P2.232: An Unrelenting Asthma Exacerbation: A Tough Nut to Crack

Introduction: Foreign body aspirations (FBAs) vary in presentation from asymptomatic to severe symptoms, such as cough, choking, dyspnea, and wheezing. They are difficult to diagnose, especially when unwitnessed or unsuspected, because they mimic other conditions. We report a case of a toddler diagnosed with bilateral mainstem bronchial foreign bodies, aspiration pneumonia, and bronchiectasis after presenting with a suspected asthma exacerbation secondary to Influenza B and poorly-treated new-onset wheezing.

Case Description: A 19-month-old male with history of eczema was admitted with acute hypoxemia, URI symptoms, and bilateral wheezing that began after exposure to his father with COVID-19 three weeks ago. Around time of onset, he went to urgent care for an eye injury and was noted to be wheezing. Albuterol was prescribed but not given. On the evening of admission, he had choked on a walnut and parents took him to an outside ED where he tested positive for Influenza B. He received dexamethasone IM, nebulized albuterol, DuoNeb x 2, and racemic epinephrine x 2. He was transferred to our ED on HFNC 12 L/min and FiO2 0.21 with minimal response to bronchodilators and steroids. Physical exam revealed congestion, rhinorrhea, tachycardia, and diffuse bilateral wheezing. CBC revealed a WBC count of 16k/uL. CXR was unremarkable.

Given persistent wheezing exclusively in the right lower lobe on day 3, foreign body imaging was ordered. Parents then recalled patient choking on an almond 3 weeks ago where father had to flip him over and hit his back multiple times. A 4-view CXR demonstrated a new right upper lobe opacity and air trapping of the right lung on decubitus view.

On day 4, rigid and flexible bronchoscopy revealed bilateral mainstem bronchi occlusion. Multiple pieces of presumed walnut (from left mainstem) and almond (from right mainstem considering significant granulation tissue) were removed. Pathology reported fragments of white-tan nut-like particles measuring 1 x 1 x 0.3 cm in aggregates. Non-contrast chest CT on day 6 demonstrated bilateral opacities with mild cylindrical bronchiectasis throughout and no visible foreign body.

Discussion: FBA symptoms can be nonspecific, making diagnosis challenging, especially when patients present with concurrent viral URI symptoms and bilateral wheezing. Delayed diagnosis results in prolonged respiratory symptoms along with complications, including pneumonia, bronchiectasis, and atelectasis. We suspect our patient initially obstructed on the right due to extensive granulation tissue, which resulted in aspiration pneumonia and bronchiectasis. It is important to maintain a high level of suspicion for prompt diagnosis and management of FBAs.

Conclusion: Our case emphasizes considering FBAs with persistent or worsening respiratory symptoms, particularly in young children with no wheezing history, using multiple view CXRs to detect signs like air trapping, and inquiring about choking events to reduce delayed parental recall. Timely diagnosis prevents irreversible bronchiectasis.