Correspondent author
Rosário Stilwell
Hospital Dona Estefânia, CHULC – EPE
Rua Jacinta Marto, 1169-045 Lisbon, Portugal
Phone: +351916149491
Fax: +351213126667
e-mail:maria.stilwell@chlc.min-saude.pt
Keywords: Pneumonectomy, destructed lung, button battery
ingestion
Paper presented at: Jornadas da Sociedade Portuguesa de
Pneumologia Pediátrica e do Sono
Short title: Pneumonectomy in a child post button battery
ingestion
Unperceived button battery ingestion in infants may be associated with
significant morbidity, especially when medical assistance is restricted.
To the Editor,
We report the case of a 3-year-old girl who was transported from a rural
area of an African country for medical investigation. She reported a
one-year history of recurrent vomiting, coughing, and growth arrest. On
initial physical examination, she was normoxemic and presented with
subcostal respiratory retraction and abundant purulent respiratory
secretions. Pulmonary sounds were abolished in the left hemithorax, and
there were crackles on the right side. The weight was below the third
percentile for age.
The initial chest radiograph (Figure 1) revealed a circular radio-opaque
foreign body in the medial chest with the typical double halo sign of
button batteries. Mediastinal enlargement and heterogeneous generalized
hypotransparency of the left lung were also visible. Chest computerized
tomography (CT) (Figure 2A) confirmed a battery lodged in the proximal
esophagus, associated with esophageal perforation and fistula to the
left bronchus, extensive fibrous mediastinitis without collection,
abscess, or pneumomediastinum, and partial consolidation of the inferior
and medial lobes of the right lung. The left lung was severely
destroyed, with main bronchus stenosis, multiple cystic and varicose
bronchiectasis, and extensive parenchymal atelectasis, which conditioned
the left mediastinal deviation.
Endoscopy was performed, but the extensive fibrosis and adhesion of the
battery to the esophageal wall called for a surgical removal in a
multidisciplinary procedure, during which the fistula was closed with a
pericardial patch, and a gastrostomy was performed.
After recovery from surgery, the girl maintained nocturnal
hypoventilation and abundant respiratory secretions. The right lung
pneumonia resolved after three weeks of meropenem and vancomycin
treatment. Esophageal post-procedural fistulae, stenosis, and
dysmotility were excluded. Four months later, she gained weight with
exclusive oral feeding, and the gastrostomy was closed.
Ten months after surgery, the left lung parenchyma on CT (figure 2B)
showed no healing due to extensive necrosis. However, the right lung
showed preserved parenchyma with moderate compensatory expansion.
A pneumonectomy was performed without any complications. Rapid recovery
and improvement in respiratory hypersecretion were observed, and
nocturnal non-invasive ventilation was suspended a week after the
pneumonectomy. In the subsequent months, the girl showed consistent
growth and weight gain in the 5th percentile, no pulmonary hypertension,
infections, chest wall deformation (Figure 3), or other chest
radiographic changes besides compensatory right lung expansion (Figure
4). The girl returned to her family and home country after 14 months.
Button batteries are commonly used in households. Toddlers are at risk
of accidental ingestion. Exposure to the battery can lead to caustic
mucosal injury within two hours, and severe, potentially
life-threatening complications may arise from delayed removal. Ingestion
is frequently unwitnessed, and early medical suspicion and intervention
are crucial for preventing and reducing morbidity and mortality. In our
patient, unrecognized ingestion resulted in permanent left lung
destruction, which is a severe and rarely described complication.
Chronic inflammatory lesion cause lung destruction. It is rare in
children and is mostly caused by bronchiectasis, tuberculosis, and
cystic fibrosis. When a single lung is affected, most patients exhibit
minor symptoms in the basal state. However, this condition may
complicate with massive hemoptysis, empyema, secondary fungal
infections, secondary amyloidosis, septicemia, and pulmonary-systemic
shunting.
Children can easily tolerate pneumonectomy, and the remaining lung
expands to compensate for the resection. On long-term follow-up after
pneumonectomy for destroyed lungs, children were reported to have good
exercise tolerance, lung volumes, nutritional status, and quality of
life without major skeletal deformation.
In conclusion, button battery ingestion is a risk to children’s health.
Clinicians should be aware of its potential complications to optimize
management and reduce injury. Pneumonectomy is a complex and invasive
procedure that improved our patient’s quality of life and prevented lung
damage complications.