LAUSR

A 58-year-old male presented with a five-day history of right-sided pleuritic chest pain and shortness of breath. He denied preceding coryzal symptoms, cough or sputum production. He denied a history of foreign body ingestion and denied ingesting any meat or fishbone (FB). However, on close questioning he reported a large part of his diet consists of fish. On examination in the emergency department, he showed signs of sepsis; heart rate: 118/minute, temperature: 38.2 C, respiratory rate: 28/min and oxygen saturation:96% on 15 L of oxygen. Chest examination revealed dullness to percussion and decreased air entry on the right side. Blood laboratory test revealed; white cell count: 15.5 10/L, neutrophils: 13.7 10/L and c-reactive protein: 304 mg/L. Chest radiography showed right-sided pleural effusion (Fig. 1). Computed tomography pulmonary angiogram (CTPA) was negative for a pulmonary embolism but revealed a complex rightsided loculated effusion, suspicious of empyema. Additionally, a linear hyperdense foreign body (suspicious for a FB) connected the right distal oesophagus wall, within the area of the right crux of the diaphragm, to medial costophrenic angle of the right hemothorax (Fig. 2). Endoscopy showed that the oesophagus was normal in appearance and did not reveal any oesophageal foreign body or any mucosal abnormality. Intravenous ceftriaxone and metronidazole were commenced, and a decision was made for surgical management of likely empyema and retrieval of foreign body. Right, posterolateral thoracotomy was performed for pleural washout and decortication. There was extensive pleural exudate in the right pleural cavity with thick pleural rind. The pleural exudate was cleared, and the pleural rind was carefully peeled from the lung surface, which achieved satisfactory lung expansion. Careful examination of the medial costophrenic recess revealed a sharp linear structure which had pierced the right crux of the diaphragm within the pleura, it was retrieved, confirming a 3 cm FB (Fig. 3). The culture grew Streptococcus milleri and was pan sensitive to anti-biotics. The patient was kept nil by mouth for 48 hours, a barium swallow study was performed, which did not reveal an oesophageal perforation. A progressive diet regimen was initiated, which the patient tolerated well and he made a full recovery. Fig. 1. Chest radiography showing right sided pleural effusion.