foreign body aspiration ( fba ) is the most common cause of intra - luminal airway abnormalities in children . however , fba is unusual in adults and is often overlooked as a cause of airway obstruction . fba has variable clinical manifestations , ranging from trivial symptoms to irreversible lung damage and life - threatening infection and massive hemoptysis . radiographic findings of aspiration include lobar or segmental collapse , recurrent pneumonia , bronchiectasis and an endobronchial mass . a chronic inflammatory reaction with granulation tissue formation around the inhaled foreign body may mimic bronchogenic carcinoma . we report two cases of accidental aspiration of the same brand of calcium tablet manifesting in different ways . a 62-year - old non - smoking woman presented with a one - week history of cough , yellowish sputum , fever of 38.3c and right - sided pleuritic chest pain . she also gave a four - month history of dyspnoea and reported a weight loss of 8 kgs . her past medical history was notable for invasive ductal right breast adenocarcinoma , 14 months prior treated with right mastectomy , axillary lymph node resection and radiotherapy . she was also hypercholesterolemic and osteoporotic , and treated with simvastatin , calcium carbonate and sodium alendronate . chest radiograph initially was reported as normal , however on careful inspection a small round opacity is visible at the level of the right hilum respiratory examination revealed evidence of a small right - sided pleural effusion . blood investigations showed an elevated white blood cell count ( wbc ) of 16.28 x10/l , hemoglobin of 10.6 g / dl , platelets of 342,000 , and esr of 92 mm . biochemistry of the pleural fluid revealed : protein of 45.8 g / dl , albumin of 22.4 g / dl and lactic dehydrogenase of 1,610 u / l ( normal < 200 chest radiograph at presentation showed a right lower zone consolidation associated with a pleural effusion a diagnosis of right lower lobe pneumonia and a parapneumonic effusion was made following initial evaluation . the patient was started on intravenous cefuroxime axetil 750 mg three times daily and oral clarithromycin 500 mg twice daily . however , due to lack of improvement after three days of therapy , her antibiotic regime was changed to intravenous piperacillin sodium - tazobactam 4.5 g three times daily . the patient 's clinical condition improved within 24 hours and the effusion resolved after 14 days of antibiotic treatment . at the four - week follow - up visit , the patient brought along with a whole tablet of calcium carbonate that she had coughed prior to the visit . on further questioning , she recalled an accident during which she had choked on the tablet several months before . a follow - up ct scan of thorax ten weeks after her hospitalization was normal . a 74-year - old woman was admitted with recurrent episodes of fever associated with non - purulent productive cough of a few months duration . clinical examination revealed fever of 38c , decreased air entry over the right lung base and a monophonic wheeze over the right mid - chest zone . a chest radiograph and a ct scan of thorax showed a tablet lodged in the right lower lobe bronchus and right lower lung segmental consolidation . the patient was started on intravenous clindamycin 450 mg six hourly , ciprofloxacin 200 mg twice daily and meropenem 1 g three times daily and intensive chest physiotherapy . the right lower lobe bronchus was occluded with a hard , whitish mass surrounded by erythematous mucosa and granulation tissue . a rigid bronchoscopy thereafter showed granulation tissue over the embedded foreign body . a second attempt at rigid bronchoscopy successfully retrieved and removed fragments of the calcium tablet and allowed visualization of the right lower lobe bronchi . a 62-year - old non - smoking woman presented with a one - week history of cough , yellowish sputum , fever of 38.3c and right - sided pleuritic chest pain . she also gave a four - month history of dyspnoea and reported a weight loss of 8 kgs . her past medical history was notable for invasive ductal right breast adenocarcinoma , 14 months prior treated with right mastectomy , axillary lymph node resection and radiotherapy . she was also hypercholesterolemic and osteoporotic , and treated with simvastatin , calcium carbonate and sodium alendronate . chest radiograph initially was reported as normal , however on careful inspection a small round opacity is visible at the level of the right hilum respiratory examination revealed evidence of a small right - sided pleural effusion . blood investigations showed an elevated white blood cell count ( wbc ) of 16.28 x10/l , hemoglobin of 10.6 g / dl , platelets of 342,000 , and esr of 92 mm . biochemistry of the pleural fluid revealed : protein of 45.8 g / dl , albumin of 22.4 g / dl and lactic dehydrogenase of 1,610 u / l ( normal < 200 chest