March 1950 63

CLINICAL MEMORANDUM

A Case of Acute Asphyxia produced by of a Caseating Mass into the Bronchus,

Recovery. By HOWARD WILLIAMS

Medical Registrar, Harefield Hospital

the Rupture followed by

Acute asphyxia p roduced by the rup tu re of a tuberculous medias t inal l y m p h gland into the ma in air passages is a rare pheno- menon in. p r i m a r y p u l m o n a r y tubercu- losis of children. In I934 Scobie reviewed 94 cases, only 19 o f which ended i n r e c o v e r y and presented his own case where the pa t ien t recovered f rom the asphyxial episode. T h e latest recorded case of acute asphyxia ending fatal ly was tha t o f perfora t ion of the t rachea by a caseous hi lar g land in a boy aged 6 years, described by A n g e l m a n and T u r n e r in I949. T h e authors of this art icle cited ano the r case of fatal asphyxia in a boy aged 22 months i n which a caseous hilar g land had per fora ted the r ight ma in bron- chus jus t below the bifurcat ion of the t rachea. In addi t ion to these cases the authors m a d e a br ie f but comprehens ive reference to the l i terature on this subject.

T h e following case appears sulliciently interesting to record:

M. P., a glrl aged 2 )'ears 5 months, was admitted to Harefield Hospital on January 4, I949, with pr imary pulmonary tuberculosis. and a tuberculous lesion in tile left foot.

History before Admissiol,.--It was as a contact of her father that the child was taken to Edmon- ton Chest Clinic on February 2~, 1948. An x-ray of her chizst on this day showed 'an opacity in the area of the right middle lobe'. A patch test was positive. There was no histo D' of pre- vious illness. Tile child was kept under obser- vation at tile Chest Clinic until August I948, when she was stated to have fallen whilst playing. Her left foot became painful and swollen as a result of this flail. On August 14, 19.t8 , site was admitted to Chase Farm Hospital with a dischat'ging ulcer on the dorsunl of her left foot. The left leg was then immobilized in a short metal splint anti the child was rested in bed until her admission to Harefield.

01, AdMssion.---The patient was a frail nervous child. Temperature range 98-00-99.6 ~ , pulse range lo8-x-',o, respirations 2o-~2 per minute. Oil examination of the respiratory system a few fine rales were detected in the right lower axilla. An x-ray of the chest on the same date showed a localized lesion in the right lower zone probably middle lobe with some element of collapse. Gastric lavage culture was positive for T.B. on January 7, z949. Tile E.S.R. was i6 mm. in two hours on x~.I.49.

A small discharging sinus was present over the lateral aspect of the tipper third of tile left thigh. There were two discharging sinuses on the dorsum of the left foot with surrounding induration. X-ray of tlae left femur was normal but the left foot showed evidence of osteitis in tile tarsal region.

Two weeks after admission at 7 a.m. on Janua ry 18, the patient had a severe bout of coughing and produced about ', oz. of mucoid material mixed with vomit. She immediately became breathless (respirations 34 per minute) cyanosed, shocked, and developed a well- marked stridor. E x a m i n a t i o n of her chest revealed noticeable intercostal retraction on inspiration with fidi use of the accessory nmscles of respiration. There was no impaired move- ment on either side of the chest. The percussion note was resonant in all areas. The air entry was harsh, bronchial in character, particu- larly over the right upper and middle zones, but less markedly so to tile left upper zone. No improvement was effected by 'tipping'. She was found to get most relief sitting in the upright position and turned towards her right side. In this position and aided by oxygen therapy, the patient became less distressed, the stridor and dyspnoea persisting to a lesser degree.

Two hours later a fitrther bout of violent coughing commenced. The child was tipped once more and she coughed up a small cream- coloured mass, firm in cousisteney, resembling a French bean, hut with a ragged surl~ace; This was followed by inunediate and dramatic improvement in respiratory fitnction. The stridor ceased, respirations became normal, the

64 T U B E R C L E March 1950

cyanosis and the shocked appearance clearing in a like manner.

