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Case 2: The foreign body that wasn't.

A one-year-old previously healthy girl was referred to a paediatric emergency department with a two-day history of cough and nasal discharge. There was no history of wheezing, feeding difficulties or recall of foreign body aspiration. On physical examination, she was alert and afebrile. Her heart rate was 124 beats/min, her respiratory rate was 32 breaths/min and her oxygen saturation was 98% on room air. There was no evidence of increased work of breathing. She weighed 7.0 kg, which placed her below the third percentile for her age. Normal heart sounds, although louder over the right hemithorax, were heard on cardiac auscultation. There were no murmurs heard. The trachea was midline. Bilateral diminished air entry was present with no wheezes or crackles heard, although breath sounds transmitted on the right side were harsh in quality. A chest radiograph revealed a hyperinflated left lung with a mediastinal shift to the right (Figure 1). The hyperlucent lung suggested a ball-valve effect, raising the possibility of a foreign body aspiration in the left mainstem bronchus, but subsequent bronchoscopy did not reveal a foreign body. Further investigation established the diagnosis. 
 
 
 
Figure 1) 
 
Posterior to anterior chest radiograph revealing hyperinflation of the left lung with a mediastinal shift to the right