Vol.2, No.6, 370-374 (2013) Case Reports in Clinical Medicine
http://dx.doi.org/10.4236/crcm.2013.26099
Diagnostic difficulties in chronic obstructive
pulmonary disease exacerbations: A case report
Simona Stefania Bucsa1*, Petre Iacob Calistru2
1Department of Pneumology, “Dr Victor Babes” Diagnosis and Treatment Center, Bucharest, Romania;
*Corresponding Author: [e-mail]
2Department of Infectious Diseases, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
Received 16 May 2013; revised 10 June 2013; accepted 30 June 2013
Copyright © 2013 Simona Stefania Bucsa, Petre Iacob Calistru. This is an open access article distributed under the Creative Com-
mons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work
is properly cited.
ABSTRACT
Exacerbations of COPD (chronic obstructive pul-
monary disease) influence, by their frequency
and severity, the life prognosis of patients with
COPD. Most exacerbations are caused by res-
piratory infections with negative impact on pa-
tient quality of life. The impact of frequent ex-
acerbation in COPD is manifested by the rapid
decline of lung function, decreased quality of life
increased airway inflamation and high mortality.
Bronchial obstruction by foreign bodies meets
frequently during childhood but can occur in
adults under certain conditions of loss of con-
sciousness (sleep, administration of tranquili-
zers, after anesthesia, intoxicated). The long-
standing intrabronchial foreign body presents
problems of diagnosis and treatment which are
very different from those associated with the
recently inhaled foreign body. W e herein repor t a
77-year-old male, smoker (40 pack-year) pre-
sented to the clinic with severe dyspnoea, fever
and cough with purulent sputum for about 6
months. Persistent symptoms require repeated
hospitalizations for receiving different regi-
mens of antibiotics, but they have not helped.
Chest radiography showed extensive consoli-
dation of the right lower lobe, intensity rib, he-
terogeneous and Chest CT scan showed me-
tallic foreign body in right lower lobar bronchus
with secondary pneumonic process in the lower
right lobe. Emergency was performed broncho-
scopy and extracted dental crown consists of
three teeth and then the patient received com-
bined antibiotic therapy for 14 days, in asso-
ciation with anti-inflammatory, mucolytics and
bronchodilators. After 2 weeks he was overall
in very good condition and all other complaints
disappeared and C hest X-ray control sho wed ful l
resorption of pneumonia opacity, without dis-
abling signs. In this particular case, only minor
symptoms are seen at the beginning and the
aspirated foreign body was forgotten until later
symptoms (inflammation, infection) were devel-
oped and developing clinically manifest. The
diagnosis was delayed due to lack of radiogra-
phic view which may be aspirated foreign body
embedded in granulation tissue formed around.
Keywords: Retrostenotica Secondary Pneumonia;
Metallic Foreign Body Aspirated Intrabronsic
1. INTRODUCTION
Bronchial obstruction by foreign bodies (FB) meets
frequently during childhood, and commonly after the age
of 1 year to 45 years. The highest incidence occurs be-
tween the age of 1 - 3 years that is 77% [1] and it is rare
in adults. Aspiration of FB is multifactorial in their aeti-
ology, in their broad spectrum of different resolutions for
the same FB and in the response of each patient to the
treatment.
In aspiration of foreign body symptoms are three clini-
cal phases: initial stage (first stage or impaction or FB)
showing choking, gagging and paroxysms of coughing,
obstruction of the airway (AW), occurring at the time of
aspiration. These signs calm down when the FB lodges
and the reflexes grow weary (second stage or asympto-
matic phase).
Complications occur in the third stag e (also defined as
the complication phase), when the obstruction, erosion or
infection cause pneumonia, atelectasis, abscess or fever.
The first symptoms to receive medical care may actually
represent a complication of impaction of FB [2]. Early

S. S. Bucsa, P. I. Calistru / Case Reports in Clinical Medicine 2 (2013) 370-374 371
diagnosis and treatment is imperative to prevent mor-
tality as well as complications.
The long-standing intrabronchial foreignbody presents
problems of diagnosis and treatment which are very
different from those associated with the recently inhaled
foreign body. There may be no history to suggest the
original incident; the clinical picture is usually clouded
by superadded pathological changes-atelectasis, pneu-
monitis, bronchiectasis, or lung bscess-and the broncho-
scopic appearances are often misleading. The symptoms
of aspiration of FB can simulate different diseases such
as asthma, croup or pneumonia, delaying the correct
diagnosis [2]. The delay in the removal of FB is po-
tentially harmful. Even when correctly diagnosed, the
choice of treatment is not always easy. The treatment of
choice for AW is endoscopic removal [2].
Bronchoscopy may be necessary to make a definitive
diagnosis and to remove the object. Prevention remains
the best treatment, but in case of complications anti-
biotics and resp iratory therapy techniques may b e used if
infection develops. Sometimes, for the removal of highly
difficult and high risk tracheobronchial foreign bodies,
preoperative analysis and discussion should be sufficient,
appropriate surgical skill and surgical instruments may
improve the success rate of the surgery and prevent the
operation complications [3].
