Iron Lung: Bronchoscopic and Pathological Aspiration of Ferrous

142 McNamee, Meyns, Pagliero

diameter of the fibreoptic bronchoscope is only 2 Xu I T, Sun ZF, Wu LH, Wang ZZ. 'I'racheobronchial tumors: an eighteen year series from Capital Hospital, 5 mm. We believe that this is a safe technique Peking, China. Ann Thorac Surg 1983;35:590-6. Thorax: first published as 10.1136/thx.46.2.142 on 1 February 1991. Downloaded from for flexible bronchoscopy under general anaes- 3 Stell PM, Maran AGD. Head and neck surgerv. London: thesia. We do not, however, recommend it for Heinemann, 1978:194-204. 4 Brain AIJ. 'I'he laryngeal mask-a new concept in airway patients likely to aspirate or for the control of management. Br l Aniaesth 1983,55:801-5. massive haemoptysis. 5 Kambic V, Radzel Z. Intubation lesions of the larynx. Br I AInaesthl 1978;50:587-901 6 Brain AIJ, McGhee 'I'D, Miatier EJ, 'homas A, Abu-Saael MAW, Bushman JA. the laryngeal mask airway. Anaes- I Simpson FG, Arnold AG, Purvis A, Belfield PW, Muers thesia 1985;40:356-61. MF, Cooke NJ. Postal survey of bronchoscopic practice 7 Geffin B, Bland J, Grillo HC. Anaesthetic management of bv physicians in the United Kingdom. Thorar trachcal resection and reconstruction. ,4naesth Analg 1986;41:311-7. 1 969;48:884-90.

T[lorax 1991;46:142-143

mediate bronchi were lined with greenish Iron lung: brown necrotic material. The left main bronchus was entirely normal. The right inter- bronchoscopic and mediatc bronchus was partially occluded by a hard polypoid mass covered with similar pathological necrotic material. A bronchial biopsy specimen was taken, which histologically con- consequences of sisted of proteinaceous debris and elements of partially necrotic fibroconnective tissue. Frag- aspiration of ferrous ments of disrupted bronchial epithelium were clearly identifiable and these, together with sulphate the subepithelial connective tissue, were cncrusted with golden brown pigment that showed a very strong reaction for ferric iron David J Godden, Keith M Kerr, (Prussian blue). Iron had precipitated par- Stephen J Watt, Joseph S Legge ticularly heavily on elastic fibres and bronchial epithelial cells, including their cilia Abstract (fig 1). Overlying some of the degenerate tissue was a reactive metaplastic squamous Acute bronchial damage was caused by http://thorax.bmj.com/ aspiration of a ferrous sulphate tablet, epithelium, devoid of iron precipitate. early histological changes (unlike in the Repeat bronchoscopy, seven days later, few previously reported cases) being showed similar appearances but the observed in the biopsy specimens. polypoidal lesion was no longer visible. The

Foreign body aspiration occurs mainly in chil-

dren' but may occur in adults, particularly in on September 25, 2021 by guest. Protected copyright. the presence of oesophageal abnormalities. We describe the radiological, bronchoscopic, and histological findings in an elderly women with a hiatus hernia who aspirated a ferrous sulphate tablet.

Case report An 84 year old woman, a non-smoker, sud- denly developed vigorous coughing, which produced a cupful of blood. The cough persisted for four weeks until presentation, and right pleuritic chest pain developed. The patient had a hiatus hernia but no previous history of dysphagia, and was taking ferrous Department of sulphate tablets, 200 mg thrice daily, for Thoracic Medicine chronic blood loss from the hiatus hernia. She l.. D J Godden of S J Watt could not recall a specific episode aspira- J S Legge tion. Department of A chest radiograph showed an incarcerated Pathology hiatus hernia and patchy opacification in the K M Kerr right mid and lower zones. Thoracic com- Aberdeen Royal puted tomography showed concentric narrow- Infirmary, Aberdeen and Figure 1 High power view offragmented bronchital AB92ZB ing of the right lower lobe bronchus patchy linear subsegmental collapse in the epithelial cells. Superiorly cilia are well seen and Reprint requests to: centrally the columnar cell nucleus is in focus. Irotn salt Dr Godden posteromedial aspect of the right lower lobe. criystals (arrows) are precipitated otn cilia as well as cell anid eosin.) Accepted 2 August 1990 At bronchoscopy the right main and inter- memtibranes anid cytoplasm. (Haematoxylin Ironi lung: bronchoscopic and pathological consequences of aspiration offerrous sulphate 143

