Squalene aspiration pneumonia in children: radiographic and CT findings as the first clue to diagnosis

A case of infantile exogenous lipoid pneumonia with an unusual complication managed by modified whole lung lavage

Exogenous lipoid pneumonia (ELP) is a known complication of lipid administration through either the nasal or oral route. ELP in paediatric patients is usually managed by discontinuing lipid administration and supportive care, including respiratory support and the use of antibiotics for secondary bacterial infection. The other modalities that remain controversial include the use of corticosteroids and clearing lipids by whole lung lavage. We report a 2-month-old infant who presented with pneumonia and whose further history revealed exposure to ghee over a month period while visiting her grandparents in the south region of Saudi Arabia. The patient was later diagnosed as having ELP and was successfully managed with modified whole lung lavage till weaned off from oxygen. Unfortunately, the case was complicated by nontuberculous Mycobacterium chelonae, and the patient died despite maximum intervention.

Aspiration pneumonia during general anesthesia induction after esophagectomy: A case report

BACKGROUND

Esophageal cancer is a common malignant tumor of the digestive system. At present, surgery is the most important treatment strategy. After esophagectomy and gastric esophagoplasty, the patients are prone to regurgitation. However, these patients currently do not receive much attention, especially from anesthesiologists.

CASE SUMMARY

A 55-year-old woman was scheduled for right lower lung lobectomy. The patient had undergone radical surgery for esophageal cancer under general anesthesia 6 mo prior. Although the patient had fasted for > 17 h, unexpected aspiration still occurred during induction of general anesthesia. Throughout the operation, oxygen saturation was 98%-100%, but the airway pressure was high (35 cmH₂O at double lung ventilation). The patient was sent to the intensive care unit after surgery. Bedside chest radiography was performed, which showed exudative lesions in both lungs compared with the preoperative image. After surgery, antibiotics were given to prevent lung infection. On day 2 in the intensive care unit, the patient was extubated and discharged on postoperative day 7 without complications related to aspiration pneumonia.

CONCLUSION

After esophagectomy, patients are prone to regurgitation. We recommend nasogastric tube placement followed by rapid sequence induction or conscious intubation.

Metabolic Functions of the Lung, Disorders and Associated Pathologies

The primary function of the lungs is gas exchange. Approximately 400 million years ago, the Earth's atmosphere gained enough oxygen in the gas phase for the animals that emerged from the sea to breathe air. The first lungs were merely primitive air sacs with a few vessels in the walls that served as accessory organs of gas exchange to supplement the gills. Eons later, as animals grew accustomed to a solely terrestrial life, the lungs became highly compartmentalized to provide the vast air-blood surface necessary for O2 uptake and CO2 elimination, and a respiratory control system was developed to regulate breathing in accordance with metabolic demands and other needs. With the evolution and phylogenetic development, lungs were taking a variety of other specialized functions to maintain homeostasis, which we will call the non-respiratory functions of the lung and that often, and by mistake, are believed to have little or no connection with the replacement gas. In this review, we focus on the metabolic functions of the lung, perhaps the least known, and mainly, in the lipid metabolism and blood-adult lung vascular endothelium interaction. When these functions are altered, respiratory disorders or diseases appear, which are discussed concisely, emphasizing how they impact the most important function of the lungs: external respiration.

Investigation of rare chronic lipoid pneumonia associated with occupational exposure to paraffin aerosol

Objectives:

Occupational exposure to paraffin is an infrequent cause of lipoid pneumonia (LP) and related data are scare. We investigated the possible relationship between three rare cases of chronic LP and occupational exposure to paraffin aerosol in an iron foundry.

Methods:

The three cases of LP and their workplaces were investigated using data from field investigations, air monitoring, pulmonary radiological examinations, cell staining, and lung biopsies.

Results:

The patients had long-term occupational exposure to paraffin. X-ray diffraction testing revealed that the raw material from the workshop was paraffin crystal. The air concentrations of paraffin aerosol in workplaces were significantly higher than outdoor background levels. Small diffuse and miliary shadows with unclear edges were observed throughout the whole lungs via radiography. Computed tomography revealed diffuse punctate nodules and a high density of stripe-like shadows in both lungs (ground-glass opacity in a lower lobe, and a mass-like lesion and high translucent area near the bottom of the lung). Lipid-laden macrophages were found in the sputum and bronchial lavage. A broadened alveolar septum and local focal fibrosis were also discovered via lung biopsy. The inflammatory reaction in the lung tissues appeared to resolve over time.

Conclusions:

These three rare cases of chronic LP in workers during molding and repair processes were associated with occupational paraffin aerosol exposure. Therefore, primary prevention is essential for molding or repairing workers in the iron foundry, and a differential diagnosis of occupational chronic LP (vs. pneumoconiosis) should be considered when treating these workers.

