Aspiration of a cockroach

case report
Aspiration of a cockroach
Aspiração de barata
Albert Bousso1, Iracema de Cassia Oliveira Fernandes2, Ricardo Yamaguchi3, Lincoln Andrade4, José Carlos Fernandes5
ABSTRACT
It is described a five-month-old infant admitted to our pediatric
intensive care unit who aspirated a cockroach. The cockroach was
removed through bronchoscopy. The child arrived at the emergency
room in cardiopulmonary arrest and despite full respiratory and
cardiovascular support was discharged with evidence of severe
neurological sequelae. It is known that this is the first case of a
cockroach aspiration in a five-month-old infant and reinforces that
aspiration of an insect must be considered a possibility in patients
with an unidentified organic foreign body aspiration.
Keywords: Foreign bodies; Respiratory aspiration; Respiratory
insufficiency; Child; Insect; Case reports
RESUMO
Os autores descrevem o caso de uma criança de cinco meses de idade
admitida à unidade de terapia intensiva pediátrica por apresentar quadro de aspiração de barata. O inseto foi removido com a ajuda de
broncoscopia. A criança chegou ao setor de emergência do hospital
em parada cardiorrespiratória e apesar de ter recebido reanimação
completa e suporte cardiovascular teve alta com evidência de
graves seqüelas neurológicas. Sabe-se que esse é o primeiro caso de
aspiração de barata em uma criança de cinco meses e é salientado
que a aspiração de inseto deva ser considerada como possibilidade
em crianças que apresentem quadro de aspiração de corpo estranho
orgânico não-identificado.
Descritores: Corpos estranhos; Aspiração respiratória; Insuficiência
respiratória; Criança; Inseto; Relatos de casos
INTRODUCTION
Foreign body aspiration is a very common condition
in young children and can lead to significant morbidity
and mortality. The pediatric age group corresponds to
75% of cases, with a peak incidence of 48% occurring
on the second year of age(1). Sixty-five percent of deaths
occur in children bellow three years(2). Therefore, it is
imperative to establish an early suspicion in order to
rapidly initiate the proper therapy and avoid potential
damages to the airways.
Various types of foreign bodies have been reported
including food residues, toy parts, needles, plastic
spoons and fishing weights(2-3). Aspiration of insects or
insect parts is very rarely reported. It was found three
cases of cockroach aspiration(4-6) and one case of wasp
aspiration(7) in the Medline database. It is described
a five-month-old child, admitted to our pediatric
intensive care unit, who aspirated a cockroach.
CASE REPORT
It is described a five-month-old male child who, according
to the mother, was placed over a small carpet while she
was preparing his bath. After approximately one minute
the mother noticed that the child was coughing and
observed a dark object in his mouth. While trying to
remove this object with her hands the mother was only
able to extract two small parts recognized as being insect
legs, probably of a cockroach. After almost five minutes
trying to remove the insect from the child’s mouth the
patient became cyanotic, hypotonic and with respiratory
distress. At this point, the mother started to administer
mouth-to-mouth ventilation. The child was taken to
the emergency room, where he presented respiratory
insufficiency, wheezing and markedly reduced breath
sounds. The chest X-ray revealed left lung atelectasis.
Shortly after arrival, the child presented cardiopulmonary
arrest which lasted approximately 15 minutes.
After resuscitation he was transferred to our
intensive care unit. Apart from the respiratory and
Study corried out to Hospital Universitário da Universidade de São Paulo – USP, São Paulo (SP), Brazil.
1
PhD, Physician at Hospital Universitário of Universidade de São Paulo – USP, São Paulo (SP), Brazil.
2
Master´s degree, Physician at Hospital Universitário of Universidade de São Paulo – USP, São Paulo (SP), Brazil.
3
Preceptor of Pediatric Intensive Care at Instituto da Criança of Hospital das Clínicas of Faculdade de Medicina da Universidade de São Paulo – HC-FMUSP, São Paulo (SP), Brazil.
4
Assistant physician of the Endoscopy Service at Hospital Universitário of Universidade de São Paulo – USP, São Paulo (SP), Brazil.
5
Assistant physician at the Pediatric Intensive Care Unit of Hospital Universitário of Universidade de São Paulo – USP, São Paulo (SP), Brazil.
