Radiological and Clinical Findings in Acute and Chronic Exogenous Lipoid Pneumonia

Bronchoalveolar Lavage (BAL) and Pathologic Assessment of Electronic Cigarette or Vaping Product Use-associated Lung Injury (EVALI): The EVALI-BAL Study, A Multicenter Cohort

BACKGROUND

E-cigarette or vaping-use related acute lung injury (EVALI) is a spectrum of radiographic and histologic patterns consistent with acute to subacute lung injury. However, limited data exist characterizing bronchoalveolar lavage (BAL) findings. The goal of this study is to further define the pathologic findings from BAL and biopsy samples of subjects with EVALI across 7 institutions.

METHODS

A multicentered registry of patients admitted with EVALI who underwent flexible bronchoscopy with BAL+/-transbronchial biopsy from July 2019 to April 2021 was compiled for retrospective evaluation from 7 academic institutions throughout the United States. Radiographic and cytopathologic findings and frequencies were correlated with the substance vaped.

RESULTS

Data from 21 subjects (42.9% women) who were predominantly White (76.2%) with a median age of 25 years (range, 16 to 68) with EVALI were included in this study. Sixteen patients (76.2%) reported use of tetrahydrocannabinol; the remainder used nicotine. BAL was performed in 19 of the 21 subjects, and transbronchial lung biopsy was performed in 7 subjects. BAL findings revealed neutrophilic predominance (median, 59.5%, range, 3.1 to 98) in most cases. Ten BAL samples demonstrated pulmonary eosinophilia ranging from 0.2% to 49.1% with one subject suggesting a diagnosis of acute eosinophilic pneumonia associated with the use of e-cigarettes. Lipid-laden macrophages were noted in 10 of 15 reports (66.7%). Transbronchial biopsy most frequently demonstrated patterns of organizing pneumonia (57.1%).

CONCLUSION

EVALI-associated BAL findings typically demonstrate a spectrum of nonspecific inflammatory changes, including neutrophilia, lipid-laden macrophages, and in some cases eosinophilia.

Mycobacterium infection secondary to exogenous lipoid pneumonia caused by nasal drops: a case report and literature review

BACKGROUND

Exogenous lipoid pneumonia (ELP) is a rare disease and its diagnosis is often mistaken or delayed. Secondary infection with rapidly growing non-tuberculous mycobacteria is a rare complication of lipoid pneumonia.

CASE PRESENTATION

A 38-year-old man presented with fever, cough, sputum, chest tightness, and shortness of breath. He had a 2-year history of allergic rhinitis and used liquid paraffin-containing menthol nasal drops daily. A chest CT scan showed multiple patchy ground glass opacities with blurred borders in both lungs, which were located in the inner pulmonary field and distributed along the bronchi. His ambient air PO₂ was 63 mmHg. The patient was diagnosed with ELP by CT-guided lung biopsy. The nasal drops were discontinued, and systemic glucocorticoids were administered. During treatment, the pulmonary lesions deteriorated, and bronchoalveolar lavage was performed during bronchoscopy. Additionally, Mycobacterium abscessus was detected in the lavage fluid. Upon detection of a secondary M. abscessus infection, glucocorticoids were gradually discontinued, and anti-M. abscessus treatment was implemented. The patient's symptoms rapidly ameliorated. After 11 months of anti-M. abscessus treatment, a repeat CT scan showed clear regression of the lung lesions.

CONCLUSION

Routine microbiological examination of samples, including sputum or alveolar lavage fluid, is necessary for patients with diagnosed or suspected ELP.

Hydrocarbon pneumonitis with abscess formation following diesel siphoning

A man in his early 40s presented with a 1-month history of fever after accidental diesel aspiration. He had received treatment with intravenous antibiotics, steroids and supportive care. Contrast-enhanced CT of the thorax revealed a right middle lobe lung abscess and bronchoscopy revealed hyperaemia around the middle lobe bronchus. The abscess was initially managed by drainage using a pigtail catheter and intravenous antibiotics. However, only partial drainage of the abscess was achieved and fever persisted. The cardiothoracic surgery team performed drainage of lung abscess through a right posterolateral thoracotomy. Postprocedure, the patient's symptoms improved and the patient was discharged in good health. This case demonstrates a rare complication of hydrocarbon aspiration pneumonitis and lung abscess. Post acute management of diesel aspiration, patients should be advised to return for medical assessment immediately, should symptoms like persistent fever and chest pain recur or persist as these symptoms may herald the development of post-hydrocarbon-aspiration lung abscess.

