Cough lung shadow - inflammatory granuloma - bronchial foreign body

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Summary of medical recordsPatient male, 73 years old, due to repeated coughing for six months, increased in January, chest tightness of D in


Summary of medical records

Patient male, 73 years old, due to repeated coughing for six months, increased in January, chest tightness of D in the hospital on March 2, 2010, admitted to the hospital in. In the first half patients began to appear repeatedly cough, do not play, I cough a few white mucus sputum, chills, fever, no chest tightness, shortness of breath, no chest tightness, heart palpitations, without persistent dyspnea, does not take seriously. In January the cough symptoms, frequent seizures, occasional shortness of breath, nearly 10 d patients perceived dyspnea symptoms, symptoms more than before. He was treated at a local hospital, chest CT scan showed a lower lobe of the left lung mass shadow, left lung door slightly larger, left pulmonary emphysema performance, consider "lung cancer?". Then transferred to our hospital, outpatient with lung shadow admission. Since attack, appetite, sleep well, no toilet, weight loss of about 3Kg.

Past history: hypertension for 8 years, oral antihypertensive drugs, recent blood pressure control can be. 8 years ago, there was a history of stroke. Diagnosed with type 2 diabetes mellitus Yu Tian 10, not standardized treatment. There was no history of trauma surgery and no history of occupational exposure.

Analysis of physical examination: 36.8, /min (pulse), /min (1mmHg = 0.133KPa) of blood pressure, 128/78mmHg. Lucid, spirit. No lips cyanosis, superficial lymph nodes were palpable enlargement. Two lung breathing is low, and no obvious wet rales. Rhythm of the heart qi, the valve area without pathological murmur. The abdomen is soft, no tenderness and rebound tenderness, and not under the ribs. Edema of lower extremities. Physiological reflex, pathological reflex was not elicited.

Admission: laboratory examination of peripheral blood white cells 3.0x109 /L, neutrophils 32.8%. Urine routine without exception. Serum electrolytes, liver and kidney function and coagulation were not abnormal, fasting blood glucose 6.2mmol/L, white ball ratio 1.25. The arterial blood PaO2 was 77mmHg and erythrocyte sedimentation rate (ESR) was 21mm/h. Tuberculosis antibody was negative (-), cancer antigen (CA-125) and carcinoembryonic antigen (CEA) were normal. The three line shows the quantitative hepatitis B hepatitis B surface antigen of hepatitis B surface antibody (+) and (-), e (-) hepatitis B antigen, hepatitis B e antibody (+), hepatitis B core antibody IgG (+), IgM (-) hepatitis B core antibody, hepatitis B S2 antigen (+).

Imaging examination of admission: chest X film showed double lung texture enhancement, left lung penetration increased, the left lower lung shadow overlap density increased. Enhanced chest CT scan showed left main bronchus segmental soft-tissue filling (Figure 1), the posterior basal segment of lower lobe of left lung showed a size of about 29mmX21mmX56mm soft tissue mass, lobulated, lesions and pleural adhesions, visible around the mass of dendrites (Figure 2), lower lobe of left lung and right lower lobe patchy shadow bands. The presence of small lymph nodes in the mediastinum. Echocardiography showed aortic valve degeneration, mild mitral valve, three cusp, aortic regurgitation, bradycardia.

After treatment: improve the relevant examination after admission, the first to be anti infection, cough and phlegm, blood glucose monitoring, liver and other symptomatic treatment. On March 3rd, fiberoptic bronchoscopy (FB) examination showed left main bronchus in a new creature, the surface is smooth, with breathing can activity, lumen (Figure 3), bronchoscopy can not enter, biopsies and pathological examination, the pathological result showed: inflammatory exudate and necrosis of granulation tissue hyperplasia. In March 8th, the combination of cryotherapy and argon plasma coagulation (argon knife) combined with fiberoptic bronchoscopy was performed to remove the new gas in the lumen of the left main branch, and the diameter of the mass was 1cm (Figure 4). After operation, the left main lumen was completely unobstructed (Figure 5). Remove the left main lesion after bronchoscopy to enter, see the left lower lobe bronchus opening an elongated bony body (Figure 6), a 4cm distance foreign body and left main cavity tumor roots, to a foreign body forceps. The foreign body was a piece of bone with a size of about 1.8cmX1.0cm. The diagnosis of bronchial foreign body was clear, and the history of the patient was not clear. Review of the chest CT scan on admission, the lower left branch of the gas tube can be seen in the bone foreign body, foreign body not only with the main cavity in the mass of a certain distance, and the lower left mass also have a certain distance (Figure 7, 8). According to the imaging findings of the patients, the left lower lung lesions could not completely exclude the possibility of lung cancer. In March 11th, CT guided biopsy of the left lower lung lesion was performed, and the pathological examination after operation showed that organizing pneumonia. The final diagnosis: (1) the lower left bronchial foreign bodies; (2) the left main inflammatory granuloma; (3) left by organizing pneumonia; (4) chronic obstructive pulmonary disease; hypertension; (5) (6) (7) type 2 diabetes mellitus; hepatitis B virus. After the patient's left main inflammatory granuloma and the removal of foreign bodies in the left side, the symptoms of cough and chest tightness were relieved. After a week, the chest CT showed that the mass shadow of the lower left lung was significantly reduced (Figure 9). No recurrence was followed up.

