Purpose or Case Report: In a child with escalating hemoptysis, negative TB testing, and history of penetrating thoracic trauma, chronic inflammation and vascular injury as a result of radiolucent foreign body should be considered.
Methods & Materials: A previously healthy 8.5 year old female presented with 10 months of escalating hemoptysis, prompting admission to an outside facility.

18 months prior to the onset of hemoptysis, the patient was playing hide and seek among pine trees, which resulted in wooden pine needles penetrating her anterior chest. Her parents removed part of one, but they felt it broke off and brought her to the ER, where she underwent bedside and subsequently surgical exploration of the anterior chest wall. No foreign body was identified. Radiography revealed no radiopaque foreign body.

She underwent multiple tests for TB, with all results negative. She was empirically started on 4 drug TB therapy given radiographic findings of chronic consolidation in the right upper lobe. Laboratory data was otherwise significant for anemia.
Results: She underwent CTA at our institution, which revealed pseudoaneurysm of the ascending aorta with a subtle linear filling defect at this level. There was adjacent soft tissue thickening in the mediastinum and consolidation within the anterior right upper lobe. Associated lymphadenopathy was also noted. Right bronchial artery hypertrophy was also present.

These findings in combination were suspicious for traumatic injury to the ascending aorta with pseudoaneurysm formation, either as a consequence of radiolucent foreign body or chronic inflammatory state secondary to foreign body in adjacent lung parenchyma with formation of a mycotic aneurysm.

Preoperatively, the patient went to angiography for embolization of the right bronchial artery and diagnostic aortogram to confirm the CT findings.

At surgery, a 5cm wooden pine needle was recovered from the patient's right upper lobe, and the aortic pseudoaneurysm was repaired with a pericardial patch.

Treatment for TB was ceased.
Conclusions: Wooden and other radiolucent foreign bodies are an important cause of morbidity in children. Although traumatic aortic injury is rare, the diagnosis could have been made more promptly with a high level of suscpicion paired with the knowledge that radiography may not reveal radiolucent foreign bodies. Sonography is of benefit in other areas, though aerated lung in the chest makes imaging for thoracic radiolucent foreign body challenging. CT or MR angiography should be considered in these patients.