CASE REPORT

The Clinical Respiratory Journal

The tracheobronchial foreign body in welder without the history of allotriophagy and foreign body aspiration Yi-Lan Sun1, Zhang Bao1, Xue-Fen Wang1, Li-Hong Wang2 and Jian-Ying Zhou1 1 The Respiratory Department of the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China 2 The Cardiovascular Department of Zhejiang Provincial People’s Hospital, Hangzhou, Zhejiang Province, China

Abstract The typical chest computed tomography (CT) finding of the arc welders is illdefined micronodules diffusely distributed in the lung. We report a rare case of tracheobronchial foreign body in welder without the history of allotriophagy and foreign body aspiration. We used the CT and mineralogical analysis in diagnosis and the flexible fiberoptic bronchoscope in therapy. The CT showed bronchiectasis with pulmonary infiltration of the right lower lobe and high-density shadow in the basal bronchus of the right lower lobe. The foreign bodies were removed by a fibreoptic bronchoscope. Semiquantitative chemical analyses showed that the constituent of foreign body was similar to the dregs which were collected in the same garage. This is an unusual case of the welding-related respiratory diseases, which is different from Welder’s siderosis and broncholith. Please cite this paper as: Sun Y-L, Bao Z, Wang X-F, Wang L-H and Zhou J-Y. The tracheobronchial foreign body in welder without the history of allotriophagy and foreign body aspiration. Clin Respir J 2015; ••: ••–••. DOI:10.1111/crj.12265.

Key words aspiration – computed tomography – foreign body – welding Correspondence Jian-Ying Zhou, MD, The Respiratory Department of the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province 310003, China. Tel: +86-571-87236875 Fax: +86-571-87236875 email: [email protected] Received: 30 August 2014 Revision requested: 11 December 2014 Accepted: 20 January 2015 DOI:10.1111/crj.12265

Authorship and contributorship Yi-Lan Sun, Zhang Bao, Xue-Fen Wang, Li-Hong Wang and Jian-Ying Zhou performed research, collected data, analyzed data and wrote the paper. Ethics Informed consent was obtained from the patient. Conflicts of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article.

Introduction The nature of tracheobronchial foreign body is diverse, including dry nuts, beans, bone fragments, fruit seed, tooth and so on. However, the tracheobronchial foreign body associated with welding is rare. Welding mainly involves exposure to fumes, and the respiratory diseases associated with welding include metal fume fever, airway irritation, increased frequency of pulmonary infection, pulmonary siderosis and pulmonary fibrosis (1, 2). The typical chest computed tomography (CT) finding of the arc welders is ill-defined micronodules diffusely distributed in the lung (3, 4). Here,

The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2015 John Wiley & Sons Ltd

we report an unusual case because of the welding, in which the predominant CT findings are bronchiectasis and high-density shadow in the basal bronchus of the right lower lobe.

Case report A 49-year-old man presented to the respiratory department in July 2006 with a productive cough for 2 weeks. He also had a fever, right chest wall pain and dyspnoea on exertion for 1 week. His past medical history included repeated airway infection and inflammation

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Tracheobronchial foreign body in welder

for more than 10 years. The patient had a 30 pack-year history of smoking. Thirty-one years before admission, the patient had been working as a welder, exposed to iron fumes in the garage for 15 years without any respiratory protective equipment. During his subsequent job as an administrator, there was no exposure to iron fumes. The patient denied the history of choking and foreign body aspiration. He also had no allotriophagy. Physical examination disclosed the patient’s temperature was 38°C. Other vital signs were normal. Chest auscultation revealed rhonchi and crackles on the right lower lobe of lungs. The rest of examination was unremarkable. Sputum and bronchoalveolar lavage analyses did not disclose Mycobacterium tuberculosis, fungi or malignant tumor cells. Sputum culture and the result of a tuberculin test were negative. Routine blood test showed hemoglobin 129 g/L and white blood cell 9.3 × 109/L, with a differential of 76% neutrophils, 19.5% lymphocytes, 4% monocytes and 0.5% eosinophils. Erythrocyte sedimentation rate was elevated to 35 mm/h. C-reactive protein was elevated to 16 mg/L. There were no other significant haematological or biochemical abnormalities. Serologic studies including antinuclear antibody, tumor markers and serum ferritin level were all normal. Pulmonary function testing demonstrated normal results. The first chest radiograph revealed bilateral pulmonary infiltration and right pleural effusion (Fig. 1). The helical CT showed bronchiectasis with pulmonary infiltration of the right lower lobe and high-density shadow in the basal bronchus of the right lower lobe (Fig. 2A). The

Sun et al.

