Betel nut aspiration causing cold abscess-like endobronchial lesion and right lung upper lobe collapse in an elderly patient.

Foreign body aspiration (FBA) shows a bimodal age distribution. In young children and older adults, impaired airway protection and comorbidities increase susceptibility. Aspiration of betel nut (supari/areca nut), widely consumed in South Asia, is almost unheard of in older adults. Events may go unrecognised due to subtle symptoms and radiographic findings mimicking common conditions, such as pneumonia, tuberculosis or malignancy. Diagnostic complexity is amplified by immunosuppression, blunting the expected inflammatory response. Our patient, an elderly woman with focal segmental glomerulosclerosis on tacrolimus and corticosteroids, presented with 3 months of cough, fever and weight loss. Imaging showed right lung upper lobe collapse. Bronchoscopy revealed a betel nut fragment embedded within granulation tissue in an ulcerated, cold abscess-like endobronchial lesion without suppurative changes. Endoscopic removal resulted in complete recovery, highlighting the diagnostic challenges of FBA in immunosuppressed older adults and the importance of considering culturally specific aspirated materials in atypical non-resolving respiratory presentations.