CASE REPORT


https://doi.org/10.5005/jp-journals-10030-1435
Panamerican Journal of Trauma, Critical Care & Emergency Surgery
Volume 12 | Issue 03 | Year 2023

Migration of Retained Bullet Fragments Inducing Recurrent Hemoptysis: A Case Report


Mackenzie Snyder1, Thomas Scalea2, Sayuri P Jinadasa3

1University of Maryland School of Medicine, Baltimore City, Maryland, United States

2R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore City, Maryland, United States

3Division of Acute Care Surgical Services, Department of Surgery, VCU Health, Richmond, Virginia, United States

Corresponding Author: Sayuri P Jinadasa, Division of Acute Care Surgical Services, Department of Surgery, VCU Health, Richmond, Virginia, United States, Phone: 8048271207, e-mail: sayuri.jinadasa@vcuhealth.org

Received: 31 July 2023; Accepted: 18 November 2023; Published on: 30 December 2023

ABSTRACT

Aim: We present a case of bullet fragments migrating into the endotracheal space and discuss the assessment of patients with retained bullets.

Background: Many patients who have sustained a gunshot wound (GSW) have retained bullets. Bullets that are not encountered during operative management are rarely removed because of the secondary injuries and complications that removal can cause. Bullets rarely migrate, and thus, the secondary complications from migration are not often considered when patients later present with complications.

Case description: A patient initially presented with multiple GSWs and had several retained bullets and bullet fragments in the mediastinum. Over the next 3 years, he presented numerous times with hemoptysis, cough, and chest pain but no clear etiology. Eventually, it was recognized that a collection of bullet fragments had eroded through the tracheal wall.

Conclusion: Migration of bullets and/or bullet fragments into the bronchi or trachea should be considered in patients who have a history of GSW to the mediastinum and present with hemoptysis or pneumonia.

Clinical significance: This patient presentation shows that bullet migration can occur at any time after injury, and delays in considering the diagnosis and initiating the appropriate workup can result in a delay in diagnosis.

How to cite this article: Snyder M, Scalea T, Jinadasa SP. Migration of Retained Bullet Fragments Inducing Recurrent Hemoptysis: A Case Report. Panam J Trauma Crit Care Emerg Surg 2023;12(3):162–164.

Source of support: Nil

Conflict of interest: None

Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.

Keywords: Case report, Gunshot wound, Hemoptysis, Retained bullet migration, Retained bullet

BACKGROUND

Patients with retained bullets can experience pain and damage to surrounding structures in the years following injury.1 While retained bullets are typically enveloped in a fixed fibrous capsule, they can migrate, causing damage to surrounding tissue and organs.2 Most patients do not undergo removal of retained ballistics as the removal itself increases the risk of neurovascular injury, infection, thrombosis, and bleeding.3 In this case report, we present a rare case of bullet migration into the trachea 3 years following initial injury.

CASE DESCRIPTION

A 36-year-old male initially presented to our urban level 1 trauma center in 2017 with multiple gunshot wounds (GSWs) to his chest, abdomen, pelvis, and right arm. He underwent bilateral chest tube placement, left nephrectomy, splenectomy, distal pancreatectomy, and open reduction and internal fixation of the right radius and ulna. A chest X-ray during his initial admission demonstrates a retained ballistic on the right side of the trachea (Fig. 1A). Computed tomography (CT) imaging performed during this admission revealed ballistic fragments in the right anterior chest, anterior to T1, and right superior retrotracheal space (Fig. 2). Following a 32-day hospital stay, he was discharged to a rehabilitation facility.

Figs 1A to C: (A) Chest X-ray during index hospitalization; (B) Chest X-ray from emergency department visit for central chest pain that worsened with inspiration approximately 20 months after initial hospitalization; (C) Chest X-ray from emergency department visit for hemoptysis in 2021

Fig. 2: Computed tomography (CT) chest performed on admission during index hospitalization; arrow indicates retrotracheal bullet fragments

In 2019, approximately 20 months after his initial hospitalization, the patient presented to the emergency department with complaints of central chest pain that worsened with inspiration. Physical exam revealed tenderness of the anterior left chest. A chest X-ray showed several bullet fragments within the right lung field that were new compared to prior X-rays as well as slight migration of left chest bullet (Fig. 1B). He was diagnosed with chest wall irritation from the existing bullet fragments and was discharged home.

The patient continued to present to different emergency departments three additional times between 2019 and 2021. During these visits, he noted new symptoms of sore throat, cough, and hemoptysis, and lung exam revealed wheezing, stridor, and decreased lung sounds in the right lower lobe. An anterior-posterior chest X-ray was obtained during his fourth emergency department encounter (Fig. 1C). The retrotracheal bullet fragment appeared to be more medial on imaging compared to the X-ray obtained during his index hospitalization (Fig. 1A). The patient was diagnosed with bronchitis and a chronic obstructive pulmonary disease (COPD) exacerbation. He was treated accordingly without improvement of his symptoms.

