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Fatal Button Battery Ingestions: 30 Reported Cases

CASE # Citation
(Year Reported, Author) (2012 MMWR Case No. if Applicable*)		 Age Sex Imprint Diam (mm) Chemistry Intended Use Time to Removal Battery Location Complications Signs & Symptoms Procedures and Treatment
1 1977 Blatnik 2.5 y M PX 825 23.0 MnO2 movie camera >= 26 hours upper esophagus at thoracic inlet massive hematemesis, shock, cardiac arrest
8 days post removal (>= 9 days post ingestion); TE fistula; erosion of inferior thyroid arteries and veins; exsanguination into bronchi and lungs		 vomiting, fever, lethargy, aphonia, inability to swallow, tender swelling suprasternal notch, tracheal shift, increased WBC endoscopic removal from esophagus; steroids (presumed to have masked progression)
2 1979 Shabino 16 mo F PX 825 23.0 MnO2 camera flash >= 4 days upper esophagus Perforation of esophagus and right tension hydropneumothorax (~4 days post ingestion); widened mediastinum - drain inserted (~5 d post ing); aortoesophageal fistula - perforation of posterior aspect of aortic arch near origin of L subclavian (~5 d post ing); massive exsanguination; cardiac arrest  vomiting, fever, irritability, abdominal distention, tachypnea, 10% dehydration, acrocyanosis tube thoracostomy (~4 days post ingestion); battery removal by esophagoscopy (~4.5 days post ingestion); mediastinal drain and gastrostomy feeding tube inserted (~5 days post ingestion)
3 1991 Peralta 11 mo F unk 15 unk watch >30 hours upper esophagus extensive bilateral pneumonia, anemia requiring transfusion; tracheoesophageal fistula 3x2.5 cm diameter fever, cough, vomiting, rejecting food and fluids; respiratory distress; cyanosis; pallor endoscopic removal
4 1994 Sigalet 3 y F unk unk unk unk unk upper esophagus aortoesophageal fistula (presumed, no post done); presumed mediastinal abscess (air at impaction site and sepsis) dysphagia; fever; dehydration; elevated white blood cell count; sepsis; massive bright red bleeding from mouth 5 days post removal endoscopic removal; granulation tissue seen
5 2004 Chang YJ (Taiwan) unk U unk unk unk unk ~2 days before death (not removed) esophagus   esophageal perforation leading to pneumothorax and pneumoperitoneum; died suddenly in ER intractable cough; poor appetite none
6 2004 BBC News and telegraph.co.uk 13 mo M unk unk unk camera   11 days in esophagus, never diagnosed or removed upper esophagus or hypopharynx with damage to trachea (presumed tracheo-esophageal fistula) ulcerated esophagus with tracheoesophageal fistula and bleeding; respiratory failure; death repeated vomiting, breathing difficulty; wheezing, difficulty drinking and eating, weight loss; misdiagnosed as viral infection no x-ray done thus diagnosis missed despite hospitalization
7 2004 NBIH (MMWR 3) 2.5 y M CR 2032 20.0 lithium remote control of portable stereo system ("boom box") >=10 days upper esophagus aortoesophageal fistula (estimated 10 days post ingestion); massive exsanguination; cardiac arrest unresponsive, dyspnea, hematemesis, melena battery removal by rigid esophagoscopy; emergency thoracotomy for massive bleeding uncontrolled by ET and balloon catheters in esophagus; open cardiac massage
8 2005 Hamilton & NBIH (MMWR 4) 19 mo M unk unk lithium   garage door opener 1 day 2 batteries ingested: one in stomach, one in mid-esophagus 2 cm aortoesophageal fistula at proximal descending aorta; massive bleeding and death 10 days after battery removal presented with 1 day of abdominal pain, shallow respirations, lethargy, anorexia, cough; massive bleeding from aortoesophageal fistula 10 days post battery removal battery removal by esophagogastroscopy; contrast swallow post-op day 4 suggested walled off tract along distal esophagus; child discharged; developed cyanosis and lethargy suddenly at home; CT showed IV contrast in esophagus & stomach; thoractomy - cross-clamped hypovolemic aorta
9 2008 NBIH & Mortensen 15 mo M  CR 2032 20.0 lithium electric candle not removed; in place 2 weeks esophagus at level of tracheal bifurcation aortoesophageal fistula - child exsanguinated 2 weeks after ingestion; blood in stomach and first part of duodenum on post; erosions in esophagus at level of tracheal bifurcation; fistula a few mm in diameter fussy, crying, dark stools with suspected blood; respiratory problems battery never removed as diagnosis not made until post mortem done