Acute exogenous lipoid pneumonia: Unusual presentation as cavitating lung disease with pneumothorax

Acute lipoid pneumonia is quite uncommon and is associated with oily or lipid contents within the alveoli. Exogenous lipoid pneumonia due to kerosene poisoning, manifests with a wide clinical spectrum ranging from subtle chemical pneumonitis to marked severe pulmonary and systemic inflammation. We present an interesting case of an adult male with kerosene poisoning. He manifested with severe cavitating lung disease. In addition, he developed spontaneous pneumothorax. Both cavitating lung disease and pneumothorax are unusual manifestations of acute exogenous lipoid pneumonia and perhaps follow severe lung injury following high volume kerosene exposure.

A 66-Year-Old Man With Subacute Cough and Worsening Dyspnea Previously Diagnosed With COVID-19 Pneumonia

A 66-year-old man presented with subacute cough and worsening dyspnea. Labs were notable for moderate peripheral eosinophilia, and computed tomography (CT) scan demonstrated extensive crazy-paving throughout bilateral upper lung fields. Bronchoalveolar lavage (BAL) revealed macrophages with lipid-filled vacuoles and negative periodic acid-Schiff (PAS) stain. Further history obtained from the patient and family was notable for daily application of commercially available vapor rub to nares and intentional deep inhalation of nebulized fluids containing scented oils. The patient was diagnosed with exogenous lipoid pneumonia through an unusual route of lipid administration.

E-Cigarette Use: Device Market, Study Design, and Emerging Evidence of Biological Consequences

Electronic cigarettes are frequently viewed as a safer alternative to conventional cigarettes; however, evidence to support this perspective has not materialized. Indeed, the current literature reports that electronic cigarette use is associated with both acute lung injury and subclinical dysfunction to the lung and vasculature that may result in pathology following chronic use. E-cigarettes can alter vascular dynamics, polarize innate immune populations towards a proinflammatory state, compromise barrier function in the pulmonary endothelium and epithelium, and promote pre-oncogenic phenomena. This review will summarize the variety of e-cigarette products available to users, discuss current challenges in e-cigarette study design, outline the range of pathologies occurring in cases of e-cigarette associated acute lung injury, highlight disease supporting tissue- and cellular-level changes resulting from e-cigarette exposure, and briefly examine how these changes may promote tumorigenesis. Continued research of the mechanisms by which e-cigarettes induce pathology benefit users and clinicians by resulting in increased regulation of vaping devices, informing treatments for emerging diseases e-cigarettes produce, and increasing public awareness to reduce e-cigarette use and the onset of preventable disease.

A 48-Year-Old Amateur Bodybuilder With History of Provoked DVT With Subacute Progressive Shortness of Breath

CASE PRESENTATION

A 48-year-old man presented with 6 months of progressive shortness of breath, intermittent exertional left-sided chest pain, and bilateral lower extremity edema. During the 2 days before admission, he experienced new onset confusion, fatigue, and malaise that prompted evaluation. He denied fever, chills, cough, or sputum production. He used anabolic steroids for 20 years as part of his bodybuilding hobby. Recently, he also began injecting mineral oil into his pectoral, bicep, and shoulder muscles for an improved muscular appearance. Additionally, he had a history of provoked DVT after traumatic fracture, schizophrenia, hypertension, and epilepsy. He was a former cigarette smoker with 2.5 pack-year history, having quit 10 years earlier. The patient's occupation was construction, installing aluminum gutters. He specifically denied exposures to sand-blasting, coal, beryllium, hard metals, silicone, and fine particles. He had no recent travel, sick contacts, or animal exposures.

Differential diagnoses of COVID-19 pneumonia: the current challenge for the radiologist-a pictorial essay

BACKGROUND

COVID-19 pneumonia represents the most severe pandemic of the twenty-first century and has crucial clinical, social and economical implications. The scientific community has focused attention and resources on clinical and radiological features of COVID-19 pneumonia. Few papers analysing the vast spectrum of differential diagnoses have been published.

MAIN BODY

Complexity of differential diagnosis lays in the evidence of similar radiological findings as ground-glass opacities, crazy paving pattern and consolidations in COVID-19 pneumonia and a multitude of other lung diseases. Differential diagnosis is and will be extremely important during and after the pandemic peak, when there are fewer COVID-19 pneumonia cases. The aim of our pictorial essay is to schematically present COVID-19 pneumonia most frequent differential diagnoses to help the radiologist face the current COVID-19 pneumonia challenge.