Analysis and discussion

The patient was an old man, and the course of the disease was half a year. The main manifestations of recurrent cough were as follows: chest CT examination showed that the density of soft tissue in the left main branch and the soft tissue mass in the posterior segment of the left lower lobe of the lung were significantly affected. The former was diagnosed by fiberoptic bronchoscopy biopsy as an inflammatory granuloma, and was examined by fiberoptic bronchoscopy after resection of the left lung. The lower lobe of the left lung lesions, bronchoscopy is difficult to reach the lesion site, managed by CT guided percutaneous puncture biopsy, pathological diagnosis for organizing pneumonia. This case highlights the characteristics of 1 elderly, inhalation of bronchial foreign body, and more hidden; 2, the lesions showed jumping distribution, formation of inflammatory granuloma in foreign proximal, distal pneumonia is delayed healing of focal organizing pneumonia, three lesions had a considerable distance; 3, bronchus stimulation induced local inflammation, chronic inflammatory granuloma and organizing pneumonia in three different stages of the inflammatory process can coexist. Literature search has not been reported in similar cases. In this paper, we discuss the clinical and pathogenesis of bronchial foreign bodies and related inflammatory granuloma and organizing pneumonia.

Bronchial foreign body is more common in children, but the elderly because of the larynx, trachea and bronchial mucosa of foreign body reaction is not sensitive to decreased swallowing function and cough reflex ability, talk while eating laughing, eating too fast or swallowing too, the glottis open, very easy access to the airway foreign body. Smaller foreign body into the bronchus, and to fall into the right side of the more common. There is no obvious influence on the ventilation function after the bronchial foreign body is fixed, so the symptoms and signs of dyspnea are not obvious, and the cough is not severe. With the regulation of adaptation, patients of bronchial foreign bodies gradually tolerance, such as cough and shortness of breath symptoms are mild, or even disappear [1]. In addition, the elderly on the history of aspiration easily forgotten, and more suffering from chronic bronchitis and other basic diseases, usually have chronic cough and other symptoms, it is easy to be ignored by patients and their families, thus delaying the diagnosis and treatment. Patients are often treated with various complications arising from foreign bodies, such as obstructive pneumonia, obstructive emphysema, and so on, and clinicians tend to pay attention to the treatment of complications and ignore the original disease. The value of imaging examination in diagnosis and differential diagnosis of bronchial foreign body is relatively limited. Small pieces of foreign bodies, non-metallic foreign body or due to longer retention time and loose foreign body can not be displayed in the X-ray and CT examination, which increases the difficulty of the diagnosis and the possibility of misdiagnosis [2]. A case report on bronchial foreign bodies at home and abroad are suggested: foreign bodies in the lung or bronchial retention time is often longer covered or wrapped a large number of granulation tissue, purulent material, etc. These are the causes of necrosis, bronchoscopy and some invasive examination methods to probe and foreign bodies, which is [3-4] by bronchial foreign body the main causes of misdiagnosis or delayed diagnosis. In this case, the formation of inflammatory granuloma in the left main cavity was not covered or wrapped with foreign body, but the formation of intraluminal mass blocked the lumen. And two lesions and foreign bodies have a certain distance, resulting in chest radiograph reading of CT cavity body missing, interventional treatment of intraluminal masses after removal of Branchofiberoscopy finally found foreign bodies.

Bronchitis granuloma is the product of airway inflammatory reaction, which is characterized by the formation of clear nodular lesions mainly located in macrophages. Its formation is mainly attributed to chronic obstructive pulmonary disease, bronchial tuberculosis lesions, poor drainage caused by malabsorption or aging, diabetes due to decreased immunity, bronchial foreign body was also one of the risk factors. A large number of literature reports foreign long-term retention in the section of bronchial openings can cause a variety of irreversible airway changes, such as bronchial cartilage damage and fibrosis, airway mucosal injury, complete or partial airway obstruction, but also complicated with chronic inflammatory changes and granulation tissue hyperplasia [5]. Recently, both domestic and foreign cases of inflammatory granuloma caused by bronchial foreign body were reported [6]. The formation mechanism of foreign body granuloma is not clear, generally bronchial foreign body into the body, the mononuclear phagocyte system consisting of a fixed or migration of monocytes and tissue macrophages in the blood of the first is activated to ingest foreign body, and secretion of inflammatory mediators and stimulate immune response. When foreign body stimulation exists for a long time, can cause many macrophages and merge with each other, the formation of multinucleated giant cells and to attract inflammatory foci of lymphocytes and mononuclear cells and fibroblasts co wrapped around the body, the formation of nodular lesions. It has been reported that multinucleated giant cells can produce a large number of IL-1 alpha and TNF- alpha to induce granulomatous inflammation and maintain inflammation, while in the later stage, it produces a large number of TGF- beta to control the spread of inflammation. Therefore, it is suggested that multinucleated giant cells play an important role in the development of inflammatory granuloma [7]. In this case, the inflammatory granuloma caused by foreign body is not the core of the foreign body, but it is a little far away. This may be the formation of multinucleated giant cells, along with the blood flow away from the foreign body in the mucosa, and then secrete a large number of inflammatory factors eventually lead to the formation of inflammatory granuloma. Due to the involvement of immune factors and blood flow factors, the long-term retention of foreign body airway can lead to the spread of inflammation to form a single inflammatory granuloma in the foreign body, and even a variety of inflammatory granulomatous lesions.

