Management of Esophageal Coin with Fever in a 4-Year-Old
This child requires urgent endoscopic removal within 24 hours, and if appearing ill or toxic, emergent removal within 2-6 hours with IV antibiotics initiated beforehand. The presence of fever after 10 days of coin retention is a red flag indicating potential pressure necrosis, perforation, or mediastinitis 1.
Immediate Assessment and Risk Stratification
Critical Clinical Evaluation
- Verify true fever by obtaining a rectal temperature ≥38.0°C (100.4°F), as this is the most reliable method in young children 1, 2.
- Assess for toxic appearance or serious illness, including difficulty swallowing, drooling, chest pain, respiratory distress, or signs of sepsis 1, 2.
- Document fever pattern (height, duration, response to antipyretics) as high fever ≥39°C suggests higher risk of bacterial complications 1, 2.
Immediate Diagnostic Workup
- Obtain chest X-ray (AP and lateral views) to confirm coin location and assess for mediastinal widening, pneumomediastinum, or pleural effusion suggesting perforation 1.
- Complete blood count with differential should be performed, as elevated WBC with left shift suggests bacterial infection or abscess formation 1.
- Blood culture should be obtained if the child appears ill or has high fever (≥39°C), as bacteremia can complicate esophageal perforation 1.
- C-reactive protein or procalcitonin may help risk-stratify for serious bacterial infection, though these should not delay definitive management 1.
Management Algorithm
Well-Appearing Child with Low-Grade Fever
- Urgent endoscopy within 24 hours is required even if the child appears well 1.
- Hospital admission is warranted given the 10-day duration and presence of fever, even if endoscopy shows only mild injury 1.
- The 10-day retention period significantly increases risk of complications, as prolonged esophageal foreign bodies can cause pressure necrosis leading to perforation 3, 4.
Ill-Appearing or Toxic Child
- Emergent endoscopy within 2-6 hours is necessary 1.
- Broad-spectrum IV antibiotics before endoscopy to cover oral flora and potential mediastinitis 1.
- Coins lodged in the esophagus can serve as a nidus for abscess formation, and fever may be the only presenting symptom of serious complications 4.
Post-Removal Management
If Minimal Injury Present
- Advance diet as tolerated and complete a short course of oral antibiotics if fever was present 1.
- Hospital observation is still recommended given the prolonged retention and fever 1.
If Significant Injury or Perforation Found
- Prolonged hospitalization with IV antibiotics and surgical consultation as needed 1, 4.
- Monitor for development of mediastinitis, abscess formation, or other complications 1, 4.
Critical Pitfalls to Avoid
- Do not delay endoscopy waiting for fever to resolve or for "observation" - the 10-day retention period with new fever mandates urgent intervention 1, 3.
- Do not assume low-grade fever is benign - even minimal fever in the context of prolonged foreign body retention can indicate serious complications 1, 4.
- Do not rely solely on clinical appearance - children with serious complications may appear relatively well initially 2, 3.
- Do not attempt conservative management (waiting for spontaneous passage) after 10 days with fever - this represents a failed conservative approach and requires active intervention 1, 3.
The case report of a 10-month-old with a penny retained for 1 month who developed fever and respiratory symptoms demonstrates that prolonged retention can lead to significant morbidity 3. In that case, immediate resolution occurred after removal, emphasizing the importance of timely intervention 3.