CONCLUSIONS

Clinical data, laboratory tests and imaging are pillars of a trident, which allows to reach a correct diagnosis in order to grant an excellent allocation of human and economical resources. The radiologist has a pivotal role in the early diagnosis of COVID-19 pneumonia because he may raise suspicion of the pathology and help to avoid COVID-19 virus spread.

A case of exogenous lipoid pneumonia diagnosed by transbronchial lung cryobiopsy

A 57-year-old man visited a referral physician due to abnormal chest shadows. Transbronchial lung biopsy (TBLB) failed to diagnose his condition. As antibiotics and systemic steroids did not improve the condition, he was referred to our hospital. A second TBLB in our hospital also failed to diagnose the disease. Transbronchial lung cryobiopsy (TBLC) was performed using radial endobronchial ultrasound with guide sheath (EBUS-GS), and the patient was diagnosed with lipoid pneumonia. Right upper lobe resection was performed, and lipoid pneumonia was confirmed from the surgical specimen. We report a case of lipoid pneumonia diagnosed by EBUS-GS TBLC.

Presenting Clinicoradiologic Features, Causes, and Clinical Course of Exogenous Lipoid Pneumonia in Adults

BACKGROUND

Exogenous lipoid pneumonia (ELP) develops when lipid-containing substances enter the airways through aspiration or inhalation and incite an inflammatory response. The diagnosis of ELP often is difficult because findings may be nonspecific. The clinical course of ELP has not been well characterized.

RESEARCH QUESTION

What are the presenting clinicoradiologic features of ELP, its causative agents, and clinical course?

STUDY DESIGN AND METHODS

We searched the Mayo Clinic electronic medical records for patients diagnosed with ELP between 1998 and 2020. Inclusion diagnostic criteria were: (1) lipoid pneumonia (LP) on histopathologic examination, (2) lipid-laden macrophages in BAL fluid, or (3) fatty attenuation of parenchymal opacities on chest CT imaging. Additionally, all patients were required to have a clinician diagnosis of LP in the absence of conditions known to cause endogenous LP.

RESULTS

Thirty-four patients were identified. Mean age was 71 years, with no sex predominance; one-half were asymptomatic. The diagnosis was confirmed by lung biopsy (including three lobectomies for suspected malignancy) in 71% of patients, CT scan in 24% of patients, and BAL in 5% of patients. Most patients manifested bilateral parenchymal opacities that commonly involved the lower lobes; fatty attenuation was identifiable in only 41% of patients. A causative substance was identified in 79% of patients, in most cases after the diagnosis was established. Over a median follow-up of 1.2 years, only 20% of patients with chronic respiratory symptoms improved, whereas 50% worsened. Over a median follow-up interval of 1 year, CT scan abnormalities improved or resolved in 33% of patients and progressed in 39% of patients. Patients who deteriorated were older, with a higher prevalence of GI disorders than those who remained stable or improved.

INTERPRETATION

ELP often is asymptomatic and may not manifest fatty attenuation on chest CT imaging. Clinical and radiologic abnormalities persist or worsen in most affected patients, even when the causative agent is discontinued.

Exogenous Lipoid Pneumonia Complicated by Mineral Oil Aspiration in a Patient With Chronic Constipation: A Case Report and Review

Exogenous lipoid pneumonia is a rare and frequently misdiagnosed lung disease. It occurs as an inflammatory reaction secondary to either aspiration or inhalation of lipids. Our patient had a history significant for recurrent pneumonia and the use of mineral oil for chronic constipation. A chest computed tomography showed multifocal consolidative opacities with areas of low attenuation, highly suspicious of exogenous lipid pneumonia. The diagnosis was confirmed with combined bronchoalveolar lavage and transbronchial lung biopsy that showed lipid-laden macrophages consistent with exogenous lipoid pneumonia. After thorough medication review, apart from mineral oil, no other contributing factors were found. A diagnosis of exogenous lipoid pneumonia associated with the use of mineral oil made and successfully managed by stopping the offending agent and supportive antibiotics.

Exogenous lipoid pneumonia: when radiologist makes the difference

PURPOSE

To report high-resolution CT (HRCT) findings in our group of patients with exogenous lipoid pneumonia (ELP), confirmed with histopathological findings and clinical-anamnestic data, in order to describe the most common radiological patterns of this rare disorder.