Organizing pneumonia is relatively rare in clinic, the incidence is about 1.96/100000. It is generally believed that organizing pneumonia is not an independent disease, but a common manifestation of lung injury caused by a variety of diseases in the lungs [8]. Organizing pneumonia is generally divided into primary and secondary organizing pneumonia euplastic pneumonia, the former is cryptogenic, the latter has a clear etiology, such as pulmonary infection, aspiration pneumonia, or drug hypersensitivity reaction, also can be secondary to some systemic diseases, such as chronic collagen disease rheumatoid arthritis or connective tissue diseases etc.. According to the range of lesions, organizing pneumonia can be divided into localized and diffuse. The lack of specific clinical symptoms were fever, shortness of breath, cough, chest pain, etc.. Patients may be asymptomatic, often found in physical examination or other lung diseases. The imaging manifestations of organizing pneumonia are various, including pulmonary nodules, pulmonary infiltrates, pulmonary consolidation or ground glass changes. The imaging findings are lack of specificity, often confused with other diseases such as tuberculosis and tumor. The patients with sputum or bronchoalveolar lavage fluid were not detected in bacteria and fungi. The diagnosis mainly depends on the pathological examination. The characteristic pathological manifestations of terminal and respiratory bronchioles, alveolar, alveolar sac visible myxoid fibroblasts formed loose connective tissue or granulation tissue, alveolar septum machine, lobular bronchitis secretion obstruction with machine. It has been reported in the literature that [9], two patients with primary and secondary pneumonia, have a large overlap in clinical and histopathological manifestations. Mashimoto H et al. Have reported a case of organizing pneumonia, although pathological examination revealed granulomatous lesions and multinucleated giant cells in the presence of allergic reaction, but there was no clear antigenic substance of [10]. We report a case of left lower lung disease, which was confirmed by biopsy, and was proved to be consistent with pneumonia. Combined with the history of the disease, the patient has no systemic systemic disease, no allergic disease, but the focus is close to the insertion of foreign bodies in the bronchus. The possible pathogenesis of foreign long-term retention in the left lower lobe bronchus foreign body, foreign body is bony flaky, and did not cause complete occlusion of left lower lung, but the stimulation of foreign body, inadequate drainage can cause lung inflammation of airway inflammatory lesions widely, delayed or incomplete absorption absorption can lead to a large number of fibrous tissue hyperplasia, eventually organizing pneumonia. We have to restore the patient's condition development process: Patients with foreign body aspiration, foreign body inlaid in the lower lobe of the left lung bronchus caused by chronic local inflammation, inflammatory mediators and immune molecules and diffusion with blood flow, in the form of left main bronchus at the multinucleated giant cell mediated inflammatory granuloma. At the same time, also led to repeated infection of bronchial foreign body in bronchus distal, drainage obstacle inflammatory exudate further hindered the infection of absorption, thereby forming a vicious spiral, the interactions of many factors resulting in persistent inflammatory lesions and lead to organizing pneumonia. The whole course of the disease has experienced three stages, from pneumonia development to non dissipation pneumonia, and to localized pneumonia. In this case, the advanced age, diabetes mellitus and other factors accelerated the development of pneumonia to organic pneumonia.

This example again prompted the process of diagnosis and treatment of bronchial foreign bodies in the elderly should be inhaled by clinician, such as the discovery of atelectasis, obstructive pneumonia or pulmonary hilar mass and so on, in addition to considering pneumonia, tuberculosis, tumor, bronchus and secondary lesion is one of the causes of these changes of image. In clinical work, we should enhance the awareness of diagnosis and treatment.

Diagnostic difficulties:

The atypical clinical symptoms and signs of l can easily lead to misdiagnosis and missed diagnosis of clinical diagnosis.

There are some limitations in the diagnosis of L pneumonia, especially in the peripheral lung cancer and pulmonary tuberculosis.


The L of aged patients with bronchial foreign body should be vigilant, although there is no clear cough when eating history does not exclude foreign body aspiration may.

Although l lesions in different parts, but the process of disease occurrence and development, the outcome is a whole, in this case, can not be satisfied with fiber bronchoscope endobronchial granuloma, interventional treatment to remove bronchial tumor also check other abnormalities.


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