10 2008 NBIH & Brumbaugh (MMWR 7) 16 mo F CR 2025 20.0 lithium unk suspect ingested 7-13 days prior to removal mid-esophagus; moved spontaneously to stomach esophageal erosions with small amount of blood in paraesophageal and para-aortic tissues; child arrested (from blood loss) in OR and could not be resuscitated hematemesis vomited blood a second time just prior to planned endoscopic removal - exploratory laparotomy done instead; clot and battery evacuated from stomach; clotted blood formed cast of distal esophagus and stomach
11 2009 NBIH & Brunbaugh (MMWR 9) 2 y F CR 2032 20.0 lithium Yahtzee toy 10 hours distal esophagus  aortoesophageal fistula projectile vomiting of blood 18 days after battery removal endoscopic removal of battery from esophagus
12 2009 NBIH (MMWR 8) 2.5 y M unk unk unk receiver unit for remote control light switch 4-5 days upper esophagus exsanguinated; fistula between esophagus and right subclavian artery vomiting only with solid food x 4-5 days; tolerated liquids; otherwise acting normally; hematemesis 4-5 days post ingestion, then into shock resuscitation; balloon in esophagus to attempt to control bleeding
13 2009 NBIH (MMWR 10) 13 mo M CR 2032 20.0 lithium unk 10 days removed from stomach; suspect lodged in mid esophagus then dropped to stomach aortoesophageal fistula with massive exsanguination 2 days post removal and 12 days post ingestion coughing; gagging; chest congestion; vomiting; refusal to eat; guaiac positive, tarry stools; massive hematemesis 2 days after battery removal endoscopic removal of battery from stomach 10 days post ingestion; battery presumed to have moved to stomach from esophagus
Fatalities 1 to 13 above were included in the publication:
Litovitz T, Whitaker N, Clark L, White NC, Marsolek M: Emerging battery ingestion hazard: Clinical implications.  Pediatrics 2010;125(6): 1168-77. epub 24 May 2010.
Cases below occurred or were identified after compilation of data for this publication.
14 2010 NBIH (MMWR 14) 2 y F CR 2025 20.0 lithium unk not removed (unknown time of ingestion) mid- esophagus aortoesophageal fistula 5 cm above gastroesophageal junction hematemesis; exsanguinated orogastric tube placed and battery dislodged to stomach
15 2010 Soerdjbalie-Maikoe 2 y F CR 2032 20.0 lithium unk 11 days mid- esophagus aortoesophageal fistula between aberrant right subclavian artery (arteria lusoria) and esophagus; hemothorax, blood throughout gut on post mortem; focal mediastinitis; esophageal perforation and esophagitis sore throat, high fever, cough, diarrhea, vomiting after every drink or meal, seizure, hypotension, anemia, melena, hematemesis, collapse thoracotomy
16 2010 Baeza Herrera 3 y M   20.0 lithium remote control for video player 1 day mid-esophagus aortoesophageal fistula developed 11 days post ingestion (10 days after removal); liquid diet started on day 6 and child was asymptomatic; sudden hematemesis occurred and child exsanguinated from hemorrhagic shock in the hospital despite attempts to resuscitate; autopsy showed burns throughout esophagus and 3 cm perforation in distal third of esophagus into the thoracic aorta; large amounts of blood were fond in the stomach and the cardiac chambers were empty initial abdominal pain and vomiting; asymptomatic by day 6; hematemesis 11 days post ingestion (10 days post removal) endoscopic removal of battery from esophagus; repeat diagnostic endoscopy on day 10
17 2011 LaFrance (MMWR 11) 3 y F CR2032 20.0 lithium unk unknown,
< 3 weeks		 upper esophagus, at thoracic inlet hemoptysis, exsanguination and aspiration of blood; tracheoesophageal fistula T&A 3 weeks prior to death obscured determination of time of onset of symptoms; 10 days post T&A evaluated for fever and refusal of solid foods; 3 weeks post T&A presented with respiratory distress and vomiting, O2 sat 94% on room air, tachypnea; CXR showed diffuse bilateral infltrates and coin-like foreign body in esophagus at thoracic inlet; removal scheduled for next day but patient developed coughing spells and marked hemoptysis requiring intubation and transfusion; acute bradycardia and bleeding from mouth, nose, and ET tube followed intubation, transfusion, unsuccessful resuscitation attempts (stabilized after 30 mins of resuscitation but pupils fixed and dilated, then another episode of massive hematemesis occurred and resuscitation was unsuccessful)
18 2011
NBIH and Pae