MATERIALS AND METHODS

In this retrospective study, HRCT of 10 patients with ELP were evaluated by three radiologists. Diagnosis of ELP was made through CT, bronchiolo-alveolar lavage (BAL) and a pneumological examination associated with an accurate medical anamnesis. Five patients had a histologically proven ELP, through lung biopsy. All patients had a chronic exposition to substances made of animal fat or mineral/vegetable oils.

RESULTS

In our cohort of patients with ELP, the following parenchymal patterns were observed: 8/10 patients had lung consolidation with adipose density (attenuation values < - 40 HU); 10/10 patients had multiple areas of ground glass opacity; 6/10 patients had smooth thickening of interlobular septa and ground glass opacities ("crazy-paving" pattern); 2/10 patients presented nodules > 2.5 cm with spiculated margins (tumor-like); 5/10 patients showed reactive lymph nodes enlargement. The oldest lesions were characterized by bronchiectasis and fibrosis around the lipidic consolidations.

CONCLUSION

Pulmonary alterations found in HRCT exams can be confused with other lung diseases (especially lung tumors) and they are always a challenge even for the most experienced radiologist. In our experience, although non-specific, consolidation areas with low HU values and crazy-paving pattern are frequently associated in ELP. These characteristics should alert the radiologist to consider ELP among the possible differential diagnoses, always correlating the results of CT examination with appropriate clinical-laboratory evaluations and an accurate anamnesis.

The Diagnosis of Exogenous Lipoid Pneumonia Caused by the Silent Aspiration of Vegetable Oil Using a Lipidomic Analysis

We herein report a case of refractory exogenous lipoid pneumonia that was successfully attributed to vegetable oil through a lipidomic analysis of bronchoalveolar lavage fluid (BALF). As a 25-year-old woman diagnosed with lipoid pneumonia experienced repeated exacerbations and improvement, we performed a BALF lipidomic analysis. The major lipid components were oleic acid, linoleic acid, and α-linolenic acid, which are constituents of vegetable oil. She stopped consuming any vegetable oil and has since experienced no instances of lipoid pneumonia relapse. A lipidomic analysis appears to be useful for identifying causative lipids, since patients with lipoid pneumonia are sometimes unaware of aspiration episodes.

Idiopathic Lipoid Pneumonia: An incidental finding in autopsy specimen

Lipoid pneumonia is a rare form of pneumonia which was initially described to be caused by inhalation or aspiration of fatty substances. Certain autopsy studies have reported the incidence to be 1.0-2.5%. Based on the mode of lipid acquisition, it has been classified into endogenous, exogenous or idiopathic types. Almost 50% of the patients with lipoid pneumonia are asymptomatic, and may be discovered by chance during routine chest imaging. In symptomatic patients, the symptoms are non- specific. However, it can produce inflammatory pneumonitis that can progress to irreversible pulmonary fibrosis as seen in our case. We present a case of a 53-year-old deceased male. A piece of one of his lungs was received after autopsy, which appeared normal grossly. There was no history of any illness before death. Microscopy revealed interstitial fibrosis with collection of foamy macrophages in alveolar spaces and cholesterol crystals surrounded by inflammatory reaction including occasional giant cells. The clinical picture and radiologic changes in cases of lipoid pneumonia can mimic bacterial pneumonia and tuberculosis. The occupational history is of extreme importance and should always be investigated.

Radiologic, Pathologic, Clinical, and Physiologic Findings of Electronic Cigarette or Vaping Product Use-associated Lung Injury (EVALI): Evolving Knowledge and Remaining Questions

Proposed as a safer alternative to smoking, the use of electronic cigarettes has not proven to be innocuous. With numerous deaths, there is an increasing degree of public interest in understanding the symptoms, imaging appearances, causes of, and treatment of electronic cigarette or vaping product use-associated lung injury (EVALI). Patients with EVALI typically have a nonspecific clinical presentation characterized by a combination of respiratory, gastrointestinal, and constitutional symptoms. EVALI is a diagnosis of exclusion; the patient must elicit a history of recent vaping within 90 days, other etiologies must be eliminated, and chest imaging findings must be abnormal. Chest CT findings in EVALI most commonly show a pattern of acute lung injury on the spectrum of organizing pneumonia and diffuse alveolar damage. The pathologic pattern found depends on when in the evolution of the disease process the biopsy sample is taken. Other less common forms of lung injury, including acute eosinophilic pneumonia and diffuse alveolar hemorrhage, have also been reported. Radiologists and pathologists help play an important role in the evaluation of patients suspected of having EVALI. Accurate and rapid identification may decrease morbidity and mortality by allowing for aggressive clinical management and glucocorticoid administration, which have been shown to decrease the severity of lung injury in some patients. In this review, the authors summarize the current state of the art for the imaging and pathologic findings of this disorder and outline a few of the major questions that remain to be answered.

