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\begin{document}

\title{Pneumonectomy in a child for destructed lung secondary to lithium
batterie ingestion}



\author[1]{Rosário Stilwell}%
\author[1]{Claudia Silva}%
\author[1]{Rui Alves}%
\author[1]{Isabel Afonso}%
\author[2]{Paulo Calvinho}%
\author[1]{Ana Casimiro Malta}%
\affil[1]{Hospital Dona Estefania}%
\affil[2]{Hospital de Santa Marta}%


\vspace{-1em}



  
  \date{June 18, 2024}


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\selectlanguage{english}
\begin{abstract}
Unperceived lithium battery ingestion in infants might be associated
with significant morbidity, especially when medical assistance is
restricted.%
\end{abstract}%



\sloppy


\textbf{Title:} Pneumonectomy in a child for destructed lung secondary
to lithium batterie ingestion

\textbf{Authors :}

Ros\selectlanguage{ngerman}ário Stilwell, MD

Unidade de Pneumologia Pediátrica. Centro Hospitalar Universitário
Lisboa Central -- Hospital Dona Estefânia. Portugal.

Claudia Silva, MD

Unidade de Pneumologia Pediátrica. Centro Hospitalar Universitário
Lisboa Central -- Hospital Dona Estefânia. Portugal.

Rui Alves, MD

Unidade de Cirurgia Pediátrica. Centro Hospitalar Universitário Lisboa
Central -- Hospital Dona Estefânia. Portugal.

Isabel Afonso, MD

Unidade de Gastroenterologia Pediátrica. Centro Hospitalar Universitário
Lisboa Central -- Hospital Dona Estefânia. Portugal.

Paulo Calvinho, MD

Unidade de Cirurgia Torácica. Centro Hospitalar Universitário Lisboa
Central -- Hospital de Santa Marta. Portugal.

Ana Casimiro Malta, MD

Unidade de Pneumologia Pediátrica. Centro Hospitalar Universitário
Lisboa Central -- Hospital Dona Estefânia. Portugal.

\textbf{Correspondent author}

Rosário Stilwell

Hospital Dona Estefânia, CHULC -- EPE

Rua Jacinta Marto, 1169-045 Lisbon, Portugal

Phone: +351916149491

Fax: +351213126667

e-mail:\emph{maria.stilwell@chlc.min-saude.pt}

\textbf{Keywords:} Pneumonectomy, destructed lung, lithium battery
ingestion

\textbf{Paper presented at:} Jornadas da Sociedade Portuguesa de
Pneumologia Pediátrica e do Sono

\textbf{Short title:} Pneumonectomy in a child post-lithium battery
ingestion

To the Editor,

Unperceived lithium battery ingestion in infants might be associated
with significant morbidity, especially when medical assistance is
restricted.

We report the case of a girl aged 3 transported from rural area of
underdeveloped african country for medical investigation of one year
evolution of vomiting, cough, and growth arrest. On the emergency
department physical exam she was normoxemic, had abundant respiratory
purulent secretions and weight below the third percentile for age.
Pulmonary sounds were abolished on the left and there were crackles on
the right. Chest radiograph (Figure 1) showed a round foreign body on
the medial chest with double halo sign and left lung infiltrate
hypotransparency. Chest CT (figure 2-A) confirmed a lithium battery in
the proximal oesophagus, mediastinitis, right lung consolidation and
left lung atelectasis. Endoscopy revealed oesophagus fistula to the left
bronchus. The battery was removed and the fistula closed with
pericardical patch and a gastrostomy constructed. Invasive ventilation
was suspended seven days after surgery, with gradual progression to
nocturnal non-invasive ventilation without hypoxemia. Right lung
pneumonia resolved three weeks of empirical treatment with meropenem and
vancomycin. She started enterical nutrition three weeks post-fisula
closure with tolerance, progression and parenteral nutrition suspension
after two months. Oesophagal post-procedural fistula, stenosis or
dysmotility were excluded. Autonomous feeding was possible after four
months. After 10 months, Chest CT (Figure 2-B) still exhibited left lung
complete lung parenchyma destruction. Pneumonectomy and gastrostomy
closure were performed without complications and rapid recovery was
observed. Nocturnal non-invasive ventilation was suspended a week after
pneumectomy. She is growing and gaining weight on 5th percentile without
pulmonary hypertension, infections, or chest deformation. (Figure 3) She
was able to return to her family after 14 months.

Lithium batteries ingestion has increased as result of to the increasing
accessibility of electronic toys and devices to children Parental
recognition, medical follow up and intervention are crucial to prevent
and reduce morbidity and mortality. It might be associated with life
threatening complications like oesophagobronchial fistula. In our
patient unrecognised ingestion and chronic fistula resulted in left lung
permanent destruction.

