A Missed Coin Lesion !

Case Report A 62-year-old male with paranoid schizophrenia, depression, and neurolepticinduced extrapyramidal symptoms presented to the emergency department with complaints of coughing blood. He had intermittent dark bloody expectorations, with no associated fever, chills, or increase in sputum production. He denied any previous exposure to tuberculosis. A tuberculin skin test was negative. History was relevant for asbestos exposure. He denied any foreign body ingestion. A postero-anterior chest radiograph (Figure 1) initially was interpreted by the emergency physician as showing no acute lesion. The patient was discharged on doxycycline for possible acute bronchitis. A radiologist reviewed the chest x-ray and reported a round metallic opacity near the right hilum. A computed tomographic imaging of the chest (Figure 2) also revealed a metallic foreign body, probably a coin, which laid in the bronchus intermedius on the right, distal to the origin of the bronchus to the right upper lobe. Bronchoscopy was performed and a penny was removed.


Introduction
Aspiration of foreign objects is not uncommon in children or adults. 1 Children usually aspirate foreign objects accidentally, whereas adults usually suffer from a neurological impairment, the influence of alcohol, or an underlying psychological disorder. 2Presentation ranges from benign to more serious, which requires emergent intervention for removal. 3

Case Report
A 62-year-old male with paranoid schizophrenia, depression, and neurolepticinduced extrapyramidal symptoms presented to the emergency department with complaints of coughing blood.He had intermittent dark bloody expectorations, with no associated fever, chills, or increase in sputum production.He denied any previous exposure to tuberculosis.A tuberculin skin test was negative.History was relevant for asbestos exposure.He denied any foreign body ingestion.
A postero-anterior chest radiograph (Figure 1) initially was interpreted by the emergency physician as showing no acute lesion.The patient was discharged on doxycycline for possible acute bronchitis.
A radiologist reviewed the chest x-ray and reported a round metallic opacity near the right hilum.A computed tomographic imaging of the chest (Figure 2) also revealed a metallic foreign body, probably a coin, which laid in the bronchus intermedius on the right, distal to the origin of the bronchus to the right upper lobe.Bronchoscopy was performed and a penny was removed.

Discussion
Intentional ingestion of foreign objects in adults is more common amongst those with mental impairment, psychiatric disorders, or for secondary gain. 4Presentation usually is deferred and most present with multiple objects aspirated placing them at an increased risk for complications. 4 high index of suspicion is important in this population. 1Diagnosis was only made in 55% of patients prior to bronchoscopy. 5hest radiography was only diagnostic in 14% of cases if the object was opaque.Computed tomography scan is usually more sensitive in diagnosing radiolucent objects. 6ronchoscopy, either rigid or flexible, is considered both diagnostic and therapeutic. 1,5Surgery is the final option with good results if there is no parenchymal involvement. 7resentation can be benign or life threatening. 1Adults, unlike children, do not present with asphyxia but with symptoms of coughing, wheezing, and dyspnea to choking and hemoptysis which can mimic pneumonia or tumor. 5,7However, obvious hemoptysis is present in less than 15%. 5he most common aspirated object is a bone described in 45% of cases. 5Other aspirated objects include thorns, matches, and organic materials such as nuts, seeds and vegetables. 1,5Ingested coins also have been described in literature. 2 A foreign body should be removed once diagnosed irrespective of time of aspiration.The longer the foreign body stays, the worse the morbidity associated with it. 2The majority of aspirated objects usually are dislodged in the carina and right main stem bronchus. 1,5If the object was present for a long period, it can migrate and cause endobronchial erosion. 5With time and chronic inflammation, an aspirated object can mimic an endobronchial mass requiring investigation to rule out bronchogenic carcinoma. 6 high index of suspicion for foreign body aspirations is needed in psychiatric patients with respiratory symptoms, even those on optimal psychiatric treatment. 2If the patient presents late, the only clue for the diagnosis would be past history.

Figure 1 .
Figure 1.Postero-anterior chest x-ray: A round metallic radiopacity projected over the right paramediastinal stripe at the level of the right hilum.

Figure 2 .
Figure 2. Computed tomography of the chest without contrast: A metallic foreign body lies in the right bronchus intermedius.