Acute Lung Injury and Non-infectious Pneumonias

Lung injury can occur secondary to a myriad of causes, including infection, immunologic disorders, drug toxicity, or inhalational injury among others. Although the list of causative agents is long, the lung’s response to injury is limited resulting in similar patterns of disease irrespective of the cause. From a pathological perspective, acute lung injury refers to a group of entities that present with acute or subacute disease. These conditions are characterized by particular histological patterns including diffuse alveolar damage, acute fibrinous and organizing pneumonia, organizing pneumonia, and eosinophilic pneumonia and clinically correspond to the varying degrees of acute respiratory distress syndrome (Patel et al, Chest 125:197–202, 2004; Beasley et al, Arch Pathol Lab Med 126:1064–1070, 2002; Avecillas et al, Clin Chest Med 27:549–557, 2006; Cottin, Cordier, Semin Respir Crit Care Med 33:462–475, 2012; Ferguson et al, Intensive Care Med 38:1573–1582, 2012). In most cases, the underlying cause will not be apparent from the histological findings requiring close correlation with clinical history and laboratory findings to determine the etiology. Nevertheless, careful search for infectious organisms with application of histochemical and immunohistochemical stains should be performed in all cases in order to identify cases that benefit from more targeted treatment.

Exogenous lipid pneumonia in old people caused by aspiration: Two case reports and literature review

Background

Exogenous lipoid pneumonia is a rare entity, the diagnosis is often missed or delayed.

Objective

To investigate the clinical characteristics of exogenous lipid pneumonia in elderly patients, improve the efficiency of early diagnosis and treatment of this disease.

Methods

Retrospectively analyzed the clinical information and imaging data of these 2 exogenous lipid pneumonia patients, reviewed related literature.

Results

Both of the 2 patients were over 60 with a history of gastrointestinal diseases. The clinical presentation is nonspecific. Chest CT showed many different manifestations. Histopathology analysis revealed the accumulation of lipid carrying macrophages, vacuolar cells and inflammation. A literature review indicated that 25 previous cases of exogenous lipid pneumonia were caused by aspiration. The most common site of the lesion was located in right lung, while mineral oil was the most common substances. We sought to discuss the patient's treatment and the corresponding outcomes.

Conclusion

The diagnosis of lipid pneumonia's mainly depends on medical history and histopathological morphology. The standard treatment for exogenous lipid pneumonia was composed of antibiotics, steroid, bronchoscopic lavage and a regular follow-up.

Clinical and radiological manifestations of lipoid pneumonia according to etiology: Squalene, omega-3-acid ethyl esters, and idiopathic

OBJECTIVES

Clinical manifestations of lipoid pneumonia (LP) vary depending on the causative agents or underlying causes. The aim of the present study was to investigate the clinical and radiological features of LP, classified according to etiologic agents.

METHODS

The clinico-radiological characteristics of LP patients were retrospectively compared among groups: exogenous versus idiopathic and squalene versus omega-3-acid ethyl esters (O-3-AEE) versus idiopathic. Idiopathic group was defined as LP with no proven or reported etiological evidence.

RESULTS

Twenty-two patients met the diagnostic criteria for LP: squalene (9 [41%]), O-3-AEE (6 [27%]), olive oil (1 [5%]), and idiopathic (7 [32%]). Compared with the exogenous group, the idiopathic group showed a higher recurrence rate; higher frequencies of bronchial anthracofibrosis (BAF) and bronchoalveolar lavage (BAL) lymphocytosis; and a higher rate of crazy-paving pattern and lower rate of consolidation on computed tomography scan. In three-group tests, compared with the O-3-AEE group, the squalene group exhibited a significantly higher percentage of neutrophils and a higher rate of right middle lobe (RML) involvement.

CONCLUSIONS

In comparison with the exogenous group, the idiopathic group demonstrated BAL lymphocytosis, higher rates of recurrence and BAF, and a higher rate of crazy-paving pattern. Compared with the O-3-AEE group, the squlaene group showed a higher percentage of BAL neutrophils and predominant RML involvement.

