In a rare and diagnostically challenging case, doctors successfully identified and removed multiple pieces of betel nut (supari) lodged across the airways of a young, otherwise healthy adult who presented with bilateral pneumonia and persistent hypoxemia.The patient initially presented with cough, bilateral pneumonia and low oxygen levels, requiring supplemental oxygen. A CT scan revealed bilateral pneumonic changes with extensive mucus plugging. The patient tested positive for Influenza A on the BioFire respiratory panel and was treated with oseltamivir and cefoperazone-sulbactam.Despite appropriate treatment, the patient’s oxygen requirement and hypoxemia persisted. A repeat CT scan showed worsening pneumonia and extensive mucus plugging, prompting clinicians to investigate an additional underlying cause.The patient was subsequently taken up for diagnostic and therapeutic bronchoscopy. During the procedure, multiple pieces of betel nut were found lodged in different airways, including the right middle lobe bronchus, right lower lobe bronchi, left intermediate bronchus and left lower lobe bronchi. Pus was also observed emerging from the affected airways and was aspirated for microbiological evaluation. All visible foreign bodies were successfully removed bronchoscopically, along with clearance of the obstructing material and secretions.Following the procedure, the patient’s oxygenation improved significantly, with saturation reaching approximately 94% without further supplemental oxygen.Dr Manu Madan, Senior Consultant, Respiratory & Sleep Medicine, Medanta Noida, said, “While foreign-body aspiration is commonly associated with children, elderly individuals or patients with impaired consciousness, this case highlights that it can also occur in young and otherwise healthy adults. The coexistence of Influenza A infection and multiple retained betel-nut fragments made the diagnosis particularly challenging. The patient’s lack of expected improvement despite appropriate treatment prompted us to look beyond the initial diagnosis. Bronchoscopy was crucial in identifying and removing the foreign bodies, following which the patient’s oxygenation improved significantly. This case reinforces the importance of reassessing the diagnosis when pneumonia does not respond as expected and considering less obvious causes such as foreign-body aspiration.”The case was particularly unusual as the patient was young, conscious and otherwise healthy, with no obvious conventional risk factors for foreign-body aspiration. The patient had also reportedly undergone bronchoscopy twice previously at another hospital.A detailed history subsequently revealed that the patient had a habit of sleeping with betel nut (supari) in the mouth, providing a plausible explanation for repeated aspiration of betel-nut fragments during sleep.Following bronchoscopic removal and airway clearance, the patient showed significant clinical improvement and was maintaining oxygen saturation without supplemental oxygen. The patient was subsequently planned for discharge.
A Reminder to Look Beyond the Initial Diagnosis
The case highlights the importance of reconsidering the diagnosis when pneumonia does not improve despite appropriate treatment. Foreign-body aspiration, although more commonly associated with children, elderly individuals and patients with impaired consciousness, can also occur in young, conscious adults.The coexistence of Influenza A infection and multiple retained airway foreign bodies demonstrates the importance of correlating clinical progression and radiological findings with bronchoscopic evaluation when pneumonia continues to worsen despite appropriate therapy.