Muddy clinical waters: a missed betel nut in the bronchus

A toddler presented with a 5-month history of recurrent episodes of cough, wheezing and fever. Before referral, the toddler had been initially diagnosed as having bronchial asthma and later as having pulmonary tuberculosis. On examination, the patient was febrile and had severe respiratory distress. Chest radiograph and high-resolution CT of the chest revealed collapse of the entire left lung with diffuse bronchiectasis along with a grossly hyperinflated right lung. CT virtual bronchoscopy did not reveal any foreign body. The parents denied any history suggestive of foreign body aspiration and refused consent for rigid bronchoscopy. Nine days after admission, chest physiotherapy was inadvertently prescribed to the patient. Within an hour, the patient experienced acute respiratory deterioration and died. Autopsy revealed a piece of betel nut in the right main bronchus; it had got dislodged from its initial site in the left main bronchus following the chest physiotherapy session.