Case Study: Endobronchial Foreign Objects Can Present as Cough, Chest Pain

A recent case study published in Cureus suggests that clinicians should consider the potential for aspiration of illicit drug packets in patients presenting with intermittent chest pain and productive cough.

Foreign body aspiration is less common in adults than in children, but it can be life-threatening regardless of age. The true incidence in adults is unknown because these cases are often misdiagnosed, undetected, or are discovered incidentally, but experts estimate that foreign body aspiration in adults accounts for approximately 1 in 400 bronchoscopic procedures.

Patients with a high risk of foreign body aspiration include those with primary neurologic disorders such as seizures, brain tumors, Parkinson disease, cerebral palsy, brain trauma, and alcohol or sedative use. The site of lodgment of the foreign body can vary based on the anatomic structure, the patient’s body posture at the time of aspiration, and the type of foreign body. Common types include food items, iatrogenic objects, and miscellaneous items such as pins, coins, and buttons.

A rare but important differential diagnosis of aspiration in adults is body packing or stuffing syndrome. Body packing is the act of swallowing or inserting drug-filled packets into a body cavity. This most often involves cocaine and heroin, but can also include methamphetamine, ecstasy, oxycodone, cannabis, or synthetic cannabinoid receptor agonists. Body stuffing involves rapid ingestion of drugs to avoid arrest, and individuals who attempt body stuffing are at increased risk for aspiration.

Body packing or stuffing is challenging because it can lead to serious health consequences if not identified and treated quickly. If packets rupture, sympathomimetic drugs, such as cocaine, can cause agitation, hypertension, tachycardia, mydriatic pupils, and diaphoresis. Severe toxicity can present as seizures, hyperthermia, myocardial ischemia, heart failure, ventricular dysrhythmias, coma, and cardiac arrest.

Patients may initially present with cough, and less common symptoms may include wheezing, chest pain, hemoptysis, and recurrent pneumonia. Early complications can include acute dyspnea, asphyxia, laryngeal edema, pneumothorax, and cardiac arrest. Late complications can include bronchiectasis, hemoptysis, development of inflammatory polyps at the site of lodgment, bronchial stricture, and diminished lung perfusion.

In the case study, a 51-year-old man presented with intermittent chest pain for 1 month and productive cough for 7 days. He had a history of chronic kidney disease, depression, and polysubstance abuse and a chest X-ray showed mil hazy opacity in the right lower lobe. A chest CT scan without contrast also indicated multiple nodular opacities in the left mainstem bronchus with clear lungs.

Clinicians administered 1 dose of ceftriaxone and 1 dose of azithromycin in the emergency department, but the antibiotics were discontinued because pneumonia was deemed unlikely. The patient was intubated for a flexible bronchoscopy, during which the left mainstem bronchus was found completely occluded by a clear plastic bag containing an unknown substance.

Two more similar-looking bags about 1 x 0.5 cm in size were found in the endotracheal tube, containing what appeared to be cocaine. After the bronchoscopy, the patient noted that his cough and chest pain improved, and he was discharged with a pulmonary clinic appointment. However, he did not follow up with the pulmonary clinic after discharge.

In such cases, the case study authors said a standard posteroanterior and lateral chest X-ray should be obtained, although it may only identify foreign bodies in 25% of cases. Chest CT has become the gold standard of imaging studies in patients with suspected foreign body aspiration.

Once a foreign body is confirmed on imaging, patients may go for bronchoscopy. Flexible bronchoscopy is generally considered superior, although rigid bronchoscopy is preferred in cases of acute respiratory distress because it provides a stable airway and enables bronchoscopists to better manage the central airway and asphyxiating foreign bodies.

Once foreign bodies are extracted, patients should be monitored for 1 to 2 days for complications. These can include noncardiogenic re-expansion pulmonary edema, airway inflammation, hemoptysis, pneumothorax, tracheoesophageal fistula, pneumonia, atelectasis, fever, and ventilatory failure.

Treatment for patients with symptoms of overdose due to drug packet leakage or rupture is supportive, including airway protection, respiratory and circulatory support, antiseizure drugs, and specific antidotes if necessary. Benzodiazepines should be used as soon as possible for cocaine toxicity, and nitroprusside, nitroglycerin, or phentolamine may be used if blood pressure is not controlled with sedatives. Arrhythmias may be treated with sodium bicarbonate.

REFERENCE

Risal R, Aung HM, Jahir T, Subedi KR, et al. Endobronchial Foreign Bodies Presenting as Intermittent Chest Pain and Productive Cough. Cureus; 2022 Sep; 14(9):e29599. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9595348/