Worrisome chronic cough in a 3-year-old girl
A 3-year-old girl presents to the emergency department (ED) with a 2-day history of worsening cough. Within the last 6 months, she has been diagnosed with gastroesophageal reflux disease (GERD) and asthma as the etiology of her persistent cough.
Over the 2 days prior to her presentation, the patient’s cough was severe and persistent. Her parents denied any drooling, shortness of breath, or dysphagia. Her vital signs were stable, and she was afebrile. Further history revealed a 6-month chronic cough unrelieved by common medications for asthma and GERD. Her mother reported that the cough was persistent and seemed to be worse in the morning. The parents denied any foreign body (FB) ingestions.
An outpatient nasopharyngolaryngoscopy had revealed a normal upper airway, and a referral to gastroenterology had included a differential diagnosis of GERD and eosinophilic esophagitis. She began treatment with omeprazole and was scheduled for repeat outpatient visits for a possible endoscopic examination. Given the persistence and severity of her cough, her parents brought her to the ED.
The patient’s physical examination was fairly unremarkable. Her vital signs were all within normal limits. Her cardiac exam was normal, and her lungs were clear to auscultation bilaterally. She was noted, however, to have mild increased work of breathing with subcostal and supraclavicular retractions. No laboratory studies were obtained at this time and she was scheduled for chest radiography (x-ray).
When children present to primary care offices with a chief complaint of chronic cough, the 2 most common diagnoses are asthma and GERD. However, it is important to always keep a broad differential, and a systems-based approach is best. Common diagnoses include GERD and reactive airway disease (Table). Whereas FB ingestion is less prevalent in older pediatric patients, the diagnosis must be considered in infants and toddlers as a cause for new-onset cough.
The patient’s chest x-ray revealed an infraclavicular foreign body in her esophagus that was concerning for a button battery (Figure 1). Gastroenterology removed the object emergently in the operating room. During the endoscopy, the esophageal wall was noted to be thin and friable. The esophagus surrounding the button battery was ulcerated with abundant granulation tissue formation (Figure 2).
Approximately 100,000 cases of FB ingestion are reported each year, of which 80% occur in children aged between 6 months and 3 years.1 Although a majority of FBs pass through the gastrointestinal (GI) tract, 10% to 20% require endoscopic removal.1 Whereas coins, toys, and batteries are commonly ingested, button batteries account for about 2% of all FB ingestions.2,3 Despite being less common, button batteries can be fatal when swallowed, making early detection imperative.4
Several different types of button batteries are on the market, with the majority being composed of alkaline material.3 Along with pressure necrosis, alkali production, mercury toxicity, and electrolyte leakage from the battery can result in catastrophic injury.3 Specifically, if the button battery is embedded within the esophagus, emergent removal is required, because in just 2 hours severe tissue damage can result.4
Children who have ingested an FB can present with a variety of respiratory and gastrointestinal (GI) symptoms including cough, dysphagia, respiratory distress, and weight loss.5 Most pediatric patients present within hours or days after FB ingestion; however, delayed presentation can be seen in cases of unwitnessed ingestion or subtle clinical findings. Presenting symptoms can be variable, which underscores the importance of obtaining a thorough history, examination, and radiographs when concern for FB ingestion exists.
Even if parents deny FB ingestion, medical providers must maintain a high clinical suspicion when the clinical scenario is concerning. A simple chest x-ray to rule out FB ingestion can be potentially lifesaving.3,6 Because approximately 75% of patients with chronic esophageal FB ingestions present with respiratory symptoms, these patients are commonly misdiagnosed with asthma, respiratory viral illness, or GERD.7 Our case demonstrates that when any chronic GI or respiratory symptoms are not responding to usual therapies, FB must be ruled out regardless of length of time from the onset of symptoms.
Treatment and outcome
Our patient’s FB removal procedure was well tolerated, but the child’s postoperative course was complicated. She suffered an esophageal tear and mediastinitis in the acute postoperative time period, as well as esophageal strictures that developed over several weeks. These complications required additional esophageal manipulations. She was treated with a 9-day course of intravenous antibiotics. A repeat endoscopy demonstrated no further perforation.
On postoperative day 9, her diet was advanced from parenteral nutrition to a mechanical soft diet. She was discharged home on postoperative day 11 with close follow-up with gastroenterology. At 14 weeks postdischarge, she reported dysphagia and an esophagram demonstrated an esophageal stricture. She subsequently received 2 endoscopic balloon dilations for her esophageal strictures.
The patient currently reports no dysphagia and continues to thrive after the dilations.
The literature reports over 2000 cases of button battery ingestions over the last several decades. In each case that resulted in serious complications, the FB was lodged in the esophagus.8 Maximum reported length of time for button battery ingestion to its retrieval was 4 weeks. We present the longest case of button battery retrieval at 6 months. Because of the rarity of this length of time until diagnosis, there is a paucity of literature discussing chronic button battery ingestion, and its postretrieval clinical course.
Our case demonstrates the importance of close follow-up after the initial retrieval of the FB because of increased risk of further complications given esophageal damage.
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