Figure 1. The chest x-ray revealed bilateral pulmonary infiltration and right pleural effusion.

fibreoptic bronchoscopy revealed foreign bodies in the basal bronchus of the right lower lobe. The foreign bodies were removed by a fibreoptic bronchoscope (Fig. 3A–C). The foreign bodies, 9–15 mm in diameter, were black, hard and irregular, resembling the stone (Fig. 3D). The subsequent CT scan confirmed the disappearance of the high-density shadow in the basal bronchus of the right lower lobe (Fig. 2B).

Figure 2. The helical computed tomography (CT) revealed bronchiectasis with the high-density shadow (white arrow) in the basal bronchus of the right lower lobe (A), and confirmed bronchiectasis without the high density shadow in the basal bronchus of the right lower lobe (B). The repeated CT scan demonstrated bronchiectasis without the high-density shadow once more after 7 years (C).

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The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2015 John Wiley & Sons Ltd

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Tracheobronchial foreign body in welder

Figure 3. The picture of the fibreoptic bronchoscope, revealing the basal bronchus of the right lower lobe before the foreign bodies were removed (A), after the foreign bodies were removed partly (B), and after the foreign bodies were removed completely (C). The foreign bodies, 9–15 mm in diameter, were black, hard and irregular, resembling the stone (D).

Samples from both the foreign bodies and dregs, collected from the patient and the same garage, were analysed by electron microscopy with energy-dispersive x-ray spectroscopy (CorlzeisD Company, Oberkochen, Germany). Semiquantitative chemical analyses showed similar results of components from both samples. The mean values for atomic weight of the foreign body, obtained through the microanalysis, were: 23.04 carbon, 30.39 oxygen and 25.20 iron (Fig. 4A). The mean values for atomic weight of the dreg were: 32.02 carbon, 19.86 oxygen and 34.93 iron (Fig. 4B). During the 7-year period of follow-up, the patient had no relapse of respiratory symptoms. The repeated

The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2015 John Wiley & Sons Ltd

CT scan demonstrated similar bronchiectasis without the high density (Fig. 2C).

Discussion Welding involves exposure to fumes, gases, radiation, electricity, noise and heat. Pulmonary effects observed in full-time welders have included metal fume fever, airway irritation, lung function changes, susceptibility to pulmonary infection, pulmonary siderosis and pulmonary fibrosis (1, 2). Welder’s siderosis or pneumoconiosis siderotica was first 3

Tracheobronchial foreign body in welder

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(A) Wt %

At %

CK

23.04

39.13

OK

30.39

38.74

MgK

00.47

00.40

PK

04.46

02.93

SK

09.71

06.17

CaK

06.73

03.43

FeK

25.20

09.20

Element

Energy (KeV)

(B) Element

Energy (KeV)

Wt %

At %

CK

32.02

53.26

OK

19.86

24.81

NaK

00.78

00.68

MgK

00.93

00.76

AlK

06.28

04.65

SiK

03.36

02.39

SK

00.25

00.16

KK

00.25

00.13

CaK

01.33

00.66

FeK

34.93

12.50

Figure 4. Graph showing the energy-dispersive spectrometry, semiquantitative chemical analysis of the foreign bodies (A) and dregs (B), collected from the patient and the same garage.

described in 1936 by Doig and McLaughlin as a lung disease caused by chronic inhalation of iron fume in welders (5). Akira’s studies found that the most CT findings in the 21 arc welders were ill-defined micronodules diffusely distributed in the lung (3). Han et al. observed 85 arc welders with thin section CT scanning and concluded that poorly defined centrilobular micronodules and branching linear structures were the thin section CT findings most frequently seen in patients with arc welder’s pneumoconiosis. Less commonly, extensive ground-glass attenuation was also seen (4). In this case, the patient was a welder in the garage without any respiratory protective equipment. Thus

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iron fumes could be inhaled and deposited in the lung. As shown on the chest CT scan, the predominant findings of this patient were bronchiectasis with pulmonary infiltration of the right lower lobe and high-density shadow in the basal bronchus of the right lower lobe, which were different from the previous reports (4, 5). The fibreoptic bronchoscopy disclosed and removed the foreign bodies in the basal bronchus of the right lower lobe. The mineralogical analysis revealed that foreign body comprised carbon, oxygen, iron, calcium, phosphorus, sulphur and magnesium. It was interesting that the constituent of foreign body was similar to the dregs which were collected in the same garage. The foreign body and dregs both contained carbon, oxygen, iron, calcium, sulphur

