Abstract Foreign-body aspiration in adults is rare, accounting for less than one percent of pulmonary disease, yet it remains a classic masquerader.¹,² Risk is amplified by predisposing factors such as dysphagia, cricopharyngeal web, chronic lung disease, or neurologic impairment, while a clear history of aspiration is frequently absent. Chronic aspiration of organic material like betel nut (areca nut) can incite granulomatous inflammation, squamous metaplasia, and persistent consolidation, producing radiologic and histologic findings indistinguishable from cancer.5-7 Case Description A 78-year-old man with asthma, bronchiectasis, and a known cricopharyngeal web presented with progressive cough and right-sided chest pain. CT Chest (June 2025) demonstrated a right-upper-lobe consolidation with obstruction of RUL bronchus and mediastinal adenopathy concerning malignancy. Prior biopsies (2020) showed filamentous bacterial elements consistent with Actinomyces/Nocardia and reactive squamous changes, but no malignancy. Given new FDG-PET avidity, repeat bronchoscopy was performed and revealed complete obstruction of RUL bronchus with what appeared to be severe granulation tissue. Following cryodebridement of granulation tissue, two tan-brown intrabronchial foreign bodies (FB) were identified distally lodged into the anterior segment of the RUL bronchus. A size 4 fogarty balloon was inflated distally to the FB and was used to proximally dislodge it into the central airway. Extraction uncovered fragments of betel nut, and histopathology demonstrated ulceration, squamous metaplasia, and foreign-body giant-cell inflammation. Cultures again grew mixed oral flora. On reflection, the patient recalled chewing betel nut years earlier during travel to India, suggesting recurrent aspiration. Following removal and antibiotics, both symptoms and radiographic findings resolved entirely (CT chest July 2025). Discussion This case illustrates how chronic aspiration can convincingly mimic endobronchial malignancy—clinically, radiographically, and pathologically.4-6 Chronic aspiration of vegetable matter provokes granulation tissue and metaplastic epithelium, as described by Mukhopadhyay and Katzenstein in their seminal series of aspiration-related lung disease.4 Inflammatory hypermetabolism further produces false-positive PET uptake, a phenomenon well-documented in aspiration pneumonia and organizing pneumonia.5,6 Radiologically, retained betel nut is often radio dense but obscured by post obstructive consolidation, and when coupled with reactive lymphadenopathy, it becomes virtually indistinguishable from carcinoma.7-9 The clinical deception is amplified in older adults, where recurrent aspiration events may be silent, chronic, and progressive.10 Bronchoscopy remains the defining diagnostic and therapeutic tool, with high safety and yield even in elderly patients.11 Our patient’s case is singular in demonstrating recurrent aspiration events separated by years, each mimicking neoplastic disease on imaging and histology. This abstract is funded by: None
Arif et al. (Fri,) studied this question.