Esophageal coin with moth eaten appearance: A cause for caution

A 10-year-old male with autism, levoconvex scoliosis, and frequent chewing on nonfood items presented with an esophageal foreign body on scoliosis imaging. Further history yielded an unwitnessed choking event 9 months prior, with subsequent refusal of solid foods. Limited healthcare access prevented dysphagia evaluation. Examination showed a healthy child with normal vital signs and no issues swallowing liquids. Radiographs (Figure 1) confirmed a mid-esophageal 20 mm disc-shaped foreign body with irregular lucencies. Per NASPGHAN guidelines,1 endoscopy was attempted for foreign body removal. At 15 cm, an esophageal stricture (6–8 mm diameter, 2 cm length) with eccentric, well-epithelialized diverticulum (2–3 mm diameter) was encountered (Figure 2A). Intubation of the true esophageal lumen showed an adherent penny at 18 cm, prompting procedure termination. Water-soluble contrast esophagram (Figure 2B) confirmed the esophageal diverticulum. Repeat endoscopy could not achieve retrograde removal, prompting penny advancement into the stomach for natural passage. At 3-month follow-up, the dysphagia had improved. The “moth eaten“ appearance is a rare finding that indicates prolonged foreign body retention and unforeseen mucosal injury in an otherwise common scenario.2, 3 It is specific to post-1982 pennies, composed of 97.5% zinc.4 Hydrochloric acid exposure dissolves zinc, forming caustic zinc chloride, causing lucencies on radiographs in 1–6 weeks.5-7 Caustic mucosal injury then ensues.8 This effect has prompted safety concerns regarding gastric advancement of pennies,9 leading us to retrospectively consider duodenal advancement. We theorize caustic and mechanical damage caused stricturing, with subsequent diverticulum formation via pulsion.10 Levoconvex scoliosis is a risk factor for gastroesophageal reflux, possibly facilitating gastric acid lavage.11 We urge clinicians to recognize this radiographic finding and consider ancillary investigation when encountered. The authors declare no conflicts of interest. The parent of our patient was contacted regarding the efforts to publish this anonymized case, including anonymized images related to this case for educational purposes. After explanation of the motivations and nature of this publication the parent of our patient verbally consented to the production and publication of this manuscript and related images.