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

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.

Endothelial Function of Patients with Morbid Obesity Submitted to Roux-en-Y Gastric Bypass With and Without Obstructive Sleep Apnea-Hypopnea Syndrome

BACKGROUND

Obesity is associated with obstructive sleep apnea-hypopnea syndrome (OSA) and both induce endothelial dysfunction. However, the effect of OSA on endothelial function after bariatric surgery has not been investigated yet.

OBJECTIVES

This study aims to evaluate the impact of weight loss on endothelial function in patients with and without obstructive sleep apnea (OSA) in the first 6 months after bariatric surgery.

SETTING

This study was conducted at a university hospital, in Brazil.

METHODS

The sample consisted of 56 patients homogeneously divided into groups with and without OSA. All patients underwent Roux-en-Y gastric bypass (RYGB), and the diagnosis of OSA was performed by polysomnography. The patients were evaluated preoperatively and 6 months after surgery. The evaluations included anthropometric measures, electrical bioimpedance, clinical symptoms of OSA, and endothelial function (flow-mediated dilation). RYGB improved the anthropometric, bioimpedance, and endothelial function results in both groups.

RESULTS

Patients presented a significant clinical improvement in OSA symptoms throughout the study. However, patients with OSA had an improvement in the endothelial function 2.5% lower (p < 0.001) than patients without APNEA syndrome.

CONCLUSION

This study demonstrates that the existence of OSA prior to bariatric surgery interferes in the improvement of endothelial function.

Lipoid pneumonitis in a patient with an accidental ingestion of kerosene successfully treated with bronchoscopic segmental lavage and systemic steroid: Case report

RATIONALE

Standard treatment of lipoid pneumonitis remains unclear. This study reports a case of kerosene pneumonitis successfully treated with systemic steroid and segmental bronchoalveolar lavage (BAL).

PATIENT CONCERNS

A 30-year-old woman referred to our hospital because of worsening of respiratory symptoms and fever despite antibiotic therapy following accidental ingestion of kerosene. She had no underlying disease.

DIAGNOSES

Chest CT scan showed necrotic consolidation, ground glass opacity (GGO), bronchial wall thickening in the right middle/lower lobe (RML/RLL) and right pleural effusion. The lipoid pneumonitis was confirmed by identification of a lipid laden macrophage in bronchoalveolar lavage fluid.

INTERVENTIONS

The patient was treated with systemic corticosteroid and segmental BAL.

OUTCOMES

The patient's symptoms rapidly improved after treatment and she was discharged one week after admission. A follow-up CT scan a week after discharge revealed marked resolution of consolidation. No recurrence was reported for 8 months.

LESSONS

This is the first case of kerosene pneumonitis successfully treated with systemic steroid and bronchoscopic segmental lavage therapy in Korea. Very few cases have been reported worldwide.

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.

ERS statement: interventional bronchoscopy in children

Paediatric airway endoscopy is accepted as a diagnostic and therapeutic procedure, with an expanding number of indications and applications in children. The aim of this European Respiratory Society task force was to produce a statement on interventional bronchoscopy in children, describing the evidence available at present and current clinical practice, and identifying areas deserving further investigation. The multidisciplinary task force panel performed a systematic review of the literature, focusing on whole lung lavage, transbronchial and endobronchial biopsy, transbronchial needle aspiration with endobronchial ultrasound, foreign body extraction, balloon dilation and occlusion, laser-assisted procedures, usage of airway stents, microdebriders, cryotherapy, endoscopic intubation, application of drugs and other liquids, and caregiver perspectives. There is a scarcity of published evidence in this field, and in many cases the task force had to resort to the collective clinical experience of the committee to develop this statement. The highlighted gaps in knowledge underline the need for further research and serve as a call to paediatric bronchoscopists to work together in multicentre collaborations, for the benefit of children with airway disorders.

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.

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.

Fatal Evolution in the Pneumonia Caused by Diesel Fuel Aspiration - Case Report

Aspiration pneumonia in infants emerges as a result of deglutition disorders, congenital malformations and severe gastroesophageal reflux. Hydrocarbon pneumonitis is caused by the accidental ingestion and aspiration of hydrocarbons into the body. In children, it can be seen as a result of both the lack of monitoring and the tendency for the exploration of the environment. The accidental ingestion of a large quantity is quite rare due to the bad taste of hydrocarbons. Initially, the central nervous system is the one affected, followed by the respiratory system, causing the chemical pneumonia (through direct injury of the lung). Furthermore, we shall present the case of an 18 month infant with severe trauma as a result of the accidental ingestion of diesel, followed by vomiting and who was brought late to the hospital. The pneumothorax that emerged as a complication was remitted after the treatment, but the initially chemical and then mixed pneumonia through bacterial overinfection led to the infant’s death after 12 days of medical attention in the Anesthesia and Intensive Care Unit. The histopathological examination of the analyzed lung fragments did not point out any lipid or foam cells that are characteristic to this type of pathology, but which are not mentioned by the majority of toxicology textbooks and those of pathological anatomy, through the low rate of mortality and numerous factors that can lead to negative false results.

Chronic Lipoid Pneumonia in a 9-Year-Old Child Revealed by Recurrent Chest Pain

Lipoid pneumonia in children is a rare disorder due to accumulation of fatty oily material in the alveoli and usually associated with an underlying condition. In absence of obvious context, diagnosis remains difficult with nonspecific clinical and radiological features. We report the first case of voluntary chronic aspiration of olive oil responsible for exogenous lipoid pneumonia, in a previously healthy 9-year-old boy. Clinical presentation was atypical; LP was revealed by isolated chest pain. We discuss radiological and bronchial alveolar lavage characteristics suggestive of lipoid pneumonia. Conclusion. Lipoid pneumonia is a disease to be reminded of in children, which can occur with original findings in terms of etiology and clinical presentation.

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.