Foreign Body Aspiration Presenting as Croup: 2 Cases

A mother telephoned on a Friday at 4:30 pm during peak cold and flu season. She said that her 9-month-old boy had had a croupy cough for the last 4 to 5 days. She said the child was otherwise healthy, with no significant rhinorrhea, fever, or difficulty breathing. His past medical history was normal except for a few episodes wheezing.

While I had the diagnosis of viral croup or asthma in mind, the mother was hesitant to bring the boy to the office; she was advised to take him to the nearby emergency department. Because of the child’s uncertain immunization status and history of wheezing, I asked for neck and chest radiographs. A short time later the radiologist called to inform me that a foreign body had been detected on radiographs at the thoracic inlet (A).

Upon further questioning at the hospital, the mother denied any significant rhinorrhea, episodes of choking, difficulty in breathing, or any significant difficulty swallowing in her child. The boy was transported to tertiary care facility for foreign body removal.

In hindsight, the mother’s description during our initial phone call of the boy’s persistent cough in the absence of rhinorrhea, fever, and stridor could have alerted me to the possibility of foreign body aspiration.

In a separate recent case, a 5-year-old girl who had been playing and drinking on her bed was found by her father gasping on the floor. The father, assuming a head injury or a seizure, called 911. The girl was resuscitated during transport to the emergency department, where she received a diagnosis of head injury.

After discharge, the child developed a cough, however, for which she was seen in my office a day later.

On presentation, the girl had a croupy cough. She had no history of rhinorrhea or fever, but she was in respiratory distress. Her past medical history was unremarkable except for asthma. Radiographs revealed an aspirated foreign body (B).

Routine imaging in typical viral croup cases is not necessary. However, alternative diagnoses and imaging studies should be considered in children presenting with a croupy cough who are outside the typical age range for croup (approximately 6 months to 6 years) or in whom stridor persists for longer than 1 week. I found the absence of rhinorrhea and fever helpful in these two cases; poor response to empiric treatment also should prompt consideration of diagnoses other than croup, including possible foreign body aspiration.