Increased FDG Uptake and Chronic Lung Changes in a Case of Persistent Lipoid Pneumonia

Lipoid pneumonia is uncommon disease caused by presence of macroscopic fat in the lung parenchyma commonly originating from exogenous source secondary to aspiration or inhalation of animal fats or mineral or vegetable oils. Alternatively, it can be due to endogenous fat accumulated in the alveoli in the setting of chronic bronchial obstruction or inflammation. The imaging findings include ground-glass opacities, consolidation, nodules, and masses. Presence of macroscopic fat on CT is helpful; however it might not always be present. Increased FDG uptake can be present secondary to ongoing inflammation mimicking malignancy. Tissue diagnosis might be needed in some cases.

Adult exogenous lipoid pneumonia: A rare and underrecognized entity in cytology - A case series

Background:

Exogenous lipoid pneumonia (ELP) is a rare benign entity without specific clinical or imaging presentation. Although cytological studies – either bronchoalveolar lavage (BAL) or fine-needle aspiration (FNA) – may be pursued in patients with ELP, a definitive diagnosis is frequently rendered only on histology. The aim of this study is to highlight the cytological features of ELP.

Methods:

A search of cytopathology (CP) and surgical pathology (SP) diagnoses of ELP was conducted. The corresponding clinical and imaging features were obtained, and the morphology, particularly the presence and size of the intracytoplasmic vacuoles and background, was assessed.

Results:

Nine cases of ELP were identified, including eight with corresponding CP and SP. A neoplasm was suspected in three based on imaging, but ELP was not in the differential clinically or radiographically in any. Among the cases, six patients had BALs and three FNAs. All of the samples showed multiple large vacuoles within macrophages with at least some equal to or larger than the size of the cell nucleus. Similar vacuoles were noted extracellularly on smears.

Conclusions:

ELP is typically described in case reports in the clinical or radiological literature. To the best of our knowledge, this represents the largest series of adult ELP in CP. When large vacuoles are present in macrophages in cytology specimens, at least a suspicion of ELP can be suggested to initiate appropriate therapy, identify/remove the inciting agent, and preclude a more invasive procedure.

Respiratory failure caused by lipoid pneumonia from vaping e-cigarettes

A young female vaper presented with insidious onset cough, progressive dyspnoea on exertion, fever, night sweats and was in respiratory failure when admitted to hospital. Clinical examination was unremarkable. Haematological tests revealed only thrombocytopenia, which was long standing, and her biochemical and inflammatory markers were normal. Chest radiograph and high-resolution CT showed diffuse ground-glass infiltrates with reticulation. She was initially treated with empirical steroids and there was improvement in her oxygenation, which facilitated further tests. Since the bronchoscopy and high-volume lavage was unyielding, a video-assisted thoracoscopicsurgical biopsy was done later and was suggestive of lipoid pneumonia. The only source of lipid was the vegetable glycerine found in e-cigarette (EC). Despite our advice to quit vaping, she continued to use EC with different flavours and there is not much improvement in her clinical and spirometric parameters.

An unusual case of recurrent chest infections

This case presentation relates to a 53 year old male, cachectic in appearance, who presented with progressively worsening dyspnoea, cough, intermittent haemoptysis and a history of nasal dryness ongoing over five months. The patient had received multiple courses of oral antibiotics for suspected community acquired pneumonia with no significant improvement. He was referred to our Respiratory Department for further evaluation of his symptoms. His HRCT showed right middle lobe consolidation with central cavitations. Furthermore, the transbronchial biopsy had been performed and the cytological examination revealed lipid laden macrophage with interstitial inflammatory changes. With return to the patient over the counter drug history, he described the frequent use of petroleum jelly to alleviate the symptoms of nasal dryness. This is the first report case of exogenous lipoid pneumonia presented with haemoptysis and cavitations in the HRCT.

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Chronic cough and haemoptysis can include a broad range of differentials. However, exogenous Lipoid pneumonia should be considered.

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The diagnosis of exogenous Lipoid Pneumonia can be made only when malignancy excluded by biopsy and resolution of radiological findings after stopping the offending agent.

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It is important to consider the use of over the counter medications when obtaining the patient’s history.

Teppanyaki/Hibachi Pneumonitis: An Exotic Cause of Exogenous Lipoid Pneumonia

Exogenous lipoid pneumonia (ELP) is a rare type of inflammatory lung disease caused by aspiration and/or inhalation of fatty substances and characterized by a chronic foreign body-type reaction to intra-alveolar lipid deposits. The usual clinical presentation occurs with insidious onset of nonspecific respiratory symptoms and radiographic findings that can mimic other pulmonary diseases. Diagnosis of ELP is often missed or delayed as it requires a high index of suspicion and familiarity with the constellation of appropriate history and radiologic and pathologic features. We herein report a case of occupational exposure to tabletop "Teppanyaki" entertainment cooking as a cause of ELP, confirmed by surgical lung biopsies in a 63-year-old Asian woman who worked as a Hibachi-Teppanyaki chef for 25 years.

