Case Presentation: A 78-year-old man with a history of paraplegia secondary to spinal stenosis, who presented with worsening dyspnea, fatigue, and confusion. On presentation, he was tachypneic and hypoxic, requiring 4 liters of oxygen via nasal cannula.Initial imaging revealed a large left pleural effusion with significant left lung atelectasis, a moderate right pleural effusion, and a lobulated 5.7 cm RLL mass. A chest tube was placed, draining serosanguineous fluid and analysis revealed an exudative effusion by Light’s criteria with no evidence of infection or malignancy. Cytology demonstrated rare mesothelial cells and macrophages without malignant cells. Despite pleural drainage, the patient’s oxygenation and clinical status deteriorated and he was intubated. Follow-up imaging showed RLL consolidation and signs of re-expansion pulmonary edema. He was treated with broad-spectrum antibiotics for presumed aspiration pneumonia. Bronchoscopy was performed due to worsening respiratory status and identified copious thick mucoid secretions extending from the bronchus intermedius (BI) into the RLL and right middle lobe bronchi. A yellow-brown reticular lesion resembling a plaque was noted in the BI, and bronchial lavage samples were sent for analysis.Pathology demonstrated crystalline, yellow-brown pigmented material, consistent with pill aspiration, along with inflammatory debris, neutrophils, and reactive bronchial epithelial cells. No malignant cells were identified. The findings were corroborated by the patient’s history of polypharmacy, raising suspicion for an undetected aspiration event. Repeated bronchoscopic lavage cleared some secretions. Repeat imaging continued to show mucus plugging and incomplete resolution of the RLL consolidation.
Discussion: This case underscores the significant challenges in diagnosing and managing pill aspiration in a complex patient. The yellow-brown crystalline material observed on pathology is characteristic of pill aspiration, which leads to localized inflammation, mucosal injury, and potential airway obstruction. Pills with caustic components, such as iron, potassium chloride, or other acidic substances, are known to cause severe epithelial injury and granulation tissue formation. In this case, the exact pill responsible was not identified, but the findings suggest substantial chemical irritation with secondary inflammation and mucus production.Imaging studies, including CT scans, may show localized consolidation, atelectasis, or opacities, but direct visualization through bronchoscopy remains the gold standard for diagnosis. Management of pill aspiration depends on the extent of airway injury and the systemic impact. Early bronchoscopy to remove the aspirated material is crucial to prevent complications such as persistent obstruction, granulation tissue formation, or fibrosis.
Conclusions: Pill aspiration is an underdiagnosed condition with potentially serious consequences, particularly in patients with significant comorbidities. This case highlights the importance of maintaining a high index of suspicion for pill aspiration in patients presenting with unexplained airway lesions, persistent consolidation, or mucus plugging. Bronchoscopy plays a pivotal role in diagnosis and management, allowing direct visualization, lavage, and sampling. Early recognition and intervention are crucial to minimizing airway damage and systemic complications.
