Vegetable Aspiration: Mimicking as a Malignant Pulmonary Nodule in a Non-small Cell Lung Cancer (NSCLC) Survivor

Abstract

INTRODUCTION: Foreign body aspiration (FBA) is rare in adults and account for only 20% of reported cases. Adults with altered mental status or mechanical impairment in the swallowing reflex are at an increased risk for FBA. A high Index of suspicion is pivotal in early diagnosis. In the absence of an acute clinical presentation, an aspiration can be missed and a bronchial FBA can remain occult for many years. CASE PRESENTATION: 69 years old male with laryngeal cancer diagnosed in 1998 and treated with radiation, stage IIIA NSCLC treated with right upper lobe lobectomy in 2009 with combination chemotherapy and radiation. Surveillance Computed tomography (CT) chest in 2011 revealed a 2.2 cm nodule in the left lower lobe. CT guided biopsy of this nodule showed chronic inflammation with no evidence of malignancy. A follow up chest CT after 6 months was concerning for increase in size of the nodule. Bronchoscopy with bronchial brushing and biopsy showed vegetable matter with chronic inflammation. DISCUSSION: Foreign body aspiration usually has an acute presentation requiring immediate medical attention. Occasionally symptoms of aspiration may not be prominent enough for the patient to seek immediate medical attention and may remain occult for many years. Leading causes of FBA in adults are altered mental status from alcohol or sedative use, trauma with a decreased level of consciousness, impaired airway reflexes associated with neurological disease, and dental procedures. Chest radiograph (CXR) is the imaging modality of choice. The sensitivity of CXR depends upon the physical properties of the aspirated material. Radiopaque materials such as metal or teeth may be easily identified on CXR. In cases where the foreign body is radiolucent, nonspecific radiological findings including air trapping, atelectasis, and obstructive pneumonia may be the only clue and offer a diagnostic challenge. Flexible bronchoscopy is the preferred modality in the visualization and removal of foreign bodies with successful removal in up to 90% cases. Occult foreign bodies can become embedded in the bronchial mucosa over time making it difficult to remove. CONCLUSIONS: Pulmonary nodules seen on surveillance chest CT in lung cancer survivors are worked up with invasive diagnostic approach. Often management includes empiric surgical removal. We report an interesting case of vegetable aspiration. Consultation with botanist raised concern of a plant seed aspiration with possible germination and root development.