Vol.1, No.1, 1-3 (2013) Forensic Medicine and Anatomy Research
http://dx.doi.org/10.4236/fmar.2013.11001
Choking due to fruit drink aspiration
Luv Sharma*, Basant Lal Sirohiwal, Pramod Kumar Paliwal
Department of Forensic Medicine, University of Health Sciences, Rohtak, India; *Co rre sp ond ing A uth or: [e-mail]
Received 23 November 2012; revised 26 December 2012; accepted 5 January 2013
ABSTRACT
A case of a fatal foreign material aspiration is
presented in the following paper. During the
autopsy, an orange colored mucus plug was
noted in the trachea, which was completely oc-
cluding the lumen from mid-level downwards
causing a lethal respiratory insufficiency. The
bio-chemical and chemical analy sis was positive
for fructose; there was history of intake of a
mango fruit drink just before induction for sur-
gery. The anatomo-pathological exam of the
lungs showed the signs of acute asphyxia (Mi-
croscopic examinations re vealed atelectasia, em-
physema, eo sinophilic ex udate and emp ty sp aces).
This case represents a rare lethal event related
to the aspiration of a fruit drink in a child just
prior to induction.
Keywords: L ethal Asphyxia; Complete Laryngeal
Obstruction; Ch oking; Fruit Drink
1. INTRODUCTION
Asphyxia, by definition and bearings is a complex
term. A foreign body is an acute life-threatening condi-
tion [1] and is under-reported as a cause of airway ob-
struction [2]. Diagnosis based on autopsy findings is dif-
ficult as signs and symptoms on the body are mostly
vague and non-specific [3]. Majority of such asphyxial
deaths are caused by undigested food/other foreign bod-
ies especially in children, the old and the infirm. Condi-
tions that depress the central nervous system, cause coma
or depress the gag reflex such as alcohol, narcotics, bar-
biturates or benzodiazepines increase the likelihood of
aspiration and choking [4]. The sev erity of the complica-
tions of foreign body aspiration depends on size, shape,
composition, location and orientation of the aspirated
object Delay in treatment can result in obstructive em-
physema, localized bronchoectasis, atelectasis, oedema
and collapse [5]. The diagnosis of death by choking is
based on the detection of the generic signs of asphyxia,
on the identification of the foreign body obstructing the
airways and on the exclusion of other causes of death.
The case here reported regards a rare case of complete
obstruction of the trachea by a mucous plug formed due
to the accidental aspiration of a fruit drink just after pre-
op induction.
2. CASE REPORT
2.1. Case History
A case report of a rare sudden death of a previously
healthy 13-year-old girl is examined. The deceased was
due for a planned femoral hernia operation and kept
N.P.O. She suddenly presented with acute respiratory
distress on pre-op induction and collapsed. Despite re-
suscitative efforts, the patient died within a few hours.
The patient’s family admitted giving the child a sip of a
mango fruit drink just prior to indu ction as she was com-
plaining of thir st .
2.2. Autop sy Findings
The lungs were distended and over-inflated, whose
compression showed crackling and leaking of frothy he-
matic liquid; numerous sub-pleural and sub-epicardial
petechiae were also perceptible. Asphyxial petechiae
were perceptible on the lung surface. Dissection of the
trachea revealed an orange colored mucous plug, in a
frothy pool occluding the lume n (Fig ures 1 and 2).
2.3. Histological Findings
Lung tissues for light microscopic examinations were
fixed in 10% (w/w) neutral buffered formaldehyde solu-
tion and stained with hematoxylin-eosin. The histological
exam of the lung samples revealed massive emphysema-
tous areas with rupture of the septa, alternated with peri-
bronchial alveoli plugged by erythrocytes and emosi-
derophage hystiocytes; abundant cellular debris, con-
stituted by degenerated lining epithelium and mucous,
were noticed in the bronchial and bronchiolar terminal
branches.
2.4. Toxicological Analysis
The analyses were performed on blood and urine
samples collected during the autopsy; the toxicological

L. Sharma et al. / Forensic Medicine and Anatomy Research 1 (2013) 1-3
2
Figure 1. Orange colored mucus pug completely occluding the
tracheal lumen from midlevel.