Pulmonary melanoma and "crazy paving" patterns in chest images: a case report and literature review

Background

In the lung, melanoma is mostly arranged as patterns of multiple nodules, solitary nodules, or miliary invasions. Very rarely, it also displays a “crazy paving” pattern (also described as a “paving stone,” “flagstone,” or “slabstone” pattern), which is rarer still in discrete bilateral nodules. This pattern is considered to be caused by pulmonary alveolar proteinosis, but its association with various diseases is unclear.

Case presentation

A 60-year-old man was diagnosed with pulmonary melanoma. Computed tomography revealed discrete bilateral nodules surrounded by a “paving” pattern. A literature review found more than 40 types of diseases that have presented with “paving” patterns in the lung—predominantly pulmonary alveolar proteinosis, viral pneumonia, exogenous lipoid pneumonia, bacterial pneumonia, pulmonary alveolar microlithiasis, interstitial pneumonia, ARDS, squalene aspiration pneumonia, radiation pneumonitis, drug-induced pneumonitis, pulmonary leptospirosis, pulmonary hemorrhage, and pulmonary nocardiosis.

Conclusions

We describe the first case of pulmonary melanoma in the form of discrete bilateral nodules accompanied with a computed tomography paving pattern. Although pulmonary paving patterns are rare, more than 40 diseases reportedly display them; clinicians should consider melanoma of the lung in differential diagnoses for patients who show such a pattern.

Study of Acute Exogenous Lipoid Pneumonia

OBJECTIVE

To analyze the clinical and imagenological characteristics of acute Exogenous lipoid pneumonia (ELP), explore its risk factors, and assess the potential role of multiple bronchoalveolar lavages (BALs) and steroid therapy in the treatment of children with acute ELP.

METHODS

Between May 2011 and July 2014, 33 pediatric patients with pneumonia caused by aspiration of oil-based substances were admitted to the Guangzhou Women and Children's Medical Center, Guangdong, China. Data on the demographics of these patients, as well as that on clinical presentations, imagenological characteristics, history of ingestion, laboratory observations, treatment protocol, response to therapy, BAL findings, and treatment outcomes were collected.

RESULTS

The study group consisted of 23 boys (69.7 %) and 10 girls (30.3 %), with ages ranging from 4 mo to 4 y. They were admitted to the hospital 2 h to 13 d after ingesting the oil-based substance. By the time of admission, most patients presented with respiratory distress and other symptoms, including tachypnea (n = 21), cough (n = 25), mild fever (n = 18), progressive dyspnea (n = 12), and pneumorrhagia (n = 5); six patients received mechanical ventilation because of complicated respiratory distress syndrome. The most common laboratory observations were leukocytosis (25 of 33, 75.8 %), neutrophilia (23 of 33, 69.7 %), and anemia (8 of 33, 24.2 %). Serum biochemical examination showed elevated sedimentation rates (24 of 33, 72.7 %), lactate dehydrogenase levels (18 of 33, 54.5 %), and C-reactive protein levels (17 of 33, 51.5 %). The most common finding on computed tomography (CT) scans was areas of consolidation. Within the follow-up duration of 2 wk to 6 mo, all patients with clinical symptoms of ELP experienced remission, and none died. The CT scans of most of the cases were normal by 1 to 3 mo, except for two patients who showed complete improvement 6 mo after treatment.

CONCLUSIONS

It was found that multiple BALs combined with steroid therapy result in significant improvement of clinical, radiologic, and laboratory parameters in children with acute ELP. Further, some traditional practices may predispose children to ELP, even in the absence of underlying risk factors. Finally, pneumorrhagia and acute respiratory distress syndrome may be the main complications of acute ELP in children.

A severe case of acute exogenous lipoid pneumonia treated with systemic corticosteroid

Acute exogenous lipoid pneumonia is a rare disorder in adults. A treatment of choice for lipoid pneumonia has not been established, and systemic corticosteroid use remains controversial. We report the case of a 32-year-old man with schizophrenia who presented with kerosene-induced acute exogenous lipoid pneumonia that was treated with a systemic corticosteroid. In this case, supportive therapy did not improve the patient's condition, so systemic corticosteroid therapy was commenced four days after he ingested the kerosene. After corticosteroid commencement, the patient's symptoms and hypoxia improved within a few days. Although some radiological characteristics of this disorder have been reported previously, the process of radiological improvement of exogenous lipoid pneumonia is not well known. In this case, computed tomography findings changed dramatically after corticosteroid therapy was initiated. Extensive bilateral consolidations that were observed on admission improved. Although pneumatoceles developed two weeks after corticosteroid commencement, they were nearly gone after two months of the treatment. While corticosteroid therapy is not suitable for all cases, it should be considered for severe or refractory cases.

