FINGERNAIL CLIPPING AS A FOREIGN BODY CAUSING SEVERE EMPYEMA

ABSTRACT

SESSION TITLE Chest Infections with Pleural Involvement Case Posters SESSION TYPE Case Report Posters PRESENTED ON 10/19/2022 1245 pm - 0145 pm INTRODUCTION: Foreign body aspiration (FBA) is an uncommon cause of dyspnea and respiratory infection. 80% of cases occur in children under 15-years-old, with the highest mortality in children under 1 and adults over 75. We present an unusual case of a fingernail clipping causing severe empyema in a middle-aged male. CASE PRESENTATION A 44-year-old male with diabetes mellitus presented with a 3-day history of dyspnea, productive cough, and anorexia, and a 1-day history of fevers and substernal chest pain. Exam was notable for fever, tachypnea, tachycardia, and hypoxemia requiring a non-rebreather mask. Labs were significant for a negative COVID-19 polymerase chain reaction (PCR) test, white blood cell (WBC) count 17,000 μL, and lactate 3.4 mmol/L. He was given albuterol-ipratropium nebulizer treatments and methylprednisolone 125 mg. Chest x-ray revealed a large right-sided air-fluid level, dense consolidation of the lung base, and complicated pleural effusion. Computed Tomography (CT) of the chest revealed a large right mid-lung abscess, right middle lobe (RML) and right lower lobe (RLL) consolidations, and loculated pleural effusion with hydropneumothorax. A surgical chest tube was placed that drained purulent fluid. The effusion grew Klebsiella pneumoniae, which was treated with ampicillin-sulbactam. Repeat CT chest revealed improved loculated effusion, but persistent RML and RLL consolidations with concern for endobronchial obstruction. Flexible bronchoscopy was performed, which identified and removed a human fingernail clipping obstructing the RML. Post-procedure, his oxygen requirements, cough, and dyspnea improved remarkably. He was discharged with a 4-week course of amoxicillin-clavulanate. On outpatient follow-up 6 weeks later, he was asymptomatic. DISCUSSION: In our patient, a fingernail clipping was lodged in the opening of the RML, resulting in a post-obstructive pneumonia complicated by empyema. Post-bronchoscopy, the patient admitted to anxiety-induced nail-biting. FBA most commonly occurs in the right bronchial tree (71.5%) as compared to the left bronchial tree (22.8%) and trachea (5.7%). Objects were most commonly lodged in the bronchus intermedius (27%) and right lower lobe (33%). Foreign bodies can be removed via rigid or flexible bronchoscopy, with a 90% success rate in the latter. Instruments such as forceps and baskets can be used to remove the foreign body, and Trendelenberg positioning can be useful in moving the object proximally. In up to 76% of cases, granulation tissue caused by a localized reaction to the foreign body may occur and can be minimized with systemic steroids for 24 hours. CONCLUSIONS: FBA in a middle-aged patient is an unusual cause of respiratory infection, but should be on the differential diagnosis for post-obstructive pneumonia. Reference #1 Hsu Wc, Sheen Ts, Lin Cd, Tan Ct, Yeh Th, Lee Sy. Clinical experiences of removing foreign bodies in the airway and esophagus with a rigid endoscope a series of 3217 cases from 1970 to 1996. Otolaryngol Head Neck Surg. 2000 Mar;122(3)450-4. doi 10.1067/mhn.2000.98321. PMID 10699826. Reference #2 Blanco Ramos M, Botana-Rial M, García-Fontán E, Fernández-Villar A, Gallas Torreira M. Update in the extraction of airway foreign bodies in adults. J Thorac Dis. 2016;8(11)3452-3456. doi10.21037/jtd.2016.11.32. Reference #3 Fang YF, Hsieh MH, Chung FT, Huang YK, Chen GY, Lin SM, Lin HC, Wang CH, Kuo HP. Flexible bronchoscopy with multiple modalities for foreign body removal in adults. PLoS One. 2015 Mar 13;10(3)e0118993. doi 10.1371/journal.pone.0118993. PMID 25768933;PMCID PMC4358882. DISCLOSURES No relevant relationships by Nuzhat Batool No relevant relationships by Lisa Glass No relevant relationships by Alice Mei No relevant relationships by Daisy Young