Lipoid pneumonia presenting as non resolving community acquired pneumonia: a case report

A Rare Case of Post-Primary Tuberculosis Which Was Pathologically Diagnosed as Lipoid Pneumonia

Case Presentation

The patient was a middle-aged housewife who had been using the household spray for a long time, and the main symptoms were cough and sputum production. Chest CT showed lobar ground-glass opacities (GGOs) with small patchy consolidation in the right middle lobe (RML), specifically, lung tissue pathology showed a large number of foamy cells and scattered multinucleated giant cells. The patient received empirical anti-infective treatment, but no clinical improvement was observed. Laboratory tests, including smears and cultures of sputum, blood and bronchoalveolar lavage fluid (BALF), did not provide clear evidence for pathogenic microorganisms. Therefore, the presumptive diagnosis was exogenous LP (ExLP). After 28 days of prednisone treatment, her symptoms improved, but 2 months later, she presented with a worsening cough, and the GGOs had progressed into lobar consolidation. Transbronchial lung biopsy (TBLB) culture showed mycobacterium tuberculosis (MTB), and lung tissue pathology showed granulomatous inflammation. After anti-tuberculosis treatment, the consolidation in the right middle lobe was gradually absorbed, along with a considerable symptom improvement. The final diagnosis of the patient was MTB infection with an endogenous lipoid pneumonia (EnLP)-like presentation.

Conclusion

The current case highlights that the MTB infection should be considered when pathology shows LP accompanied by scattered multinucleated giant cells.

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.

The efficacy and safety of therapeutic lung lavage for exogenous lipoid pneumonia: A systematic review

INTRODUCTION AND OBJECTIVES

Exogenous lipoid pneumonia (ELP) is a lung inflammatory disease with low prevalence and has the feature of external lipid substances presented in the alveoli. Therapeutic lung lavage (segmental bronchoalveolar lavage and whole lung lavage) has been gradually recognized as an important therapy for the disease. There was no comprehensive summary on its efficacy and safety.

METHODS

We searched PubMed, Embase, Cochrane Library, CNKI, Wanfang Database, clinicaltrials.gov, and the references of included studies. After study selection, data extraction and quality assessment, we performed a qualitative description of current data.

RESULTS

We included 90 ELP patients from 25 case reports and 8 case series studies. Eighty-four (93.3%) patients received segmental bronchoalveolar lavage and six (6.7%) patients received whole lung lavage. Eighty-seven (96.7%) patients got clinical improvement after lavages, while three (3.3%) patients had no improvement and eventually died. The follow-up status was reported in 29 patients, of whom 24 patients remained well without any use of drugs and 4 patients remained well with some periods of corticosteroids. One patient endured recurrence. The radiological change was reported in 72 patients, of whom 41 (56.9%) patients had full resolution until the last follow-up. Two studies reported acute pulmonary edema and transient hypoxemia during lavages.

CONCLUSIONS

Therapeutic lung lavage might be an effective and safe therapy with long-term benefits for ELP. Current studies were all case reports and case series with relatively high risk of bias. Prospective controlled studies are needed to explore the actual efficacy, safety, individualized indications, and optimized treatment procedures of therapeutic lung lavage for ELP.

Diesel siphoner's lung: An unusual cause of hydrocarbon pneumonitis

The practice of manual siphoning of diesel from fuel tanks is common among automobile mechanics in Nepal. When an automobile mechanic with a history of diesel siphonage presents with respiratory symptoms, the diesel siphoner's lung diagnosis should be considered. Clinical suspicion confirmed by radiological findings can help in early management and prevention of permanent damage.

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.

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.

Acute exogenous lipoid pneumonia presenting as spontaneous air leak following accidental baby oil aspiration

Exogenous lipoid pneumonia (ELP) is an uncommon cause of respiratory distress. The practice of oil massage and oil instillation into the nostrils is common in the Indian subcontinent. Accidental aspiration of baby oil may lead to significant chemical pneumonitis. This presentation may vary from subtle to severe respiratory distress requiring intensive care management. Spontaneous air leaks are rare in acute ELP. We successfully managed a six-month-old girl presenting with mineral oil-induced ELP and air leaks. However, these children require long-term follow-up, as a small proportion may evolve into chronic lung disease.

Hydrocarbon pneumonitis following fuel siphonage: A case report and literature review

BACKGROUND

People sometimes siphon fuel to fill their tanks. However, this is a potentially dangerous procedure and may cause hydrocarbon pneumonitis. We present the case of a patient with severe hydrocarbon pneumonitis after siphoning fuel. The patient underwent artificial ventilation and was admitted to hospital for 97 days.

METHODS

We review the relevant literature for a better understanding of clinical features and management strategies for hydrocarbon pneumonitis following fuel siphonage.

