Introduction 

Foreign body aspiration (FBA) is a common emergen­cy in children under three years of age, although it may also occur unintentionally in older children. If not recog­nized and treated early, it can lead to recurrent respiratory infections, bronchiectasis, and other forms of permanent lung damage. Clinical suspicion should be raised in cas­es of recurrent pneumonia in the same location, localized wheezing, persistent cough, or pneumonia with poor re­sponse to standard treatment.

Clinical case

An 11-year-old boy with no relevant medical history pre­sented to the emergency department with a 24-hour his­tory of fever and mild dyspnea. Lung auscultation revealed decreased breath sounds on the left side and isolated ex­piratory wheezing. Due to the auscultatory asymmetry, a chest X-ray was performed, which was incorrectly reported as normal (Figure 1); upon later review, an infiltrate in the left lower lobe was identified. The patient was diagnosed with acute bronchitis and discharged with bronchodilator therapy.

He returned 48 hours later due to persistent fever and dyspnea. His vital signs were normal, and auscultation again demonstrated decreased breath sounds on the left side. A lung ultrasound revealed consolidation in the left lower lobe and the apex. Directed history-taking identi­fied a choking episode with a sunflower seed shell three months earlier, coinciding with the onset of recurrent pneumonic episodes in the same lobe (three episodes were documented in the shared medical record).

Based on these findings, the case was considered pneu­monia in the context of foreign body aspiration. A chest CT scan revealed obstruction of the left main bronchus by a foreign body consistent with a seed shell, pulmonary hypo­vascularization, and parenchymal consolidation (Figure 2 and Figure 3).

The patient was admitted and scheduled for bronchos­copy. A flexible bronchoscopy was initially performed in the operating room and allowed visualization of the for­eign body but not its extraction. A rigid bronchoscopy under general anesthesia with orotracheal intubation was then performed, successfully removing the object without complications.

Preoperative laboratory tests showed leukocytosis with neutrophilia and elevated acute phase reactants. Treat­ment with amoxicillin–clavulanic acid was initiated, result­ing in complete clinical resolution. The patient remained asymptomatic with no further pneumonic episodes during short-term follow-up.

Radiology report:

Left lung: Extensive parenchymal consolidation pre­dominantly affecting the lower lobe and including the pulmonary apex, compatible with an inflammatory/infec­tious process. Vascular hypoattenuation of the left lung parenchyma suggests hypovascularization secondary to bronchial obstruction. The left main bronchus is occu­pied by a hyperdense structure compatible with a foreign body, resulting in near-complete obstruction.

Right lung: Preserved parenchymal architecture with no consolidation, effusion, or visible masses. Normal venti­lation and vascularization.

Tracheobronchial tree: Mediastinal shift to the right with reduced left lung volume. No other remarkable findings.

Mediastinal and pleural structures: No significant me­diastinal lymphadenopathy. No evidence of pleural effu­sion or pneumothorax.

Conclusion:

• Foreign body in the left main bronchus with near-complete obstruction.

• Pulmonary consolidation in the left lower lobe, likely due to post-obstructive pneumonia.

• Secondary hypovascularization and hypoventilation of the left lung.

• Findings consistent with foreign body aspiration syndrome.

Discussion

This case highlights the importance of a thorough medical history and accurate interpretation of imaging studies. Recurrent pneumonia in the same lobe should prompt suspicion of an undiagnosed foreign body, espe­cially when there is a history of choking, even if not spon­taneously recalled.

A diagnostic error occurred during the interpretation of the initial chest X-ray, which already showed decreased vascularity in the left lung and a small infiltrate. However, it is important to recognize that initial diagnostic tools—particularly chest radiography—have limited sensitivity. It is estimated that 9% to 35% of chest X-rays may appear normal in confirmed aspiration cases^(6,10). CT imaging, although highly sensitive (99%) and specific (97%)⁽⁶⁾, is not always required for diagnosis and should be reserved for complex cases or when clinical uncertainty remains. In this case, the history of repeated pneumonias in the same loca­tion and the prior choking episode already suggested the diagnosis, making the CT scan not strictly necessary. CT involves a considerable radiation dose, which is especially relevant in children.

In this case, flexible bronchoscopy was initially per­formed because it is useful as a diagnostic tool; howev­er, therapeutic extraction of foreign bodies in children is predominantly performed by rigid bronchoscopy. Swan­son et al.⁽¹⁾ reported a success rate greater than 95% for rigid bronchoscopy in the removal of foreign bodies in children, while flexible bronchoscopy has shown success rates of 87% in large series⁽⁷⁾. Flexible bronchoscopy is mainly reserved for distal foreign bodies or as a diagnos­tic step prior to rigid bronchoscopy, which remains the treatment of choice^(8,9).

Foltran et al.⁽²⁾ reported that between 40% and 50% of children with foreign bodies present with pneumonia as the initial manifestation, which can lead to diagnostic er­rors if the underlying cause is not investigated.

Recent studies emphasize that computed tomography has a sensitivity of 99% and specificity of 97% for detecting foreign bodies in the pediatric airway⁽⁶⁾.

Timely extraction helps prevent complications such as bronchiectasis, atelectasis, or pulmonary fibrosis. This case also underscores the importance of maintaining a high index of suspicion and reassessing diagnostic tests when clinical progression is unfavorable.

An essential aspect in preventing complications is ed­ucating caregivers and healthcare professionals on early identification of aspiration signs. Warning signs include chronic cough, unreported prior choking episodes, per­sistent wheezing, and recurrent pneumonia in the same pulmonary location.

Conclusions 

• Recurrent pneumonia in the same location should prompt suspicion of an airway foreign body.

• Medical history and accurate interpretation of imaging studies are essential for early diagnosis.

• CT can be useful but is not required in all cases; its use should be weighed against radiation risks in children.

• Rigid bronchoscopy remains the therapeutic gold stan­dard for foreign body removal in children.

• Early detection and removal prevent severe pulmonary complications.

Funding

This research received no specific grant from public, commercial, or not-for-profit funding agencies.

Conflicts of Interest

The authors declare no conflict of interest.

Authors’ Contributions

The authors certify equal contributions to the scientific and intellectual content, data analysis, and writing of the manuscript.

Ethical Responsibilities

The authors confirm that informed consent was ob­tained from the patients involved in accordance with the ethical principles of the Declaration of Helsinki.

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