Case Presentation: A 34 year –old man presented with cough that began twelve years ago after he underwent thoracotomy after suffering a gun-shot wound to his chest. Shortly thereafter, he was incarcerated, resulting in fragmented care. Previous imaging of his chest revealed scarring and a left lower lobe cavitary lesion. The patient had several negative PPDs, the last being about six months prior to this presentation. Over the intervening years he was prescribed several courses of antibiotics without relief in his symptoms. The cough became productive of foul-smelling yellow sputum, and he developed tenderness at the site of the thoracotomy scar, prompting him to seek further care. He was not hypoxic nor tachypneic. He had diminished breath sounds over the left posterior chest field. He was referred for admission for potential bronchoscopy. CT of the chest revealed: mediastinal and bilateral hilar adenopathy, more prominent on the left suspicious for infection versus metastatic process; left basilar consolidation with cavitation surrounding tree-in-bud opacities is most suggestive of an atypical infection; left lower lobe bullet fragments; 8cm mass-like lesion in the left lower lobe with internal radiopaque material and gas felt to represent a gossypiboma.
Discussion: Gossypiboma refers to a retained surgical sponge. Risk factors for retained surgical equipment include emergency surgical procedure, unexpected course during surgery, involvement of two or more surgical procedures, and prolonged surgical procedures. Retained sponges present either with an exudative patterns with wound infection, abscess or fistula; or fibrinous with the sponge encapsulated. Fibrinous sponges are often discovered months, years or decades after the surgical procedure and can appear as a soft tissue mass or similar to a granuloma. Gossypiboma are usually discovered by imaging although a small number are discovered incidentally. Management can be just observation in asymptomatic patients or surgical removal. However, this can be associated with significant morbidity and morality depending how long the sponge has been retained.
Conclusions: Causes of chronic cough (greater than eight weeks) can include: asthma, reflux, ACE inhibitors, interstitial lung disease, recurrent aspiration, foreign body aspiration, and lung cancer among others. Although sputum production would be suspicious for infection, failure to improve after appropriate treatment should prompt further investigation for non-infectious etiologies with advanced imaging or direct visualization. In this case, a chronic unexplained symptom persisting long after a surgical intervention should prompt a thorough review of the patient’s entire surgical history, even if prior workups for more common conditions have been unrevealing.
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