Figure 2. The mucus plug on a filter paper after removal from
trachea.
results were negative for psychotropic, antidepressants
and sedatives drugs, as well as for other organic nitrogen
toxic xenobiotics. The search for ethylic alcohol and
other volatile organic solvents (i.e.: ethylic ether, chlo-
roform, petrol, etc.) w as n eg ative too.
2.5. Bio-Chemical Tests
Bio-chemical analysis of mucus plug was positive for
Fructose glucose sucrose (Fructose-Glucose) and other
sugars.
3. DISCUSSION
Inhalation of foreign body into the tracheobronchial
tree is a medical emergency sometimes resulting into
sudden death. The current mortality rate due to foreign
body inhalation ranges from 0% to 1.8% [6]. As well
known; choking is a form of mechanical asphyxia caused
by the aspiration of a foreign body able to obstruct the
airways. Choking can be defined as typical or atypical
depending on the capacity of the foreign body to com-
pletely or partially occlude the airways, respectively [7].
The typical form of choking is generally caused by any
object able to adapt and completely obstruct the air pas-
sage (i.e.: meat or vegetable food, etc.). In the atypical
form of choking, the foreign body is characterized by a
well-defined shape (i.e.: buttons, coins, balls, etc.), not
necessarily correspondent to the airways profile and of-
ten not able to obstruct it completely. In both cases, the
spasm of the larynx contributes to the asphyxial mecha-
nism [8]. When a complete obstruction occurs, the ex-
ternal resuscitation techniques may be useless, being
unable to ventilate the lung s. Only once the foreign body
has been removed, a rapid intubation allows pulmonary
ventilation, whilst the obstruction at laryngeal level may
be treated only by a prompt tracheotomy. Anyway, the
timing of care intervention must be very quick, because
irreversible brain damage or death may occur even 5 - 10
minutes after a lesion the beginning of mechanical ob-
struction [9-13].
Berzlanovich et a l., in an autopsy based study, demon-
strated that semisolid foods were the cause of a large
number of asphyxiations, especially among the elderly,
while in contrast, younger individuals choked signifi-
cantl y more often on large pieces of foreign material [14].
Prevention and early recognition remain critical fac-
tors in the treatment of foreign body inhalation and in-
gestion in children. Accidental inhalation or ingestion of
both organic and non-organic foreign body material con-
tinues to be a caus e of childhood morbidity and mortality.
The diagnosis of foreign body aspiration may easily be
missed. An unusual case of foreign body ingestion in a
child is presented. A 2 years old female patient was a
fibro optic bronchoscopy showed a popcorn kernel in her
right main bronchus. The first known fatality attributed
to aspiration is said to be the Greek poet Anacreon who
died in 475 BC after aspirating a grape seed. Sir James Y.
Simpson attributed the first well documented anesthesia
related death in 1848. A significant advancement in
bronchoscopy was achieved by introduction of Hopkins
telescope in 1976 [15].
Qureshi et al. report 3 cases of aspiration of a popular
fruit-flavored gel snack leading to cardiopulmonary ar-
rest and death in 1 case and respiratory failure in 2 other
cases. They commented that items lodged in the oral
cavity, hypopharynx, or larynx can produce airway ob-
struction leading to hypoxia, respiratory failure, or even
cardiac arrest. However, most items pass through the
larynx and become lodged in the trachea or main stem
bronchus [16].
The longer a foreign body resides in the airway, the
more likely it is to migrate distally. When this occurs,
symptoms of chronic cough and wheezing may mimic an

L. Sharma et al. / Forensic Medicine and Anatomy Research 1 (2013) 1-3 3
asthma-like condition [17].
The aspired foreign material being a liquid did not oc-
clude the whole extent of the trachea in itially, but exces-
sive salivation in the inner air passages admixed with
mucus led to formation of the plug eventually occluding
the tracheal lumen. Usually an individual can easily
make movements in the internal airway between the
pharynx and the bifurcation of the trachea in order to
expel the foreign body. Ho wever, lulli ng of the gag reflex
due to pre-anesthetic medications led to fatal choking.