2. CASE REPORT
A 77-year-old male, smoker (40 pack-year), living in
villages, presented to the clinic with severe dyspnoea,
fever and cough with purulent sputum for about 6
months. He has a history of Chronic Obstructive Pulmo-
nary Disease (COPD) 5 years ago, with two exacerba-
tions in the past year, diabetes mellitus with oral treat-
ment and chronic use of ethanol. Current disease onset
was 6 months ago with cough with purulent sputum,
intermitent fever and chills, shortness of breath. He was
hospitalized in the village with diagnosis of COPD ex-
acerbations, community acquired pneumonia and receiv-
ed antibiotic treatment with Amoxicilin-Clavulanat and
Gentamicin, then Ceftriaxon, with temporary improve-
ment. Then recurrence the simptoms determined repeated
hospitalizations for which he received different antibiotic
regimens, but they have not helped. A few days before
presenting to hospital , the symptoms worsened, the pa-
tient presenting malaise, severe dyspnoea with weezing,
fever and cough with purulent sputum. Physical exami-
nation on admission: General appearance: underweight;
Respirator stetacustic. prolonged expiration, weezing,
bronchial rales crackles in lower right lung, SaO2 = 91%
- 93%; Febrile, T = 38 .5˚C; Vital signs: in normal limits;
No other significant signs revealed. Blood tests showed:
leucocytes 17.800/mm3, with neutrophils 9.900/mm3;
VSH = 68/105 mm/h/2h; CRP = 8.68 mg/dl; Fibrinogen
= 785 mg/dl; TGP, TGO, Glycemia, BUN within normal
ranges; specific tumor markers-negative. Chest radiog-
raphy showed extensive consolidation of the right lower
lung lobe,intensity rib, heterogeneous (Figure 1). Spiro-
metry: severe mixed ventilatory dysfunction with reduc-
ed FEV1 with 73% (FEV1 = 27%, FVC= 63%, Tiffeneau
Index = 34.6) (Figure 2). Abdominal ultrasound, cardiac
ultrasound, all in normal limits. We performed a Chest
CT scan contrast enhanced which showed metallic for-
eign body in right lower lobar bronchus with secondary
pneumonic process in the lower right lobe (Figures 3(a)
and (b)).
The diagnosis is: Intrabron chial foreign body with air-
way obstruction secondary pneumonia, COPD group D.
Emergency bronchoscopy was performed. Bronchoscopy
showed that the mucosa of the right lower lobe was
hyperaemic, granular, much pus and extracted a dental
crown made of three teeth. Than we started antibiotics
treatment with Amoxicilin-Clavulanat 1 g three times a
day and Metronidazol 1 g twice a day for 14 days in
association with anti-inflammatory, mucolyti cs and bron-
chodilators (Corticosteroid inhaled with Long action β
agonist fixed combinations). With tratment and postural
drainage, he became afebrile in three days, general con-
dition improved and than the cough and dyspnoea im-
proved.
Treated, after 2 weeks he was overall very good
condition and all other complaints disappeared. Control
Chest X-ray showed complete resolution of pneumonia
opacity without other signs added (Figure 4).
3. DISCUSSION
Although FB aspiration can occur at any stage in life,
it is far more common in children. In adults, FB as-
piration is uncommon and is mostly related to accidental
aspiration of working tools (paper clips, tacks, or nails)
Figure 1. Pretreatment chest X-ray posterior-anterior shows ex-
ensive consolidation in the right lower lung lobe. t

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372
Figure 2. Spirometry show severe mixed ventilatory dysfunction with reduced FEV1 with 73% (FEV1 = 27%, FVC = 63%,
Tiffeneau Index = 34.6).

S. S. Bucsa, P. I. Calistru / Case Reports in Clinical Medicine 2 (2013) 370-374 373
(a) (b)
Figure 3. (a), (b) CHEST CT scan findings metallic foreign body in right lower lobar bronchus with secondary pneumonic
process in the lower right lobe.
Figure 4. After treatment chest X-ray showed complete resolu-
tion of pulmonary opacity without other signs added.
and bone fragments, as well as occurring during uncon-
sciousness (trauma, general anesthesia, sedation, intoxi-
cation, seizures, and neurological disorders) [1].
Clinical onset is sudden, often impressive and some-
times with rapidly fatal evolution. However, in some
cases, only minor symptoms are seen at first, and the
object may be forgotten until later symptoms (inflam-
mation, infection) develop. After overcoming the acute
episode, the patient may remain asymptomatic for a pe-
riod then symptoms debilitating chronic recurrent infec-
tions may delay late foreign body extraction. In the case
of retained foreign bod ies, the p ossibilities o f granu lation
tissue and post-obstruction infection exist. The accurate
diagnosis may be missed even by an experienced clini-
cian because often the initial choking episode is not
witnessed and also the delayed symptoms may mimic
other common conditions like asthma, COPD exacerba-
tions, recurrent pneumonia, upper respiratory infection
and persistent cough. Diagnosis and removal of an in-
haled foreignbody are required as quickly as possible in
order to preven mortality as well as complications.
