A 12-year-old boy (from a rural area) was presented to our hospital with shortness of breath, cough, purulent sputum and hemoptysis. He had a history of recurrent respiratory tract infections that were resolved with antibiotics. He had a history of chest trauma, after falling from a tree five years back (Figure 1). His treatment was done in a private hospital at the time of trauma and chest drainage tube was placed and improved. But patient had episodes of recurrent fever, purulent sputum and later on hemoptysis. Repeated chest X-rays showed opacity in right lower lung fields (Figure 2). He was given multiple courses of antibiotics but failed to improve. He was then started on ATT suspecting pulmonary tuberculosis. But he had recurrent infections and hemoptysis despite anti tubercular treatment. Patient was referred to cardiothoracic unit of our institute for further management. He was investigated and repeat chest X-rays revealed an area of hyperdensity in right lower lobe lung fields. CECT Thorax was done which was suggestive of consolidation with multiple cavities formation in right lower lobe with right sided pleural collection with single linear hyper-dense focus with CT value of 190 HU(bony fragment/foreign body) with adjacent pleural thickening (Figure 3). A thoracotomy with removal of two wooden foreign bodies was done. Peroperatively two wooden foreign bodies were removed–one from anterior basal and another from posterior basal segment of right lower lobe, each measuring 4x2 cm (Figures 4–6). The lung parenchyma was having two pieces of wood, which were enveloped in granulation tissue and fibrosis although CECT reported only a single foreign body. Postoperatively patient improved uneventfully and discharged. He was doing well till the time of last follow up.

Although aspiration of a wooden foreign body into the tracheobronchial tree is not uncommon, [11] pulmonary parenchymal wooden foreign bodies are quite rare. Most parenchymal wooden foreign bodies are a result of trauma, and the diagnosis is made on the basis of the history and physical examination at the time of presentation. [2] Pulmonary wooden parenchymal foreign bodies are a rare cause of chronic lung disease and infrequently are considered in a differential diagnosis of pulmonary opacities on chest radiographs. [1] Despite advances in imaging techniques, the detection of retained wooden foreign bodies remains a difficult and challenging task. [12] The detection of wood is especially important because it may serve as an unrecognized nidus for infection [8]. Wood, with its porous consistency and organic nature, is an excellent medium for microorganisms. The retained foreign bodies may result in abscess, fistula formation [3] and hemoptysis. [4] [5] [6] Our patient was unaware of his pulmonary wooden foreign body and the treating physicians also failed to keep a possibility of a foreign body in the chest even when the patient did not improve after prolonged treatment including anti-tubercular therapy until the CECT was done five years after the trauma. The injury most likely occurred while the patient fell from a tree on the ground and a wooden fragment impaled her chest. In patients with recurrent uni-focal pneumonia, an underlying problem such as a foreign body should be considered. [8] Wooden fragments account for the largest proportion of retained foreign bodies after trauma to the human body. [13] Radiographs have been reported to revealed wooden foreign body in only 15% of patients. [13] CECT scan showed that the abnormality had consistency which could be a single piece of bone or foreign body. CT scan has been proved to be useful in the evaluation of suspected wooden matter. Brewer and Leonard [14] stated that CT scans are the most sensitive tool available for the detection of wooden foreign bodies in lacerations on puncture wounds. The attenuation of a retained wooden foreign body varies in relation to the content of air and fluid in the interstices of the wood. Within approximately one week, the wood absorbs blood products and exudates and increases its attenuation. [15] Dry wood, with high air content, has been reported to mimic a gas collection [7]. Bodne et al. [16] cited three cases of wooden foreign bodies with various attenuation values, ranging from close to air in acute cases to high (near to calcium) in chronic cases. In our case, the attenuation value of the wood particle was 190 HU, which is a high density near to calcification.

In our opinion, pulmonary wooden foreign bodies must not be treated conservatively and operated as soon as possible because they can serve as a nidus for recurrent infection. Also one should look for multiple foreign bodies although CT scan may report just single foreign body.

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