Lipoid pneumonia in 53 patients after aspiration of mineral oil: comparison of high-resolution computed tomography findings in adults and children

OBJECTIVE

To evaluate the high-resolution computed tomography (HRCT) findings in 53 patients with exogenous lipoid pneumonia and to compare the imaging features of adults and children.

MATERIALS AND METHODS

The study included 35 children and 18 adults. Statistical comparisons of findings in the 2 age groups were performed using either Pearson chi2 or Fisher exact test, as appropriate, at 5% significance level.

RESULTS

The main HRCT findings included air-space consolidation, ground glass attenuation, air-space nodules, and crazy-paving pattern. Abnormalities predominated in the posterior regions of the right lung. The right lower lobe was most likely to show severe involvement.

CONCLUSIONS

The presence of air-space consolidation, the involvement of upper right lobe, and the central and posterior distribution of the lesions were more common in children, whereas the crazy-paving pattern and random localization were significantly more frequent in adults. The other findings were not different between the 2 groups.

Evolução da pneumonia lipoide exógena em crianças: aspectos clínicos e radiológicos e o papel da lavagem broncoalveolar

OBJETIVO: Descrever os aspectos da evolução da pneumonia lipoide em crianças, com base em aspectos clínicos, radiológicos e de achados no lavado broncoalveolar, enfatizando a importância diagnóstica e terapêutica da lavagem broncoalveolar. MÉTODOS: Foram incluídas 28 crianças, com idade média de 20 meses (1-108 meses) e diagnóstico de pneumonia crônica refratária a antimicrobianos e/ou TB. A maioria apresentava um fator de risco para aspiração, e todas apresentavam história de ingestão de óleo mineral para o tratamento de constipação intestinal (23/28) ou de ascaridíase complicada (5/28). A avaliação clínica e tomográfica e análises do lavado broncoalveolar foram realizadas no início do tratamento e em até 24 meses. RESULTADOS: Os sintomas mais frequentes foram taquipneia e tosse. As principais alterações radiológicas foram consolidações (23/28), infiltrado peri-hilar (13/28) e hiperinsuflação (11/28). A TC de tórax mostrou consolidações com broncograma aéreo (24/28), diminuição de atenuação nas áreas de consolidação (16/28), opacidade em vidro fosco (3/28) e padrão em mosaico (1/28). O estudo do lavado broncoalveolar apresentava macrófagos espumosos corados por Sudan, confirmando o diagnóstico da pneumonia lipoide. Após tratamento com múltiplas lavagens broncoalveolares (média = 9,6), 20 crianças tornaram-se assintomáticas, havendo normalização tomográfica em 18. CONCLUSÕES: O diagnóstico de pneumonia lipoide deve ser considerado na pneumonia crônica ou TB refratárias ao tratamento, especialmente se houver história de ingestão de óleo mineral. A broncoscopia com múltiplas lavagens broncoalveolares mostrou-se eficiente para a depuração do óleo aspirado do parênquima pulmonar e a prevenção da fibrose, contribuindo para a redução da morbidade dessa doença, que ainda é pouco diagnosticada.

Lipoid pneumonia in children following aspiration of mineral oil used in the treatment of constipation: high-resolution CT findings in 17 patients

BACKGROUND

Exogenous lipoid pneumonia is a rare disorder caused by aspiration of mineral, vegetable and animal oils. High-resolution CT findings of lipoid pneumonia in children taking mineral oil for constipation have been rarely reported.

OBJECTIVE

To evaluate the high-resolution CT findings in 17 children with exogenous lipoid pneumonia following aspiration of mineral oil.

MATERIALS AND METHODS

The study included nine boys and eight girls, with ages ranging from 2 months to 9 years. All patients underwent high-resolution CT and the images were reviewed by two radiologists who reached decisions by consensus. The inclusion criteria were an abnormal radiograph, history of taking mineral oil and the presence of intrapulmonary lipids proved by bronchoalveolar lavage or open lung biopsy.

RESULTS

The most common symptoms were cough (n = 13), mild fever (n = 11), and progressive dyspnea (n = 9). The main CT findings were air-space consolidations (100%), usually with areas of fatty attenuation (70.6%), areas of ground-glass attenuation (52.9%), and a crazy-paving pattern (17.6%), predominating bilaterally in the posterior and lower regions of the lungs.

CONCLUSION

The high-resolution CT features in children with exogenous lipoid pneumonia are air-space consolidations and ground-glass attenuation, occasionally with a crazy-paving pattern, distributed bilaterally in the posterior and lower zones of the lungs.