In the present case, the symptoms did not appear
immediately after bronchial obstruction and were hidden
with antibiotics and physiotherapy symptomatic treat-
ment but were repeated at intervals until th e foreign body
was finally removed. Diagnostic imaging plays a vari-
able role in identifying airways foreign bodies.Most of
the foreign bodies are not radiopaque and small foreign
bodies may cause symptoms but no radiographic signs.
Plain films may be inadequate to document a non radio-
opaque foreign body unless they are obtained in the
expiratory phase. Rodrigues AJ and colleagues showed
in their study that 25% of the chest X-ray findings were
normal, despite a clinical history of FB aspiration [4].
Regardless of the equipment used, bronchosc opy should
be performed in all cases of suspected FB aspiration,
even if the radiological findings are normal [5,6]. Bron-
choscopy remains the gold standard for the diagnosis and
treatment of FB aspiration [7]. Virtually all aspirated FBs
can be extracted by bronchoscopy, with success rates
above 98%. Rigid bronchoscopy remains the standard
procedure for the removal of FB [8] and has various
advantages over flexible bronchoscopy. Rigid broncho-
scopes are larger in diameter than being flexible bron-
choscopes, therefore allowing blood aspiration, thick

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374
secretion aspiration, and patient ventilation.
Although rigid bronchoscopy is considered the gold
standard for the removal of foreign bodies from the air-
ways, exist studys that demonstrated that flexible bron-
choscopy can be safely and effectively used in the dia-
gnosis and treatment of stable adult patients [4].
In the rare instances in which bronchoscopic removal
fails, surgical bronchotomy or segmental resection is
indicated. The presence of chronic bronchial obstruction,
together with bronchiectasis, lung abscess, and paren-
chymal destruction, might be an indication for segmental
or lobar resection [9].
In this particular case, the diagnosis was delayed due
to lack of radiographic visualization of the foreign body
intrabronsic with persistent symptoms of infection des-
pite antibiotic treatment.
4. ACKNOWLEDGEMENTS
This paper is supported by the Sectoral Operational Programme Hu-
man Resources Development (SOP HRD) 2007-2013, financed from
the European Social Fund and by the Romanian Government under the
contract number POSDRU/107/1.5/S/82839.
REFERENCES
[1] Qureshi, A. and Behzadi, A. (2008) Foreign-body aspira-
tion in an adult. Canadian Journal of Surgery, 51, E69-
E70.
[2] Rodríguez, H., Passali, G.C., Gregori, D., Chinski, A.,
Tiscornia, C., Botto, H., Nieto, M., Zanetta, A., Passali, D.
and Cuestas, G. (2012) Management of foreign bodies in
the airway and oesophagus. International Journal of Pe-
diatric Otorhinolaryngology, 76, S84-S91.
doi:10.1016/j.ijporl.2012.02.010
[3] Xu, E.M., Xu, Z.Q., Wang, Z.N., Wang, Y., Chen, P.
Zhang, Y.M., Xia, F and Zhang, Y. (2012) Experience in
the removal of difficult and high risk trachea bronchial
foreign body by bronchoscopy. Chinese Journal of Oto-
rhinolaryngology Head and Neck Surgery, 47, 982-986.
[4] Rodrigues, A.J., Oliveira, E.Q., Scordamaglio, P.R., Gre-
gório, M.G., Jacomelli, M. And Figueiredo, V.R. (2012)
Flexible bronchoscopy as the first-choice method of re-
moving foreign bodies from the airways of adults. Jornal
Brasileiro de Pneumologia, 38, 315-320.
doi:10.1590/S1806-37132012000300006
[5] Orji, F.T. and Akpeh, J.O. (2010) Tracheobronchial for-
eign body aspiration in children: How reliable are clinical
and radiological signs in the diagnosis? Clinical Otolar-
yngology, 35, 479-485.
doi:1 0.1111 /j. 1749-4486.2010.02214.x
[6] Korlacki, W., Korecka, K. and Dzielicki, J. (2011) For-
eign body aspiration in children: Diagnostic and thera-
peutic role of bronchoscopy. Pediatric Surgery Interna-
tional, 27, 833-837. doi:10.1007/s00383-011-2874-8
[7] Shlizerman, L., Mazzawi, S., Rakover, Y. and Ashkenazi,
D. (2010) Foreign body aspiration in children: The effects
of delayed diagnosis. American Journal of Otolaryngol-
ogy, 31, 320-324. doi:10.1016/j.amjoto.2009.03.007
[8] Grover, S., Bansal, A. and Singhi, S.C. (2011) Airway
foreign body aspiration. Indian Journal of Pediatrics, 78,
1401-1403. doi:10.1007/s12098-011-0488-8
[9] Isherwood, J. and Firmin, R. (2011) Late presentation of
foreign body aspiration requiring extracorporeal mem-
brane oxygenation support for surgical management. In-
teractive CardioVasc Thoracic Surgery, 12, 631-632.