Exogenous lipoid pneumonia induced by nasal decongestant

INTRODUCTION

Lipoid pneumonia is a clinical condition that may be initially asymptomatic or confused with an infectious or malignant lung disease.

OBJECTIVES

We report four cases of this pathological condition.

METHODS

The first case concerned an 85-year old woman with bilateral confluent pulmonary opacities, ground-glass type. Diagnosis was based on the cytology of the bronchoalveolar lavage (BAL) fluid followed by its ultrastructural examination. The second case was a 47-year-old man with an isolated pulmonary nodule, which was surgically removed; the diagnosis of lipoid pneumonia was formulated on the basis of the histological and electron microscopy examination. The third case concerned a 73-year-old woman, with bilateral hypodense areas at the bases of the lungs where FDG PET/CT scan showed an increased uptake. Diagnosis was formulated by BAL cytology and electron microscopy examination. The fourth case was a 69-year-old man, who performed a virtual colonoscopy for diverticulosis putting in evidence a round mass (3 cm in diameter) with two small peripheral nodules, located in the pulmonary left lower lobe. The histopathological examination of transthoracic biopsy confirmed a lipoid pneumonia.

RESULTS AND CONCLUSION

In all four cases, it was put in evidence a prolonged use of a nasal decongestant containing mineral oils. In literature, the most cases described are characterized by a subclinical evolution and were presented as ground glass opacities which evolve, in the later phases, in an interstitial involvement or in a peripheral mass, simulating a lung tumour.

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.

Exogenous lipid pneumonia related to long-term use of Vicks VapoRub® by an adult patient: a case report

Background

Use of petroleum-based over the counter remedies such as Vicks VapoRub to alleviate symptoms of rhinitis is common and can be effective, but carries under-appreciated risks of adverse side effects. In this case report we highlight Exogenous Lipoid Pneumonia (ELP), an uncommon condition that results from accumulation of exogenous lipids in the alveoli, as an adverse side effect of long-term Vicks VapoRub use.

Case presentation

We present the case of an 85-year-old female patient with ELP apparently due to continuous application of Vicks VapoRub® to her nostrils to alleviate chronic rhinitis. She was diagnosed incidentally via chest radiograph and computed tomography (CT) scan done as follow up to finding elevated C-reactive Protein during a routine exam. The CT scan revealed a pulmonary consolidation in the lower lobe of the right lung with fat density combined with low density areas associated with focal ground-glass opacities. The patient was advised to discontinue use of petroleum-based products, and was prescribed intranasal corticosteroids for her rhinitis. Follow up 2 years later showed that the lipid consolidation had diminished in size by approximately 10 %.

Conclusion

Physicians must be aware that ELP can develop as a result of long-term application of petroleum-based oils and ointments to the nose and discourage such use of these products. Patients who have used petroleum-based products in this way should be screened for ELP. CT scan is the best imaging modality for establishing the diagnosis. The treatment of this condition is not well defined, but, as shown in this case, the size of the lipid mass can decrease after use of petroleum based substances is discontinued.

Electronic supplementary material

The online version of this article (doi:10.1186/s12901-016-0032-6) contains supplementary material, which is available to authorized users.

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.

Acute respiratory distress syndrome after aspiration of lamp oil in a fire-eater: a case report

Background

Fire-eater’s pneumonia is an exogenous chemical pneumonitis after accidental aspiration of hydrocarbon fluids during the act of fire-eating. There have been few case reports in the literature regarding complications after fire-eating but so far none, to the best of our knowledge, have described such drastic and life-threatening pulmonary complications as in this case while only having swallowed a small amount of fluid.

Case presentation

We present a case of fire-eater’s pneumonia in a 28-year-old white man with severe pulmonary complications. He presented with pneumonitis and partial respiratory insufficiency. He was diagnosed with acute respiratory distress syndrome and was treated with antibiosis, oxygen therapy, and required non-invasive ventilation. He had a good recovery.

Conclusions

Accidental aspiration of even small amounts of lamp oil can lead to serious life-threatening pulmonary complications. Although fire-eaters are a comparatively small occupational group, the severity of possible complications illustrates that awareness of these consequences should be raised in teenagers and young adults who might be tempted into trying it. This case in a Western country shows that the dangers of fire-eating are not to be underestimated and are not limited to Eastern European countries where the majority of cases have been reported.