REFERENCES
[1] Blaschke, U. and Cheng, E.Y. (1989) Foreign body in
upper airway. Unsuspected cause of obstruction. Post-
graduate Medicine, 86, 235-237.
[2] Casson, A.G. and Guy, J.R. (1998) Foreign-body aspira-
tion in adults. Canadian Journal of Surgery, 30, 193-194.
[3] Lai, Y.F., Wong, S.L., Chao, T.Y. and Lin, A.S. (1996)
Bronchial foreign bodies in adults. Journal of the For-
mosan Medical Association, 95, 213-217.
[4] Munter, D.W. (2001) Foreign bodies, trachea. Emergency
Medicine Journal, 2, 28.
[5] Warshawsky, E.M. (2003) Foreign body aspiration. Emer-
gency Medicine Journal, 3.
[6] Sinha, V., Memon, R., Gupta, D., Prajapati, B., Bhat, V.
and Yogesh, M. (2007) Foreign body in tracheobronchial
tree. Indian Journal of Otolaryngology and Head & Neck
Surgery, 59, 211-214. doi:10.1007/s12070-007-0063-9
[7] Barbera, N., Arcifa, V., Valenti, V., Spadaro, G., Toma-
sello, S. and Romano, G. (2012) Fatal asphyxia by com-
plete laryngeal obstruction due to chewing-gum aspira-
tion in an adult woman—Case Report. Romanian Journal
of Legal Medicine, 20, 33-36. doi:10.4323/rjlm.2012.33
[8] Arbarello, P., Di Luca, N.M., Feola, T. and Macchiarelli,
L. (2005) Medicina Legale. 2nd Edition, Minerva Medica,
Torino, 343-345.
[9] Njau, S.N. (2004) Adult sudden death caused by aspira-
tion of chewing gum. Forensic Science International, 139,
103-106. doi:10.1016/j.forsciint.2003.09.021
[10] Berzlanovich, M.A., Manfred, M., Sim, E. and Bauer, G.
(1999) Foreign body asphyxiation—An autopsy study.
American Journal of Medicine, 107, 351-355.
doi:10.1016/S0002-9343(99)00242-9
[11] Donato, L., Weiss, L., Bing, J. and Schwarz, E. (2000)
Tracheobronchial foreign bodies. Archives de Pédiatrie, 7,
56s-61s. doi:10.1016/S0929-693X(00)88821-1
[12] Kitay, G. and Shafer, N. (1989) Café coronary: Recogni-
tion. Nurse Practitioner, 14, 35-46.
doi:10.1097/00006205-198906000-00004
[13] Eller, W.C. and Haugen, R. (1973) Food asphyxiation-
restaurant rescue. New England Journal of Medicine, 289,
81-82. doi:10.1056/NEJM197307122890206
[14] Berzlanovich, A.M., Fazeny-Dörner, B., Waldhoer, T.,
Fasching, P. and Keil, W. (2005) Foreign body asphyxia:
A preventable cause of death in the elderly. American
Journal of Preventive Medicine, 28, 65-69.
doi:10.1016/S0749-3797(04)00077-7
[15] Deepak, H., Vaidiyanathan, S., Ranganath, A.K., Patel,
A.K. and Gupta, R. (2008) Asymptomatic foreign body
aspiration in a child. Internet Journal of Anesthesiology,
17.
http://www.ispub.com/journal/the-internet-journal-of-ane
sthesiology/volume-17-number-1/asymptomatic-foreign-
body-aspiration-in-a-child.html#sthash.MLZCK7Y1.dpuf
[16] Qureshi, S. and Mink, R. (2003) Aspiration of fruit gel
snacks. Experience and reason. Pediatrics, 111, 687-689.
doi:10.1542/peds.111.3.687
[17] Swanson, K.L. and Edell, E.S. (2001) Tracheobronchial
foreign bodies. Chest Surgery Clinics of North America,
11, 861-872.