Destroyed lung refers to an extensive lung parenchyma lesion that rises
from chronic inflammatory lesion. It is rare in children and is mostly
caused by bronchiectasis, tuberculosis, and cystic fibrosis. When single
lung is affected, most patients have minor symptoms in basal state.
However this condition might be associated with acute life-threatening
complications such as massive haemoptysis, empyema, secondary fungal
infections, secondary amyloidosis, septicaemia, and pulmonary-systemic
shunting.

Children can easily tolerate pneumonectomy and the remaining lung
expands to compensate the ressection. Eren et al, and Kosar et al.,
report good exercise tolerance, higher lung volumes, better nutritional
status and quality of life, without major skeletal deformation in the
long term follow-up of children after pneumonectomy for destroyed lung.

In conclusion, lithium battery ingestion might have severe consequences
to child health of which clinicians should be aware attending to the
increasing exposure of children do electronic devices. Pneumonectomy is
a complex and invasive procedure, in this case it positively contributed
to prevent potential life-threatning complications to the patient and
allowed she to return to her origin country without significant health
restrictions.

\begin{enumerate}
\tightlist
\item
  Marom, T., Goldfarb, A., Russo, E. \& Roth, Y. Battery ingestion in
  children. \emph{Int J Pediatr Otorhinolaryngol} \textbf{74} , 849--854
  (2010).
\item
  Osarenkhoe, J., Aiwuyo, H., Aisosa, O. \& Ejiroghene, U. Destroyed
  Lung Syndrome: A Review of 31 Published Cases. \emph{Open Journal of
  Respiratory Diseases} \textbf{12} , 37--43 (2022).
\item
  Blyth, D. F., Buckels, N. J., Sewsunker, R. \& Soni, M. A.
  Pneumonectomy in children. \emph{European Journal of Cardio-Thoracic
  Surgery} \textbf{22} , 587--594 (2002).
\item
  Eren, \selectlanguage{polish}Ş., \selectlanguage{english}Eren, M. N. \& Balc\selectlanguage{polish}ı, \selectlanguage{english}A. E. Pneumonectomy in children for
  destroyed lung and the long-term consequences. \emph{J Thorac
  Cardiovasc Surg} \textbf{126} , 574--581 (2003).
\item
  Kosar, A., Orki, A., Kiral, H., Demirhan, R. \& Arman, B.
  Pneumonectomy in Children for Destroyed Lung: Evaluation of 18
  Cases.\emph{Ann Thorac Surg} \textbf{89} , 226--231 (2010).
\end{enumerate}

\textbf{Authors:} Ros\selectlanguage{ngerman}ário Stilwell \textsuperscript{1}, Cláudia
Silva\textsuperscript{1}, Rui alves \textsuperscript{2}, Isabel
Afonso\textsuperscript{3}, Paulo Calvinho\textsuperscript{4}, Ana
Casimiro Malta \textsuperscript{1}

\begin{enumerate}
\tightlist
\item
  Unidade de Pneumologia Pediátrica. Centro Hospitalar Universitário
  Lisboa Central -- Hospital Dona Estefânia. Portugal.
\item
  Unidade de Cirurgia Pediátrica. Centro Hospitalar Universitário Lisboa
  Central -- Hospital Dona Estefânia. Portugal.
\item
  Unidade de Gastroenterologia Pediátrica. Centro Hospitalar
  Universitário Lisboa Central -- Hospital Dona Estefânia. Portugal.
\item
  Unidade de Cirurgia Torácica. Centro Hospitalar Universitário Lisboa
  Central -- Hospital de Santa Marta. Portugal.
\end{enumerate}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

Figure 1 -- Admittion X-ray showing medial radiopaque round foreign body
with double halo sign, typical of round littium batteries; mediastinum
enlargement with left lung extensive hypotransparency and infiltrate
granulomatous infiltrate of the right lung\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/Sem-tituloII}

\end{center}
\end{figure}

(A)\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/Sem-tituloIII}

\end{center}
\end{figure}

(B)

Figure 2 -- Chest CT. At admittion (A) - showing lithium battery in
proximal oesophagus; probable oesophagus fistula; chronic mediastinitis
without collection, abcess or pneumomediastinum; right lung
consolidation of the superior and inferior lobes; reduced caliber
various left main bronchus with complete atelectasia of the left lung,
multiple cystic and varicous bronchiectasis; left non fibrous pleural
effusion and left mediastinum deviation. Ten months after fistula
closure, (B) showing complete fibrose of the left lung parenchyma with
multiple varicose bronchiectasia, left mediastinal deviation without
pleural effusion; right lung with preserved parenchyma with moderate
expansion\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}

(A)\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image5/Sem-tituloIV}

\end{center}
\end{figure}

(B)

Figure 3 - Three months post-pneumectomy. Chest wall (A) without major
deformaties. Chest X- Ray (B) with residual pleural effusion on the
left,

\selectlanguage{english}
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\end{document}