RESULTS

We reviewed 15 articles, which included 3 original articles and 12 case reports that reported the clinical features of fuel siphonage. In addition, we added our presented case for data analysis. A total of 40 cases were included in this review. The literature review found that hydrocarbon pneumonitis caused by fuel siphonage occurs worldwide and that most patients (80%) became symptomatic within 1 day of aspiration. Cough (70%), chest pain (62.5%), dyspnoea (55%), and fever (52.5%) presented in more than half of all patients. The right middle lobe (80%) was the predominantly involved lung field; more than one-third of patients (36.7%) showed the involvement of two lobes.

CONCLUSION

Patient history, computed tomographic scans of the chest, and bronchoalveolar lavage are the commonly used diagnostic tools. Supportive care remains the foundation of treatment, whereas antibiotics, steroids, and bronchoalveolar lavage are practical therapies. Patients' clinical improvement precedes the resolution of lesions on chest X-ray. Most complications arise from pulmonary lesions. The prognosis of patients suffering from hydrocarbon pneumonitis following fuel siphonage might be improved by accurate diagnosis and appropriate care.

A rare case of lipoid pneumonia attributed to amiodarone

We report a case of endogenous lipoid pneumonia secondary to long-term use of amiodarone (> 30 years) for atrial fibrillation in a 76-year-old Caucasian woman, presenting with cough and dyspnea. Endogenous Lipoid pneumonia is a rare underdiagnosed condition more prevalent in adults. It is usually asymptomatic and a diagnosis is generally made in patients who have become clinically unstable or when an abnormal lung shadow is found on a chest X-ray. In the case here described it was diagnosed by fiberoptic bronchoscopy with bronchoalveolar lavage (BALF) where fat-laden macrophages (oil red O stain) were identified. Since a history of use of oil-based products had been ruled out, amiodarone was deemed to be the most likely cause of lipoid pneumonia. The patient was managed with the replacement of amiodarone with digoxin and treated with oral prednisolone. The patient has remained clinically stable with radiological improvement during a follow-up of two years.

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.

Pharmacists can help prevent lipoid pneumonia: Two case reports

OBJECTIVES

To report 2 cases of lipoid pneumonia.

SUMMARY

Lipoid pneumonia is an inflammatory process in the lower airways due to the presence of lipid molecules in the alveoli. Exogenous lipoid pneumonia is due to the inhalation or aspiration of fat-containing substances. Historically, mineral oil is the most common medication cause but there have also been several reports of lipoid pneumonia associated with petroleum jelly, medicated vapor rub, and lip glosses. Two case reports are presented to illustrate the importance of identifying risk factors for lipoid pneumonia.

RESULTS

Use of the Naranjo algorithm suggested that both cases of lipoid pneumonia were "possibly" due to aspiration of lipid-containing over-the-counter agents. The first case was associated with aspiration of mentholated topical ointment applied intranasally, whereas the second case was attributed to probable aspiration of mineral oil for management of chronic constipation.

CONCLUSION

Pharmacists in many practice settings can play an integral role in preventing this condition and screening for patients who may warrant a diagnostic workup. During medication reconciliation, pharmacists should identify all prescription and nonprescription medications used by patients. Patients should specifically be asked about lipid-based over-the-counter products and cosmetic agents.

Lipoid pneumonia - an unusual cause of acute respiratory distress syndrome

BACKGROUND

Lipoid pneumonia is a rare form of pneumonia caused by aspiration of fatty substances.

CASE CHARACTERISTICS

Acute respiratory distress syndrome in an infant due to accidental aspiration of baby oil massage.

INTERVENTION

Large volume bronchoalveolar lavage.

OUTCOME

Gradual recovery over a period of 5 months.

MESSAGE

Aspiration of lipids cause prolonged and refractory hypoxemia.

Endogenous lipoid pneumonia presenting as solitary pulmonary nodule: a case report

A 63-year-old woman complained of hemoptysis was admitted to our hospital. Chest computed tomography (CT) showed a solitary pulmonary nodule (SPN) arising from the lower lobe of the right lung which was considered as lung malignancy. The patient underwent video-assisted thoracoscopic surgery (VATS) of pulmonary wedge resection to remove the nodule. Diagnosis of lipoid pneumonia was established by multiple lipid-laden macrophages found in surgical specimen. As there was no history of inhalation or aspiration of lipid containing substances, she was diagnosed as endogenous lipoid pneumonia. The patient discharged from our hospital after surgery and with no recurrence in 9 months period.

"Pills" and the air passages: a continuum

Recently, we reported a number of key, common medications that affect the air passages in a variety of fashions. The purpose of this article is to provide a comprehensive review of the literature on the subject, including supportive articles published in languages other than English. The presented information was gathered by a review of the English literature, by cross referencing, and by communication with other interventional pulmonologists. We identified several additional medications causing either direct or systemic effects on the air passages. In this review, we update the clinical presentation, mechanism of injury, diagnosis, and management of the airway complications related to these medications.

"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.