio-opaque object or a radiolucent one.
  • Previous attendances to the ED by children might be relevant in a significant number of cases. Hospital note-gathering systems may be helpful in picking up previous ED attendances. 
  • Reviewing old notes is therefore always important and might offer unexpected background to a new presentation. 
  • With modern computerised radiographic storing systems, there is little excuse not to look at previous x-rays. Both clinician and radiologist would have been alerted to the fact that the changes in the chest x-ray were chronic and would therefore be suspicious of a foreign body being present.