A:-;:.--4 ..., .-. I.o .:.: .fl.y I k 7' established. The findings at that time are I those of or predominantly fibrosis, small Thorax: first published as 10.1136/thx.46.2.142 on 1 February 1991. Downloaded from k' .0'. " moderate amounts of haemosiderin within macrophages, and perhaps an associated foreign body type granulomatous reaction. In this case we observed earlier changes, including acute mucosal damage, widespread iron precipitation on pre-existing mucosal . v .. *It elements, and squamous metaplasia over part 4 of the ulcerated surface. 41 40 The metaplastic -1 ?t.: 4 I squamous epithelium was completely devoid

'% -f. I1. .4 t of iron, suggesting that it developed after the ' 'IdA iI ,4; :* 4 episode of iron deposition. The first two biopsy specimens show very extensive sub- 9'b. mucosal tissue necrosis, whereas the third 'I,e shows much scarring and granulation tissue. It is not Figure 2 Third bronchial biopsy specimen, showing hyperplastic and squamous surprising therefore that bronchial metaplastic epithelium, subepithelial scarring, and abundant haemosiderin in the stenosis may be a late consequence of aspira- macrophages and deposited around small vessels. (Prussian blue.) tion of iron tablets. The presence of appreciable iron bronchial biopsy specimen showed necrrotic (haemosiderin) deposition in lung biopsy collagenous tissue and a mild acute infllam- material suggests a differential diagnosis of matory reaction. Brown iron pigment was still pulmonary haemorrhage, with or without abundant within respiratory epithelium, Ipar- infarction or, rarely, Goodpasture's syndrome ticularly concentrated along epithelial and or idiopathic pulmonary haemosiderosis. In capillary endothelial basement membranes these circumstances, the haemosiderin is The patient was treated with nebulised lig- largely within alveolar macrophages with less nocaine (4% solution) to reduce the freque ncy lying in the interstitium. Iron deposition in of cough. After two months the c:hest the bronchus, as seen in this case, would be radiograph had returned to normal, but aifter negligible. Bronchial mucosal iron deposits four months she developed a recurrenc4 e of may rarely be seen in haemochromatosis but cough and wheeze and of radiographic abrnor- the deposition then is intracellular and with- mality. Repeat bronchoscopy showed out associated tissue damage. The pattern and irregular, friable inflamed tissue alnnost density of deposition and the associated tissue

occluding the right intermediate bronc-hus damage in our case are unlike those seen in http://thorax.bmj.com/ just distal to the origin of the upper Ilobe any of these conditions. bronchus. Bronchial biopsy showed furither In one previously published case4 mucosal evolution of the airway injury and rep)air. appearances returned to normal during 15 Maturing granulation tissue was abunclant months of follow up, though bronchial sten- and contained many haemosiderin laden osis persisted; in the other severe bronchial macrophages. The bronchial cartilage was stenosis necessitated right middle and lower eroded with perichondral scarring, squamlous lobectomies.5 Removal of the tablet at the metaplasia was and initial was not in our widespread, iron deposi- bronchoscopy possible on September 25, 2021 by guest. Protected copyright. tion was prominent around small vessels patient but should clearly be attempted (fig 2). wherever possible to minimise tissue damage and subsequent complications.6 Discussion This patient did not recall inhaling an iron I Abulmajid OA, Ebeid AM, Motaweh MM, Kleibo IS. tablet; but the of cough, Aspirated foreign bodies in the tracheobronchial tree: history sudden report of 250 cases. Thorax 1976;31:635-40. haemoptysis, and abnormal chest findings on 2 Kim IG, Brummitt WM, Humphrey A, Siomra SW, auscultation is typical of aspiration,2 as is the Wallace WB. Foreign body in the airway: a review of 202 cases. Laryngoscope 1973;83:347-54. site of the foreign body in the right lung.3 3 Ross AHM, McCormack RJM. Foreign body inhalation. Reports of aspiration of an iron tablet are JR Coll Surg Edinb 1980;25:104-9. rare, but the late occurrence hial 4 Mizuki M, Onizuka Aoki T, Tsuda T. A of of broncl remarkable bronchial0,stenosis due to aspiration ofdelayedcase stenosis has been described.45 Reports of the release iron tablet [in Japanese with English abstract]. histological appearances in these cases are Nippon Kyobu Shikkan Gakkai Zasshi 1989;27:234-9. 5 Tarkka M, Anttila S, Sutinen S. Bronchial stenosis after from biopsy specimens taken several monLths aspiration of an iron tablet. Chest 1988;93:439-41. after the insult, when bronchial stenosis vvas 6 Anonymous. Inhaled foreign bodies [editorial]. BMJ 1981;282:1649-50.