Puzzler Answer and Case Report

Diagnosis
Endobronchial bullet causing asthma-like symptoms and recurrent pneumonia for several years.

Clinical course
The patient was taken to the operating room and underwent flexible bronchoscopy through an endotracheal tube. The right main bronchus was normal, and the distal left main bronchus was completely obstructed by an intact bullet (Fig 3). A 16-mm retrieval basket was placed around the bullet, which was removed in one unit with the bronchoscope and endotracheal tube with a moderate amount of force. Upon reintubation with the bronchoscope, there was a small amount of granulation tissue in the distal left main bronchus and a mucosal, ulcer-type lesion with no visible communication through the airway wall (Fig 4). A moderate amount of purulent secretions was suctioned out. The patient was discharged the next day to complete a course of levofloxacin and metronidazole, uneventfully.

The patient reported that 9 years prior, he had been shot in the right shoulder with the bullet traversing his right lung into the mediastinum. At that time, he was told that the bullet should not be removed do to its location.

Key points

1. The bullet likely migrated into the airway sometime after the injury, as evidenced by closure of the airway wall around the bullet.
2. Given the patient's history of recurrent pneumonias and asthma, the bullet had likely been in the airway for several years.
3. Although rare, 'wandering' foreign bodies in the thorax and mediastinum can migrate over time into other structures, such as the airway or blood vessels.
4. Long-term inclusion of foreign bodies may mimic asthma, as well as cause recurrent or nonresolving pneumonia.
5. A retrieval basket is an effective tool for foreign body removal.

References

1. Ledgerwood AM. The wandering bullet. Surg Clin North Am 1977; 57:97-109
2. Langer D, Petermann C, Lübbers H, et al. Relapsing pneumonia due to a migrating intrathoracic foreign body in a World War II veteran shot 53 years ago. J Intern Med 1999; 245:405-407
3. Bocca X, Gil L, Garrido S, et al. Management of a penetrating gunshot wound of the trachea and bullet extraction using bronchoscopy. J Bronchol 2005; 12:28-30

Puzzler and case report submitted by:
Ray Wes Shepherd, MD, FCCP
Assistant Professor of Medicine
Interventional Pulmonology, Pulmonary and Critical Care
Virginia Commonwealth University Medical Center
Richmond, VA