 		 4 y F unk 20 lithium unk unk distal esophagus aortoesophageal fistula child vomited blood and collapsed at home; unresponsive with no pulse or breath sounds on arrival in ED; CPR initiated; pH dropped to 6.9; hemoglobin undetectable; regained spontaneous circulation with fluids and blood; no prior symptoms; ingestion not witnessed; apneic and pulseless on arrival at ED thoracotomy showed aortoesophageal fistula; aorta cross-clamped but child continued to bleed; arrested in OR and could not be resuscitated; battery not removed
19 1998
MMWR 1
 		 16 mo F unk unk unk unk unk esophagus exsanguination from arterio-esophageal fistula unknown unknown
20 2002
MMWR 2
 		 15 mo F CR 2016 20.0 lithium toy watch? > 24 hours proximal esophagus exsanguination from aortoesophageal fistula vomiting, melena, hemorrhaging; symptoms developed > 5 hours post ingestion battery identified on x-ray 19 hours after symptoms developed (>24 hours post ingestion)
21 2006
MMWR 5
 		 1 y M unk unk alkaline remote car alarm ≥ 4 days esophagus tracheoesophageal fistula; anoxic encephalopathy secondary to TE fistula fever, decreased appetite, suspected croup child taken to hospital after 2 days of fever; diagnosed with croup and discharged. Returned 2 days later at which point a radiograph showed a battery in the esophagus. Battery removed but child died 6 days later.
22 2007
MMWR 6
 		 7 mo F unk unk unk unk unk proximal esophagus acute fistulous erosion of esophageal ulcer into carotid artery massive hematemesis battery removed endoscopically
23 2010
MMWR 12
 		 2 y F unk unk unk unk ≥ 5 days upper thoracic esophagus esophageal perforation; bleeding sore throat, dysphagia, choking, dyspnea, tachypnea, dark stools, listless child treated for strep by pediatrician; taken to ED 5 days later where an x-ray identified foreign body in esophagus. Battery removed in hospital where child died 2 days later.
24 2010
MMWR 13
 		 2 y F CR 20xx 20.0 lithium unk unk esophagus esophageal damage, necrosis and hemorrhage; esophageal tear vomited blood, cardiovascular collapse Unknown time of ingestion. Child "became ill" and vomited blood. Condition deteriorated after transfer from initial hospital. Died at hospital.
25 2011
MMWR footnote
 		 13 mo F unk 20.0 lithium watch unk esophagus unknown unknown unknown
26 2011
MMWR footnote
 		 3 y M unk unk unk unk unk esophagus aortoesophageal fistula hemorrhage unknown
27 2012
MMWR footnote
 		 4 y M AA (initial report: button battery) AA unk unk 4 days mid esophagus two fistulas: esophagus to aorta and esophagus to pulmonic artery initial choking and vomiting; refusal to eat, abdominal pain and fever developed over next day or so; throat pain reported 4 days after swallowing battery; child had multiple pre-existing medical problems (DiGeorge syndrome, right aortic arch with aberrant origin of left subclavian artery, arthritis treated with NSAIDs); 32 days post ingestion he developed nose bleed and hematemesis then arrested and could not be resuscitated due to massive bleeding battery removed from esophagus by rigid esophagoscopy with the aid of a balloon catheter; child died 32 days post ingestion (28 days post battery removal)
28 2012 CPSC; NBIH 2 y F unk 25 lithium unk unk esophagus esophageal-carotid fistula; battery removed from upper esophagus; 3 weeks later child presented with gastric bleeding and seizures; large necrotic mass in neck on MRI and peptic ulcer with blood clot; transfused and placed on ventilator; one day after admission began to vomit blood, went into cardiac arrest and could not be resuscitated gastric bleeding; seizures; necrotic mass in neck; peptic ulcer with blood clot battery removed from upper esophagus
29 2012 NBIH 13 mo M DL 2032 20.0 lithium unk unk stomach gastric erosions; massive upper GI bleed followed several hours after a sentinel single episode of hematemesis sentinel episode of hematemesis preceded massive upper GI bleed unknown
30 2013 Martinez 23 mo M unk 20.0 lithium unk unk proximal esophagus (thoracic inlet) esophageal ulceration; aortoesophageal fistula in upper esophagus odynophagia, sialorrhea, stridor x 2 weeks prior to presentation without improvement with steroids; repeated hematemesis following attempted battery removal; hemorrhagic shock treated with blood and pressors and CPR endoscopic removal of battery from esophagus attempted but battery displaced to stomach; unable to cauterize bleeding in esophagus on repeat endoscopy