Corresponding author: Albert Bousso – Rua Dr. Veiga Filho, 350/307 – Santa Cecília – CEP 01229-000 – São Paulo (SP), Brasil – Tel.: 11 3663-3656 – e-mail: [email protected]
Received on: Mar 20, 2008 – Accepted on: Oct 26, 2008
einstein. 2008; 6(4):485-6
486
Bousso A, Fernandes ICO, Yamaguchi R, Andrade L, Fernandes JC
circulatory support he was submitted to a bronchoscopy
for removal of the suspected insect. The presence of a
cockroach was confirmed and it was located at the distal
carina (Figure 1). After removing the cockroach, it was
possible to discontinue all intensive care support and
the child was discharged on the tenth day of admission.
Unfortunately, at discharge, the child presented clinical
evidence of severe neurological sequelae.
Figure 1. Endoscopic view of the cockroach in the distal carina
DISCUSSION
The incidence of foreign body aspiration (FBA) varies
with age, sex and geographical location. Foreign body
aspiration is more common in boys with a 1.7:1 ratio(8)
and severe cases are frequently seen in young infants.
This was the case of the patient in this study.
Clinical presentation is variable, but the most
common symptom is the so called “penetration
syndrome”(1), which is a sudden episode of choking and
coughing. The present case had a clinical syndrome
which closely resembled the penetration syndrome.
The radiological findings of this case are consistent
with those found in a typical FBA, except that the right
lung is more frequently affected than the left lung(2-3).
Additionally, no particular radiological finding has a
clear correlation with the type of foreign body involved,
if the object is not radiopaque(5).
Van Looij et al.(9), in a retrospective study, described
their experience with foreign body removal in children
aged under three years. They found that the foreign
bodies were most frequently located in the upper
respiratory tract at the larynx and proximal trachea(8-9).
einstein. 2008; 6(4):485-6
However, when the foreign body migrated to the lower
respiratory tract, there was no predominance between
right and left bronchi for children younger than three
years(3-8). Above this age group, the right bronchus is
predominant. In the present case, as would be expected
due to the size of the patient and the size of the
cockroach, the foreign body was located in the carina.
Baharloo et al.(1) report the frequency and type of
foreign body removed from 63 children. They recovered
an organic foreign body in 91% of patients. More than
half of the aspirated foreign bodies were peanuts
followed by walnuts, carrots and apple. There were
no cases of insect aspiration. Reviewing the Medline
database it was found four cases of insect aspiration(4-7).
Of these, two(4,6) cases were described in India, one(5)
in South Carolina, which was related to cockroach
aspiration. One of these patients remained with the
cockroach in the lower right lobe for two years(6). The
fourth insect aspiration case was due to a wasp(7).
This case is probably the first case of cockroach
aspiration in a five-month-old infant and reinforces that
aspiration of an insect must be considered a possibility
in patients with an unidentified organic foreign body
aspiration.
REFERENCES
1.
Baharloo F, Veyckemans F, Francis C, Biettlot MP, Rodenstein DO.
Tracheobronchial foreign bodies: presentation and management in children
and adults. Chest. 1999;115(5):1357-62.
2.
Dunn GR, Wardrop P, Lo S, Cowan DL. Management of suspected foreign
body aspiration in children. Clin Otolaryngol Allied Sci. 2002;27(5):384-6.
3.
Chiu CY, Wong KS, Lai SH, Hsia SH, Wu CT. Factors predicting early
diagnosis of foreign body aspiration in children. Pediatr Emerg Care.
2005;21(3):161-4.
4.
Gokhale AG, Rajagopal P. Cockroach in right main bronchus - an unusual
foreign body. Indian J Chest Dis Allied Sci. 1992;34(2):103-5.
5.
Marlow TJ, Schabel SI, Goltra DD Jr. Endobronchial cockroach: an unusual
foreign body aspiration. J Emerg Med. 1997;15(4):487-9.
6.
Sharma A, Tuteja S, Rattan KN, Yadav RK. Mummified insect as foreign
body in the respiratory tract. Indian J Pediatr. 1996;63(6):816-8.
7.
Kubh M. Aspiration of a wasp in the right lower lobe of the lung. Schweiz
Med Wochenschr. 1997;127(15):650.
8.
Swanson KL, Prakash UB, Midthun DE, Edell ES, Utz JP, McDougall JC, et al.
Clinical characteristics in suspected tracheobronchial foreign body aspiration
in children. J Bronchol. 2002;9(4):276-80.
9.
Van Looij MA, Rood PP, Hoeve LJ, Borgstein JA. Aspirated foreign bodies in
children: why are they more commonly found on the left? Clin Otolaryngol
Allied Sci. 2003;28(4):364-7.