Pneumonectomy in a child with necrotic lung after ingestion of a button battery.

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 1-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 (BB). Mediastinal enlargement and heterogeneous generalized hypotransparency of the left lung were also visible. Chest computerized tomography (CT) (Figure 2A) confirmed a BB lodged in the proximal esophagus, associated with esophageal perforation and fistula to the left bronchus, extensive fibrous mediastinitis without 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 3 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 reduction in respiratory secretion was observed, and nocturnal noninvasive ventilation was suspended a week after the pneumonectomy. In the subsequent months, the girl showed consistent growth and weight gain in the fifth 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. Toddlers are at risk of accidental BB ingestion.1 Esophagus narrowed regions may harbor BB impaction. Ingestion is frequently unwitnessed and nonspecific symptoms of impaction are easily misinterpreted as respiratory infection. Toddlers presenting with dysphagia, vomiting, drooling, and cough, should raise suspicion of esophageal impaction.2 Exposure to BB highly alkaline environment might produce severe mucosal lesion after 2 h.1 In esophageal BB impactions only about 3% of patients had no complications.2 Esophageal impaction at the level of the aortic arch, age less than 5 years, battery size of 20 mm or greater, and prolonged time of impaction encompass the most important predictors of severe injury.3 In our patient, delayed removal leaded to esophagus fistula and permanent left lung destruction. Patients with single destructed lung exhibit minor symptoms in basal state,4 but are prone to complications such as massive hemoptysis, empyema, fungal infections, amyloidosis, septicemia, and pulmonary-systemic shunting.4, 5 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.5 In conclusion, BB 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. Rosário Stilwell: Conceptualization; investigation; writing—original draft; writing—review and editing; visualization; validation; formal analysis. Cláudia Silva: Writing—review and editing; validation. Rui Alves: Formal analysis; supervision; writing—review and editing; visualization; validation. Isabel Afonso: Writing—review and editing; supervision; formal analysis; validation. Paulo Calvinho: Validation; visualization; writing—review and editing; data curation; supervision. Ana Casimiro Malta: Supervision; validation; visualization; writing—review and editing; writing—original draft; conceptualization; investigation. The authors declare no conflict of interest. Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.