Reminder of important clinical lesson: Pulmonary protection

doi:10.1136/bcr.08.2009.2203

BMJ Case Rep. 2010; 2010: bcr08.2009.2203.

Published online 2010 January 13. doi: 10.1136/bcr.08.2009.2203

PMCID: PMC3027945

Reminder of important clinical lesson

Pulmonary protection

Michael Bridgett

Glasgow University, Respiratory Medicine, Flat 1/1, 9 Fortingall Avenue, Glasgow G12 0LR, UK

Correspondence to Michael Bridgett, Email: m.bridgett/at/hotmail.co.uk

Abstract

This report describes the case of a 23-year-old woman who presented with symptoms, signs and radiology suggesting pneumonia. Despite courses of antibiotics, her condition did not improve. Bronchoscopy was eventually performed which revealed a membranous object in her right upper lobe bronchus. The object was easily removed and discovered to be a condom. Retrospective questioning found that the women was currently working as an escort girl and often performed oral sex on male clients. The patient remembered coughing very violently during a recent session which is presumably when the condom was inhaled. She had not volunteered this information initially as she was sensitive about her occupation, and also because she had not been directly asked. This case illustrates the importance of taking a detailed occupational history from a patient presenting with respiratory symptoms as this may have led to a quicker diagnosis and spared the patient courses of antibiotics.

Background

This case initially presents to the reader under a guise of a common treatable medical condition. However, the aetiology was something that I had never encountered before, nor had my colleagues. The occupational history is an essential part of the management of any respiratory patient and this case illustrates that in a novel way.

Case presentation

A 23-year-old woman presented to accident and emergency department with a 2 week history of fever, productive cough and pleuritic chest pain. She had been previously well with medical history of note. The patient was on no regular medicines and had no history of allergy. She had a family history of heart disease on her father’s side but nothing else that she was aware of. The patient was a non-smoker, drank 5–10 units of alcohol on weekends, had no pets at home, and had not been outside the UK in the last year. All her friends and family were well and the systematic enquiry was unremarkable, apart from the presenting symptoms.

On examination the patient was tachycardic and tachypnoeic but normotensive with saturations of 95% on air. On examination she had decreased chest expansion and decreased air entry in the right upper zone. In addition there was decreased percussion note and increased vocal resonance in her right upper lobe. Swallowing was unimpaired and she was not deemed to be at risk of aspiration. Glasgow Coma Score was 15 and there was no loss of consciousness in the history. In addition there was no evidence of upper airway obstruction or choking. Her CURB 65 score was zero.

Investigations

Haematology and biochemistry were unremarkable. Chest x-ray showed right upper lobe collapse/consolidation. Blood cultures before antibiotics were started showed no growth.

Differential diagnosis

Pneumonia.

Treatment

The patient was initially treated with oral antibiotics—amoxicillin, then later clarithromycin.

Outcome and follow-up

After a week of antibiotic treatment the patient’s condition had not improved, although she had not deteriorated. Sputum had been sent but no organisms were cultured. It was decided to arrange a computed tomography (CT) scan of the thorax. The CT scan confirmed collapse/consolidation of the right upper lobe but it also showed a foreign body in the right upper lobe bronchus. Direct visualisation by bronchoscopy showed a white membranous object emerging from the collapsed right upper lobe bronchus. It was easily removed and was discovered to be a condom.

After this discovery the patient admitted that she worked as an escort girl and told the admitting doctor that she was a legal secretary as she wished to be discrete about her job. On direct questioning she admitted to regularly performing oral sex on clients and she recently remembered coughing quite violently during a session. This is presumably when the condom became aspirated.

The patient made a good recovery after this and was discharged 3 days later. The patient was followed up in clinic 6 weeks later and a chest x-ray showed complete resolution.

Discussion

Pneumonia is a very common clinical condition with significant morbidity and mortality. Although many patients respond to first line therapy a minority of patients fail to improve and provide a challenge for the clinician. C reactive protein (CRP) is a useful test in managing pneumonia. One study done in 1996 showed that only 5% of patients admitted with community acquired pneumonia had a CRP concentration <50 mg/l.¹ Although the initial concentration does not correlate with disease severity it is useful to observe response to treatment. If CRP has not fallen by 50% by day 4 of treatment, this suggests treatment failure or development of a complication.²^,³ Elderly patients will often have a slower clinical response and this should be taken into consideration.

Misdiagnosis is one possibility and if a patient has not improved the history, examination and radiology should be carefully reviewed and repeat/further imaging should be considered.

Pneumonia can lead to secondary complications which may explain failure to improve. These can be divided into pulmonary (eg, empyema, parapneumonic effusion or abscess formation) and intrapulmonary (eg, renal failure or sepsis).

Finally, the antibiotic may be inappropriate or the pathogen unexpected. The antibiotic dose and route of administration should be reviewed as should patient compliance. All microbiology samples should be reviewed and further samples should be sent to rule out less common infection, such as Legionella. Always remember that some patients will have a mixed infection and to consider tuberculosis and fungal infections.

A literature review revealed a similar case published in 2004.⁴

Learning points

It is vital to establish good rapport with a patient so that they will be more likely to divulge sensitive information to you.
Always take a detailed occupational history in a patient presenting with respiratory symptoms.
Not all occupational respiratory patients worked in shipyards!

Footnotes

Competing interests: None.

Patient consent: Patient/guardian consent was obtained for publication.

REFERENCES

1. Smith RP, Lipworth BJ, Cree IA, et al. C-reactive protein. A clinical marker in community acquired pneumonia. Chest 1995; 108: 1288–91. [PubMed]

2. Society British Thoracic. BTS guidelines for the management of community acquired pneumonia in adults. Thorax 2001; 56(Supp 4): iv1–64. [PMC free article] [PubMed]

3. Hansson LO, Hedlund JU, Ortqvist A. Sequential changes of inflammatory and nutritional markers with community acquired pneumonia. Scan J Clin Lab Invest 1997; 57: 11–18. [PubMed]

4. Arya CL, Gupta R, Arora VK. Accidental condom inhalation. Indian J Chest Allied Sci 2004: 55–8. [PubMed]

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