Examination of the respiratory system after the attack revealed an occasional rale in the right lower a_xilla, but otherwise there were no abnormal physical signs. Two or three hours later an x-ray of tile chest was taken and showed little change from the previous film of January 5. A direct smear wa_s made from the caseous material coughed up. Microscopical examination showed pus cells and lyrnpho- cytes. Acid-fast bacilli were present in fair numbers.

Results of gastric lavage cultures subsequent to the asph).'xial attack were as follows:

Negative 1.2.49, positive 6.5.49, positive _09.6.49, negative '27.7.49 , negative _06.8.49.

A bronchoscopy was carried out on _0_0-9.49, this showed the cords and carina were normal. The right main bronclms was also patent, also the right middle lobe orifice, but its lower lip was slightly swollen. A little mucoid secretion was removed by suction from this orifice. The left bronchial tree was normal.

The progress of the patient after the asphy- xial episode was uneventful. There were no fitrther attacks of dyspnoea. Clinical examin- ation of the respiratory system was always normal. On discharge _03.1o.49, the patient's general condition was good. She had gained _0 lb. in weight since admission and was up for four hours during the day. The left foot and thigh were soundly healed with two keloid scars on the dorsum of tile foot and a minute scar on the left thigh. The temperature range was 97-980 F. and tile E.S.R. was 6 mm. on _08.9.49.

Comment In this case there was no evidence, pr ior to the occurrence o f the asphyxia, o f any mass project ing . in to the lumen of the bronchial tree, bu t there was radiological evidcncc of some right middle lobe collapse. T h e presence o f the loose body could have been suspected dur ing the first a t tack of asphyxia by the fact tha t sitting up improved the child while ' t ipping' made it worse. Al though th i s case rccovercd it would have been safer to have bronchoscoped the pat icnt immediate ly after the initial phase o f asphy 2 xia. Bronchoscopy could have been per- formed in the sitting up position. T h e child w a s for tunate in that this mass was compara t ive ly small. Both the broncho-

scopic and radiological evidence was suggestive of the mass arising somewhere in the region of the r ight middle lobe orifice.

Summary A case of acute asphyxia arising in a girl aged 2 years 5 months is described. T h e at tack was produced by the lodgment of a caseous mass in the bronchial tree, most p robab ly in the trachea. After two hours the mass was coughed u p , and the child made an uneventful recovery.

M y flmnks are due to Dr K." R. Stokes, Medical Director , Harefield Hospital , for allowing me to present this case, and to D r J . C. Roberts , for his advice and criticism, also D r Davies o f Ed m o n to n Chest Clinic for the loan of the early x-rays.

References Sc0ble, R. B. 0934) Amer. a 7. Dis. Child., XLVIII, 3 7 3 "

Angelman, H., and Turner,-W. (t9/r.l~) Lancet n, 842.

Correspondence The Prophit Report

Tim EDITOR-- 'Tu~F.ROLE'. SIR, - - In tile discussion at a recent meeting of

the British Tuberculosis Association, Dr Marc Daniels made a belated reply to xny criticism of the Prophit Report, published in your issue of September, 1948.

In my review I contended that the difference in annual morbidity of approximately 5 per i,ooo between nurses of Groups A and B meant that Group A as a whole was 0"5 per cent 'more susceptible' than Group B. Dr Daniels ridiculed this method of comparison and pointed out that according to it ttle rise in tuberculosis death-rate in Warsaw fi'om 15o per Ioo,ooo in 1938 to 500 in 1944 was a rise of only 0.35 per cent. This is true, but in the case of the Prophit Survey I was considering mor- bidity rates, not death-rates. The annual death- rate for all nurses (excluding Irish and Welsh) was o.57 per I,OOO (p. 156), whereas the annual morbidity rate for the same group was IO. 7 per Looo. For every death there were therefore 18" 7 cases of tuberculosis. If these figures we,'e applied to the population of "~Varsaw, the presumed morbidity rates for 1938 and 19.14 would be _0.8 per cent and 9"3 per cent respectively, a difference of 6" 5 per cent.