References

BBC News. Battery death hospital criticised. BBC News 2004 July 1; Available at: http://news.bbc.co.uk/2/hi/uk_news/england/derbyshire/3855967.stm. Accessed July 7, 2004.

Baeza Herrara C, Cortes Garcia R, Velasco Soria L, Velázquez Pino H. [Aorto-esophageal fistula due to ingestion of button battery]. Cir Pediatr [Spanish] 2010;23(2):126-9.

Blatnik DS, Toohill RJ, Lehman RH. Fatal complication from an alkaline battery foreign body in the esophagus. Ann Otol 1977;86(5 Pt 1):611-615.

Britten N. Doctors failed to notice dying baby had swallowed battery. Telegraph co uk 2004 July 1; Available at:  www.telegraph.co.uk/news/uknews/1465884/Doctors-failed-to-notice-dying-baby-had-swallowed-battery.html". Accessed March 22, 2009.

Brumbaugh DE, Colson SB, Sandoval JA, Karrer FM, Bealer JF, Litovitz T, Kramer RE. Management of button battery-induced hemorrhage in children. J Pediatr Gastroenterol Nutr 2011;52(5):585-589.

Chang YJ, Chao HC, Kong MS, Lai MW. Clinical analysis of disc battery ingestion in children. Chang Gung Med J 2004;27(9):673-677.

*Ferrante J, O'Brien C, Osterhout C, Gilchrist J. Injuries from batteries among children aged <13 years - United States, 1995-2010. MMWR 2012;61(34):661-666.

García Martínez S, Moralo García S, Reyes Domínguez S, López Martín F. [Aortoesophageal fistula induced by button-battery ingestion.] [Article in Spanish] An Pediatr (Barc). 2013 Jan 15. pii: S1695-4033(12)00498-5. [Epub ahead of print]

Hamilton JM, Schraff SA, Notrica DM. Severe injuries from coin cell battery ingestions: 2 case reports. J Pediatr Surg 2009;44(3):644-647.

LaFrance DR, Traylor JG, Jin L. Aspiration pneumonia and esophagotracheal fistula secondary to battery ingestion. Forensic Sci med Pathol  2011; epub 09 Feb 2011.     

Litovitz T, Whitaker N, Clark L, White NC, Marsolek M: Emerging battery ingestion hazard: Clinical implications.  Pediatrics 2010;125(6): 1168-77. epub 24 May 2010.

Mortensen A, Hansen NF, Schiodt OM. Hjertestop hos barn som følge af knapbatteri i øsofagus kompliceret med aorto-øsofageal fistel. Ugeskr Læger 2009;171(43):3098-3099.

Pae SJ, Habte SH, McCloskey JJ, Schwartz AJ. Battery ingestion resulting in an aortoesophageal fistula. Anesthesiology. 2012;1176(6):1354.

Peralta M, Fadda B, Contreras L. Tracheoesophageal fistula secondary to ingestion of a button battery (Spanish). Rev Chil Pediatr 1991;62(6):378-381.

Shabino CL, Feinberg AN. Esophageal perforation secondary to alkaline battery ingestion. JACEP 1979;8(9):360-362.

Sigalet DL, Laberge JM, DiLorenzo M, Adolph V, Nguyen LT, Youssef S, Guttman FM. Aortoesophageal fistula: congenital and acquired causes.  J Pediatr Surg 1994;29(9):1212-1214.

Soerdjbalie-Maikoe V, van Rijn RR. A case of fatal coin battery ingestion in a 2-year-old child.  Forensic Sci Int 2010;198:e19-e22.

 


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