In January 2021, approximately 3.5 years after his initial injury, he presented for a fifth time with cough, hemoptysis, chest pain, and shortness of breath. A CT of his chest was obtained, which showed that some of the retrotracheal bullet fragments from his initial hospitalization were now within the trachea at the level of the carina (Fig. 3). A flexible bronchoscopy was performed on hospital day 2, and a bullet fragment was removed from the carina (Fig. 4A). A healed mucosal defect was observed on the posterior wall of the mid trachea (Fig. 4B). This was presumably where the bullet fragment had eroded through the tracheal wall. The patient was discharged home on hospital day 3.

Fig. 3: Computed tomography (CT) chest showing bullet fragments at carina

Figs 4A and B: (A) Bronchoscopic view of fragmented bullet at carina; (B) Bronchoscopic view of healed mucosal defect in posterior trachea

At outpatient follow-up at the end of January 2021, approximately 2 weeks after the removal of the endotracheal bullet fragment, the patient reported resolution of his symptoms, including chest pain, shortness of breath, cough, and hemoptysis. A chest X-ray performed during this visit demonstrated absence of the endotracheal bullet fragment and stable position of other bullet fragments1.

DISCUSSION

Retained bullets in patients who have sustained a GSW are often thought to remain stationary over time. However, migration can occur, leading to complications involving the surrounding tissue and organs. The incidence of migration is poorly characterized but is estimated to be rare and occurs in <5% of cases.4 Bullets retained in soft tissue are enveloped in fibrous scar tissue5 and are less likely to have observed migration. Occasionally, retained missiles or fragments can erode into open tissue spaces years after initial injury.6 The symptoms that patients experience depend on the path of the migration and can present with severe organ or vascular damage.

Patients with bullets in their mediastinum are at increased risk for migration to the airways, yet only a few case reports exist. Of the published cases, all patients presented with hemoptysis from tissue damage and/or pneumonia due to endoluminal obstruction.7 These reported cases presented either quite early, within months of their injury, or in a very delayed fashion >7 years after injury.7 The patient we present experienced migration of bullet fragments into the trachea over a period of time from 19 months to approximately 3.5 years after injury, which is a time frame not previously reported. Treatments reported in the literature include lobectomy, pneumonectomy, and rigid bronchoscopy. Rarely patients have presented with spontaneous expectoration of bullets or fragments.

Our patient presented multiple times with the same complaint of cough, hemoptysis, chest pain, and shortness of breath, which were treated as bronchitis and COPD exacerbations despite no history of COPD. The treatments provided did not improve his symptoms; however, they were used multiple times. This resulted in a delay of diagnosis rather than prompting broadening the differential diagnosis. The delay in diagnosis was likely further lengthened by the patient’s presentation to the emergency room only rather than to his scheduled follow-up appointments with the trauma team and his primary care physician. The patient experienced a lengthy period of pain and respiratory symptoms but fortunately avoided other negative complications of bullet migration, including complete bronchial occlusion,8 recurrent postobstructive pneumonia,9 and even pulmonary artery embolism.10

When the patient began experiencing cough and hemoptysis, he did not receive imaging on the first three visits to the emergency department. While he received an X-ray at his fourth visit, it was a single anterior-posterior view and that did not allow for appreciation of subtle positional changes of the ballistic fragments, especially in the anterior-posterior direction. This case highlights the importance of obtaining imaging with multiple views in a patient presenting with hemoptysis and respiratory symptoms with known retained bullet fragments in the mediastinum. There is currently no reported case of migration to the airways without symptoms, so imaging is only indicated when patients present with clinical symptoms.

After removal of the bullet fragments, the patient had a persistent smaller collection of bullet fragments posterior to the trachea as seen on his final chest X-ray. Thus, this patient is still at risk of recurrent bullet fragment migration into the airway or other organs or soft tissue spaces. This fact will remain relevant to any future conditions he may develop.

Clinical Significance

This patient case illustrates that migration of bullet fragments into the airway should be included in the differential for any patient with retained mediastinal bullets who presents with cough, hemoptysis, chest pain, or shortness of breath.

Patients with retained bullets may present with symptoms secondary to migration from several months to many years after their initial injury. It is important that this diagnosis be considered in the differential of any patients with a history of thoracic GSW presenting with respiratory symptoms. Patients should be assessed with imaging that can visualize at least two different projections to detect migration with a low threshold to consider bronchoscopic evaluation.

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