The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2015 John Wiley & Sons Ltd

Sun et al.

and magnesium, but the levels of the elements were different. The patient denied the history of choking and foreign body aspiration. He also had no allotriophagy. Therefore, we hypothesise that iron fumes could be inhaled and deposited in the basal bronchus of the right lower lobe because of decreased local airway defence function, then the iron particles accumulated and formed the bulk material leading to subsequent bronchial obstruction, bronchiectasis and pulmonary infection. The foreign body, found in this case, should be differentiated with the broncholith which is endogenous calcifying material instead of inhaled matter. Most broncholithiasis cases are attributable to histoplasmosis, tuberculosis and etc (6). There was no evidence that this patient was suffering from special infection such as histoplasmosis and tuberculosis. Iron components of the foreign body argued against broncholith composed of calcium and phosphorus, supporting that the foreign body is due to welding rather than broncholith. The chest radiograph is the basic tool for identifying tracheobronchial foreign bodies; however, its sensitivity and specificity are lower than the chest CT scan. In this case, the chest CT scan provided essential information for the diagnosis of foreign bodies, but the chest radiograph failed to do that. In addition to its well-known diagnostic role, a flexible fibreoptic bronchoscope is useful for removal of foreign bodies in our case. Some studies suggested that flexible bronchoscopy was a safe and successful method used in the removal of foreign bodies both in adults and children (7, 8), which are in accordance with ours. To our knowledge, this is the first report of tracheobronchial foreign body related to welding. This case is unique and different from metal fume fever, airway irritation, lung function changes, pulmonary siderosis and pulmonary fibrosis which usually observed in welders. In order to reduce welding-related respiratory disease, the control of fumes and gases in the workplace has been by enclosure and local exhaust ventilation; respiratory protective equipment may be necessary in certain circumstances, particularly in confined spaces (9).

The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2015 John Wiley & Sons Ltd

Tracheobronchial foreign body in welder

Summary In conclusion, this is a quite rare case in welders. The chest CT scan is very important for the diagnosis and a flexible fiberoptic bronchoscope provides a valuable therapeutic modality. Improving working condition and raising welders’ awareness of protection may reduce the risk of occupational lung disease in China.

Acknowledgements We acknowledge Professor Binbo Jiang for the mineralogical analysis. This work was supported by the International Collaboration Projects of Science and Technology Department of Zhejiang Province (2011c14027) and the foundation from Zhejiang Provincial Administration of traditional Chinese Medicine (2011ZQ013).

References 1. Antonini JM, Lewis AB, Roberts JR, Whaley DA. Pulmonary effects of welding fumes: review of worker and experimental animal studies. Am J Ind Med. 2003;43: 350–60. 2. Patel RR, Yi ES, Ryu JH. Systemic iron overload associated with welder’s siderosis. Am J Med Sci. 2009;337: 57–9. 3. Akira M. Uncommon pneumoconioses: CT and pathologic findings. Radiology. 1995;197: 403–9. 4. Han D, Goo JM, Im J-G, Lee KS, Paek DM, Park SH. Thin-section CT findings of arc-welders’ pneumoconiosis. Korean J Radiol. 2000;1: 79–83. 5. Doig AT, McLaughlin AI. X-ray appearance of the lungs of electric arc welders. Lancet. 1936;1: 771–5. 6. Ginsberg RJ, Mark EJ. Case records of the Massachusetts General Hospital: weekly clinicopathological exercises. Case 46–1991. A 64-year-old man with recurrent hemoptysis, a bronchoesophageal fistula, and broncholithiasis. N Engl J Med. 1991;325: 1429–36. 7. Swanson KL, Prakash UB, Midthun DE, et al. Flexible bronchoscopic management of airway foreign bodies in children. Chest. 2002;121: 1695–700. 8. Gencer M, Ceylan E, Koksal N. Extraction of pins from the airway with flexible bronchoscopy. Respiration. 2007;74: 674–9. 9. Hewitt PJ. Strategies for risk assessment and control in welding: challenges for developing countries. Ann Occup Hyg. 2001;45: 295–8.

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The tracheobronchial foreign body in welder without the history of allotriophagy and foreign body aspiration.

The typical chest computed tomography (CT) finding of the arc welders is ill-defined micronodules diffusely distributed in the lung. We report a rare ...
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