Ann Thorac Surg 2008;86:1686-1688. doi:10.1016/j.athoracsur.2008.04.060
© 2008 The Society of Thoracic Surgeons
Case Reports
Intrabronchial Foreign Body Extracted With Tranilast and Corticosteroid
Yasuji Terada, MDa,*,
Yasuto Sakaguchi, MDa,
Tomoya Kono, MDa,
Jun Nohara, MDb,
Tetsuo Noguchi, MDb
a Department of Thoracic Surgery, Nagahama City Hospital, Nagahama, Japan
b Department of Respiratory Medicine, Nagahama City Hospital, Nagahama, Japan
Accepted for publication April 16, 2008.
* Address correspondence to Dr Terada, Department of Thoracic Surgery, Nagahama City Hospital, 313 Oinui-cho, Nagahama, 526-8580, Japan (Email: yaterada{at}ex.biwa.ne.jp).
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Abstract
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We present a case of intrabronchial foreign body buried in granulation tissue, which was successfully extracted administrating tranilast (n-[3,4-dimethoxycinnamoyl] anthranilic acid), suppressing collagen synthesis by fibroblasts in keloid and hypertrophic scars, and corticosteroid. Bronchoscopy of a 74-year-old man showed the nail was buried in reactive granulation tissue and could not be observed from the surface. Tranilast at 300 mg/day and methylprednisolone at 250 mg/day were prescribed for 4 days, followed by a reduction of the corticosteroid to 40 mg/day for 3 days. Seven days later, the granulation tissue and mucosal edema were diminished, and the nail was successfully extracted.
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Introduction
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Removal of a foreign body from the airway is usually performed using a flexible or rigid bronchoscope. However, there are some cases in which this is difficult because of the presence of reactive granulation tissue. Tranilast (n-[3,4-dimethoxycinnamoyl] anthranilic acid) is usually used for the treatment of allergic diseases, and it suppresses collagen synthesis by fibroblasts in keloid and hypertrophic scars. We present a case of intrabronchial foreign body buried in granulation tissue, which was successfully extracted after administration of tranilast and corticosteroid.
A 74-year-old man visited our hospital with a 2-month history of persistent nonproductive cough. His medical history revealed nothing of significance. He was employed as a carpenter, and during his work had often held nails between his lips. A chest roentgenogram revealed a nail of 2-cm long in the right middle bronchus (Fig 1). Subsequent bronchoscopy revealed that the nail was buried in reactive granulation tissue with edematous mucosa, and could not be observed from the surface (Fig 2A). Tranilast and methylprednisolone were prescribed at 300 mg/day and 250 mg/day, respectively, for 4 days, followed by a reduction of the corticosteroid to 40 mg/day for 3 days. Seven days later, the granulation tissue and mucosal edema had diminished (Fig 2B), and the edge of the rusty nail could be seen embedded in the right B5 bronchus. The nail, which had become swollen with rust in the reactive granulation tissue, was extracted (Fig 3) using the forceps of a flexible bronchoscope.
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Fig 2. The orifice of the right middle lobe bronchus was occluded by granulation tissue and mucosal swelling, thus obscuring (A) the foreign body. After the therapy, the granulation tissue and edema were diminished sufficiently to allow observation of (B) the embedded nail.
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Fig 3. The extracted nail was swollen with rust, some of which can be seen on the right after becoming detached during extraction with the forceps.
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Comment
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Removal of a foreign body lodged in the airway is usually performed immediately after an episode of accidental swallowing. However, when symptoms are not severe, a foreign body may only be found after several months. In such a case, it is difficult to extract the foreign body because of reactive granulation tissue. To extract a foreign body that is encased in granulation tissue, resection or reduction of the granulation tissue is necessary, and in some cases thoracotomy may be required. Debulking of a granuloma may be performed using techniques such as laser photoresection, electrocautery, cryotherapy, argon plasma coagulation, or mechanically by using a rigid bronchoscope. However, this carries a risk of massive airway hemorrhage, which is also stressful for the patient. Reduction of granulation tissue with bronchoscopic intralesional injection of triamcinolone acetonide has been reported [1], but it is difficult to inject the agent into the deep part of the granuloma.
Tranilast has been used clinically for the treatment of patients with allergic conditions such as bronchial asthma, allergic rhinitis, and atopic dermatitis, or with proliferative diseases such as keloid and hypertrophic scars. It suppresses collagen synthesis by fibroblasts in keloid and hypertrophic scars by inhibiting the release of transforming growth factor-β1, which enhances the synthesis of collagen [2]. It also modulates the fibrosis and contraction of granulation tissue by inhibiting the growth of myofibroblast-like cells and fibroblasts [3]. There are some reports of the use of tranilast to reduce granulation tissue in the airway [4, 5], and tranilast administration has been recommended for reduction of granulation tissue in all parts of the airway, such as at sites of anastomosis or tracheostomy. Corticosteroid also suppresses fibroblast proliferation and collagen synthesis, and its addition to tranilast administration is believed to enhance the granuloma reduction effect. In our patient, administration of these drugs for 1 week reduced the reactive granulation tissue sufficiently to allow extraction of the foreign body without any side effects or distress to the patient. Therefore, the combination of tranilast and corticosteroid is believed to be an effective regimen for reduction of reactive granulation tissue in the airway.
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References
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- Niwa T, Nakamura A, Kato T, et al. Bronchoscopic intralesional injection of triamcinolone acetonide treated against bronchial obstruction caused by peanut aspiration Respir Med 2005;99:645-647.[Medline]
- Suzawa H, Kikuchi S, Arai N, Koda A. The mechanism involved in the inhibitory action of tranilast on collagen biosynthesis of keloid fibroblasts Jpn J Pharmacol 1992;60:91-96.[Medline]
- Isaji M, Aruga N, Naito J, Miyata H. Inhibition by tranilast of collagen accumulation in hypersensitive granulomatous inflammation in vivo and of morphological changes and functions of fibroblasts in vitro Life Sci 1994;55:PL287-PL292.[Medline]
- Sato M, Terada Y, Nakagawa T, Li M, Wada H. Successful use of argon plasma coagulation and tranilast to treat granulation tissue obstructing the airway after tracheal anastomosis Chest 2000;118:1829-1831.[Medline]
- Yanagihara K, Matsuoka K, Hanaoka N, Toda K, Muro K. Inflammatory endobronchial stenosis Ann Thorac Surg 2001;71:698-699.[Abstract/Free Full Text]
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Abstract
Introduction