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 as a complication of Lorenzo's oil therapy in a patient with adrenoleukodystrophy

Lipoid pneumonia (LP) is a rare exogenous condition caused by inhalation or aspiration of lipid material into the lungs. It is often associated with the therapeutic use of different types of oil, and the diagnosis is based on the demonstration of lipid-laden macrophages in bronchoalveolar lavage fluid. We reported the case of a 39-year-old male with X-linked adrenoleukodystrophy who developed LP secondary to the use of Lorenzo's oil. To our knowledge, the association between the use of Lorenzo's oil and LP has never been reported in literature.

Case Report of Fire Eater's Pneumonia in Adolescent Female Patient - Evolution of Radiologic Findings

Background

We present a case of a 16-year-old girl with fire-eater’s pneumonia (hydrocarbon pneumonitis). The goal of this report was to assess evolution of radiological findings.

Case Report

The reported case was unique because that was the first completely described case of fire-eater’s pneumonia reported in an under-aged person. Moreover, this disease is very rare even in adults and only a few scientific reports can be found, mostly because of a small occupational group.

Conclusions

The aim of this report was to show that the problem of fire-eater’s pneumonia can occur in under-aged patients and should be taken into consideration in case of severe pneumonia. Another objective was to point out that chest radiograph is not sufficient to depict the evolution of radiological manifestations.

Non-resolving Findings in a Long-term Radiographic Follow-up of an Infant with Acute Paraffin Oil Aspiration

Acute lipoid pneumonia (LP) in children is a rare disorder caused by the aspiration of oil-based substances and is difficult to diagnose due to non-specific clinical symptoms and radiological findings. We report the case of a 5-month-old male infant with acute LP caused by accidental aspiration of a large amount of mineral oil. We present the imaging findings in the computed tomography scans performed during his hospitalization and focus on the residual abnormalities seen on a scan performed 7-years after the incident. This, to the best of our knowledge, is the longest follow-up report of an acute exogenous LP patient and the only case that demonstrates non-resolving abnormalities in a pediatric patient after a single acute episode of mineral oil aspiration.

"Diesel siphoner's lung": Exogenous lipoid pneumonia following hydrocarbon aspiration

Lipoid pneumonia is an unusual and uncommon form of pneumonia caused by aspiration of fatty substances. Hydrocarbon pneumonitis following aspiration of diesel is a form of exogenous lipoid pneumonia wherein, aspirated diesel reaches the alveoli rapidly without evoking any significant cough, but initiates an intense inflammatory reaction in the pulmonary parenchyma. This is a rarely described clinical scenario, although the practice of diesel siphonage from automobiles is a common practice in developing countries. We herein describe a 40-year-old male patient, in whom the diagnosis of lipoid pneumonia was delayed for a long duration and highlight the importance of taking a detailed occupational exposure history in patients with non-resolving pneumonia to rule out the underlying possibility of this rare clinical entity.

Endogenous lipoid pneumonia associated with Legionella pneumophila serogroup 1

Endogenous lipoid pneumonia is an uncommon condition. This is a report of a 29-year-old woman diagnosed with endogenous lipoid pneumonia associated with Legionella pneumophila serogroup 1 infection. The patient's endogenous lipoid pneumonia resolved completely after treatment for Legionella pneumophila infection. This suggests that early diagnosis and aggressive treatment of the underlying infection may prevent any long-term sequelae of lipoid pneumonia.

Exogenous lipoid pneumonia - a case report of a fire-eater

Background:

Exogenous lipoid pneumonia is an uncommon condition caused by inhalation or aspiration of a fatty substance. It usually presents as chronic respiratory illness mimicking interstitial lung diseases. Acute exogenous lipoid pneumonia is uncommon and typically is caused by an episode of aspiration of a large quantity of a petroleum-based product. Radiological findings vary and may imitate many other diseases.

Case Report:

We present a rare case of acute exogenous lipoid pneumonia in a fire-eater who aspirated liquid paraffin during his flame-blowing show (fire-eater’s lung). He was admitted to the hospital with productive cough, fever, hemoptysis, chest pain and dyspnea. Diagnosis was made on the basis of history of exposure to fatty substance, characteristic findings in CT examination and presence of lipid-laden macrophages in bronchoalveolar lavage fluid.

Conclusions:

Acute exogenous lipoid pneumonia is a very rare disease that typically occurs in fire-eaters and is called a fire-eater’s lung. The diagnosis is made on the basis of typical history and radiological, as well as histopathological findings.