Clinical Cases

HomeProfessionalsClinical ResourcesClinical Cases ▶ A case of progressive dyspnea and abnormal chest x-ray
A case of progressive dyspnea and abnormal chest x-ray (The Case of Being a Couch Potato)

Case Editor - Judd Flesch

Reviewed By Allergy, Immunology & Inflammation Assembly

Submitted by

Jarrod Bruce M.D.


Pulmonary, Allergy, Critical Care and Sleep Medicine

The Ohio State University Medical Center

Columbus, Ohio

Joanna Williams M.D.

Clinical Assistant Professor

Department of Pathology

The Ohio State University Medical Center

Columbus, Ohio

Nitin Bhatt M.D.

Assistant Professor of Clinical Internal Medicine

Pulmonary, Allergy, Critical Care and Sleep Medicine

The Ohio State University Medical Center

Columbus, Ohio

Maria Lucarelli M.D.

Associate Professor of Clinical Internal Medicine

Pulmonary, Allergy, Critical Care and Sleep Medicine

The Ohio State University Medical Center

Columbus, Ohio

Submit your comments to the author(s).


A 61 year old female presented to an outside hospital with increasing shortness of breath and cough. She complained of a non-productive cough for approximately six weeks.  She denied hemoptysis but complained of a low grade fever. Over this time she became progressively more short of breath. At the time of presentation she was able to only walk one hundred meters before she had to stop due to dyspnea.

Her past medical history included obesity, gastroesophageal reflux disease (GERD), peripheral vascular disease, hypertension, and type II diabetes. Family history was negative for lung cancer or chronic obstructive pulmonary disease (COPD). Her medications included aspirin, metoprolol, lisinopril, insulin glargine and esomeprazole. She denied any previous tobacco, alcohol or intravenous drug use. She was currently disabled due to chronic lower back pain.

Physical Exam

Her vital signs included a temperature of 101° F, respiratory rate of 28, blood pressure of 152/91 and heart rate of 99/min. Oximetry was 87% on room air. Physical exam revealed an obese female in mild respiratory distress. No accessory muscle use was noted. Right sided lung fields were clear. Left sided lung fields were clear posteriorly but diminished anteriorly. Cardiac exam was normal. No palpable lymphadenopathy was appreciated in the supraclavicular or axillary regions. The rest of the exam was unremarkable.


She presented to an outside hospital emergency department and was found to have an abnormal chest x-ray. Posterior-anterior (PA) and lateral films were provided (Figures 1 and 2).

Figure 1

Figure 1. Posterior-anterior chest x-ray demonstrating left sided consolidation without volume loss.

Figure 2

Figure 2. Lateral view on chest x-ray demonstrating left upper lobe consolidation.

Subsequently the patient underwent computed tomography (CT) of the chest with pulmonary angiography. Two cuts are provided below (Figures 3 and 4).

Figure 3

Figure 3. Computed tomography image of the chest demonstrating consolidation of the left upper lobe.

Figure 4

Figure 4. Computed tomography image of the chest demonstrating left upper lobe (LUL) consolidation with endobronchial lesion in LUL bronchus.

The patient was admitted to the outside hospital and underwent bronchoscopy for evaluation of left upper lobe (LUL) and lingular collapse. She was electively intubated for the procedure and bronchoscopy revealed an endobronchial lesion in the LUL. The patient was transferred on mechanical ventilation to a tertiary care center for further evaluation of suspected endobronchial malignancy. Repeat bronchoscopy was performed with results as shown in Video 1.

Bronchoscopy revealed a foreign body in the left upper lobe bronchus. Using cryotherapy, the foreign body was successfully removed and eventually identified as a popcorn kernel (Figure 5).

Figure 5

Figure 5. Foreign body identified as popcorn kernel.

Question 1

Which of the following is not a risk factor for foreign body aspiration in adults?


  1. National Safety Council, R.a.S.D. Injury Facts 2008 Edition, ed. N.S. Council. Vol.:8. 2008: Itasca, Ill.
  2. Wick R.,Gilbert J.D., Byard R.W. Cafe coronary syndrome-fatal choking on food: an autopsy approach. J Clin Forensic Med 2006;13(3):135-8.
  3. Limper A.H., Prakash U.B. Tracheobronchial foreign bodies in adults. Ann Intern Med 1990;112(8):604-9.
  4. Lan, R.S. Non-asphyxiating tracheobronchial foreign bodies in adults. Eur Respir J 1994;7(3):510-4.
  5. Boyd M., Chatterjee A., Chiles C, Chin R. Tracheobronchial Foreign Body Aspiration in Adults. Southern Medical Journal 2009;102(2):171-174.
  6. Ell S, Sprigg A. The radio-opacity of fishbones — Species variation. Clinical Radiology 1991;44:104-107.
  7. Esclamado RM. Laryngotracheal foreign bodies in children: A comparison with bronchial foreign bodies. Am J Dis Child 1987;141(3):259-62.
  8. Svedström E, Kero P. How accurate is chest radiography in the diagnosis of tracheobronchial foreign bodies in children? Pediatr Radiol. 1989;19(8):520-2.
  9. Zissin R, Shapiro-Feinberg M, Rozenman J, Apter S, Smorjik S, Hertz M. CT findings of the chest in adults with aspirated foreign bodies. Eur Radiol. 2001:11(4):606
  10. Debeljak A, Sorli J, Music E, Kecelj P. Bronchoscopic removal of foreign bodies in adults: experience with 62 patients from 1974-1998. Eur Respir J.1999;4(4):792-5.
  11. Takako H. Supplemental experimental findings on foreign body in the bronchus. J Jpn Bronchoesophagol Soc. 1973;24:30-39.
  12. Mabeza G.F., Macfarlane J. Pulmonary actinomycosis. Eur Respir J. 2003; 21:545-551.
  13. Walters G, Ware N, Handslip P.Endobronchial actinomycosis associated with aspiration of a shirt button: A 30-year latency. Respiratory Medicine CME 2009 Vol. 2, Issue 1, Pages 18-20, DOI: 10.1016/j.rmedc.2008.10.018.
  14. Rippon JW. Medical Mycology. Inc. Wonsiewicz MJ, ed. The Pathogenic Fungi and the Pathogenic Actinomycetes. 3rd edn. Philadelphia. W.B. Saunders Co., 1988; pp. 30-52.