Refractory Wheezing and Fever in a 2-Year-Old Boy
A previously healthy boy, 2 years 10 months of age, was brought by his parents to a pediatric emergency department (ED) with fever up to 103°F for 3 days and intermittent violent coughing episodes. His mother had brought him to the ED 10 days earlier because he was experiencing wheezing and cough. The patient was afebrile at that time and had no history of asthma. He was administered albuterol in the ED for bilateral wheezing in the lung bases, after which he showed some improvement. Because the wheezing was not focal and the boy seemed to be well, he was discharged with a prescription for albuterol and instructions for close follow-up with his pediatrician. The patient's parents administered the albuterol to him intermittently, and he continued to have episodes of coughing and gagging. During the past 3 days, he developed an increasingly harsh, productive cough and has had emesis 1-2 times per day.
At this visit, the patient’s father recalled that the child had choked on a plastic peg from a Lite-Brite toy approximately 3 weeks earlier. The patient’s mother subsequently found a plastic peg in the patient’s stool.
The patient was afebrile, his respiratory rate was 28 breaths per minute, his pulse was 118 beats/min, and his room air oxygen saturation was 96%. He appeared to be comfortable and had clear rhinorrhea. He had a notable expressive language delay and could not verbally communicate during the examination. Respiratory effort was normal, with markedly decreased aeration on the left. He had no wheezing or rales.
Anteroposterior chest x-ray showed consolidation of the left lower lobe consistent with pneumonia. This view also demonstrated left upper lobe hyperinflation and a 2-cm linear foreign body in the left main-stem bronchus (Figure 1). Forced expiration chest radiography demonstrated increased hyperinflation of the left upper lobe (Figure 2).
Figure 1. Chest x-ray showing left lower lobe consolidation, left upper lobe hyperinflation, and 2-cm plastic foreign body (marked with arrows).
Figure 2. Forced expiratory x-ray demonstrates hyperinflation of the left upper lobe with tracheal deviation.
The patient underwent bronchoscopy, and a red plastic peg was removed from the left main-stem bronchus. The foreign body was surrounded by large amounts of purulent secretions. The patient recovered well and had no complications.
Case Presentation
A previously healthy boy, 2 years 10 months of age, was brought by his parents to a pediatric emergency department (ED) with fever up to 103°F for 3 days and intermittent violent coughing episodes. His mother had brought him to the ED 10 days earlier because he was experiencing wheezing and cough. The patient was afebrile at that time and had no history of asthma. He was administered albuterol in the ED for bilateral wheezing in the lung bases, after which he showed some improvement. Because the wheezing was not focal and the boy seemed to be well, he was discharged with a prescription for albuterol and instructions for close follow-up with his pediatrician. The patient's parents administered the albuterol to him intermittently, and he continued to have episodes of coughing and gagging. During the past 3 days, he developed an increasingly harsh, productive cough and has had emesis 1-2 times per day.
At this visit, the patient’s father recalled that the child had choked on a plastic peg from a Lite-Brite toy approximately 3 weeks earlier. The patient’s mother subsequently found a plastic peg in the patient’s stool.
Physical Examination
The patient was afebrile, his respiratory rate was 28 breaths per minute, his pulse was 118 beats/min, and his room air oxygen saturation was 96%. He appeared to be comfortable and had clear rhinorrhea. He had a notable expressive language delay and could not verbally communicate during the examination. Respiratory effort was normal, with markedly decreased aeration on the left. He had no wheezing or rales.
Radiographic Studies
Anteroposterior chest x-ray showed consolidation of the left lower lobe consistent with pneumonia. This view also demonstrated left upper lobe hyperinflation and a 2-cm linear foreign body in the left main-stem bronchus (Figure 1). Forced expiration chest radiography demonstrated increased hyperinflation of the left upper lobe (Figure 2).
Figure 1. Chest x-ray showing left lower lobe consolidation, left upper lobe hyperinflation, and 2-cm plastic foreign body (marked with arrows).
Figure 2. Forced expiratory x-ray demonstrates hyperinflation of the left upper lobe with tracheal deviation.
ED Course
The patient underwent bronchoscopy, and a red plastic peg was removed from the left main-stem bronchus. The foreign body was surrounded by large amounts of purulent secretions. The patient recovered well and had no complications.
Source...