radiograph at presentation showed a right lower zone consolidation associated with a pleural effusion a diagnosis of right lower lobe pneumonia and a parapneumonic effusion was made following initial evaluation . the patient was started on intravenous cefuroxime axetil 750 mg three times daily and oral clarithromycin 500 mg twice daily . however , due to lack of improvement after three days of therapy , her antibiotic regime was changed to intravenous piperacillin sodium - tazobactam 4.5 g three times daily . the patient 's clinical condition improved within 24 hours and the effusion resolved after 14 days of antibiotic treatment . at the four - week follow - up visit , the patient brought along with a whole tablet of calcium carbonate that she had coughed prior to the visit . on further questioning , she recalled an accident during which she had choked on the tablet several months before . a follow - up ct scan of thorax ten weeks after her hospitalization was normal . a 74-year - old woman was admitted with recurrent episodes of fever associated with non - purulent productive cough of a few months duration . clinical examination revealed fever of 38c , decreased air entry over the right lung base and a monophonic wheeze over the right mid - chest zone . a chest radiograph and a ct scan of thorax showed a tablet lodged in the right lower lobe bronchus and right lower lung segmental consolidation . the patient was started on intravenous clindamycin 450 mg six hourly , ciprofloxacin 200 mg twice daily and meropenem 1 g three times daily and intensive chest physiotherapy . the right lower lobe bronchus was occluded with a hard , whitish mass surrounded by erythematous mucosa and granulation tissue . a rigid bronchoscopy thereafter showed granulation tissue over the embedded foreign body . a second attempt at rigid bronchoscopy successfully retrieved and removed fragments of the calcium tablet and allowed visualization of the right lower lobe bronchi . these two cases demonstrate aspiration episodes in elderly patients from the same brand of calcium tablet prescribed for osteoporosis . one of the patients clearly recalled choking on her tablet , whereas the other failed to recall the aspiration episode making the diagnosis of fba more difficult . the other difference was that while one coughed up her tablet some months after aspiration , the other did not due to local impaction of the calcium tablet . a detailed history as well as entertaining a high index of suspicion is necessary in arriving at the correct diagnosis of aspiration . fba is usually associated with conditions causing abnormalities in upper airway protective mechanisms , poor dentition , dental procedures , mental retardation , neurological disorders , impaired level of consciousness , alcohol and sedative abuse . up to two thirds of foreign bodies passing through the vocal cords lodge at the carina or the right main bronchus ( due to its more vertical orientation and slightly larger diameter ) but smaller ones may reach more distal airways . the symptoms and signs of fba depend on the site , size , composition and period for which the foreign body has been lodged . however , aspiration of toxic foreign bodies and tablets can lead to local airway inflammation . several cases of toxic fba are reported from aspiration of ferrous sulphate , aspirin , bismuth , tetracycline , phenobarbitone and charcoal . . complications of tablet aspiration range from haemoptysis , bronchiectasis , recurrent pneumonia , lung abscess , empyema , bronchiolitis obliterans , pneumothorax , pneumomediastinum , middle lobe syndrome to bronchial necrosis , bronchial stenosis , fatal pneumonia and respiratory failure . a chest radiograph taken in expiration is helpful in the diagnosis of a radio - opaque foreign body . radiolucent foreign bodies may be associated with lobar pneumonia , atelectasis , compensatory emphysema or air trapping in partial bronchial obstruction . the rigid bronchoscope remains the ideal instrument for retrieval of large foreign bodies from the main bronchi as this technique ensures better access , oxygen delivery and easy passage of grasping forceps . flexible bronchoscopy is useful in the diagnosis and the retrieval of smaller foreign bodies in the peripheral smaller bronchi .
two clinical cases of aspiration are reported in elderly ladies with differing presentations following inhalation of the same brand of calcium tablet . 
 one of the patients distinctly recalled the choking episode , whereas the other failed to do so making the diagnosis of aspiration difficult . 
 one of the aspirated tablets was successfully retrieved during rigid bronchoscopy after the patient reported several months of cough requiring multiple courses of antibiotics . 
 the other aspirated tablet was coughed up by the patient after the successful treatment of a pneumonia complicated by a parapneumonic effusion .