Case 327: Exogenous Lipoid Pneumonia.

HISTORY: A 58-year-old male patient with an active smoking status was admitted twice to the intensive care unit (ICU) of a tertiary referral thoracic center for severe hypercapnic acute respiratory failure and persistent bilateral chest radiograph opacities that were unchanged over the course of the two ICU admissions within a 3-month period. The patient had obesity (body mass index, 36), stage 3 vascular chronic renal insufficiency, and hebephrenic schizophrenia treated with haloperidol, carbamazepine, and cyamemazine. He reported chronic dyspnea on exertion, which worsened for 6 months. At the second ICU admission, the patient was afebrile, with a blood pressure of 160/72 mm Hg and pulse oximetry of 93% on 6 L/min oxygen therapy through a nonrebreathing mask. Physical examination showed signs of respiratory failure with wheezing and active abdominal expiration, and bilateral pulmonary crackles without chest pain, hemoptysis, clubbing, or signs of cardiac failure. The patient had no peripheral lymphadenopathy and no enlarged spleen. Blood gases (on 6 L/min oxygen) showed respiratory acidosis (pH, 7.15 [normal range, 7.38-7.42]; PaO2 level, 67 mm Hg [normal range, 80-100 mm Hg]; PaCO2 level, 102 mm Hg [normal range, 38-42 mm Hg]; bicarbonate [HCO3-], 29 mmol/L [normal range, 22-27 mmol/L]). Noninvasive ventilation was initiated. Imaging performed during the second ICU hospitalization included CT and MRI of the chest without contrast enhancement, and fluorine 18 (18F) fluorodeoxyglucose (FDG) PET/CT.

Extrinsic lipoid pneumonia due to chronic polyethylene glycol consumption: A case report.

Extrinsic lipoid pneumonia (ELP) results from the aspiration of lipid-containing substances. Tissue or cell histopathology after Oil-Red-O staining can confirm the diagnosis, which requires proper tissue handling and preparation during bronchoscopy. Here, we report a case of ELP in a quadriplegic patient with a long history of dysphagia and polyethylene glycol consumption. Computed tomography (CT) of the chest revealed multiple, progressively enlarging, fat-attenuated, nodular pulmonary lesions. Bronchoscopy with bronchoalveolar lavage (BAL) and a transbronchial forceps biopsy confirmed the diagnosis of lipoid pneumonia. We discuss the clinical, radiological, and pathological features of ELP and highlight the preparatory steps required for obtaining a successful diagnosis.

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.

[Cough and Exertional Dyspnoea after Oily Mentholine Inhalation]. / Husten und Belastungsdyspnoe nach ölhaltiger Mentholinhalation.

A 48-year-old-male presented with a five-week history of non-productive cough and exertional dyspnoea. A pulmonary function test showed a mild diffusion disorder. A CT scan revealed an atypical pneumonia with bipulmonary consolidations, which were accentuated in the right upper lobe. The transbronchial biopsy showed lipid-loaded macrophages. These findings confirmed the diagnosis of a lipoid pneumonia, which developed in the context of inhalation of substances containing menthol. After discontinuation of the causative agent and high-dose steroid administration the symptoms were reversible within a few weeks.

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.

A 65-Year-Old Man with Pulmonary Opacities and Worsening Cough.

CASE PRESENTATION: A 65-year-old man was referred for evaluation of several years of chest congestion and cough productive of yellow sputum as well as recently noted abnormalities on chest imaging. He denied dyspnea, weight loss, fevers, chills, or hemoptysis. He had no history of systemic illness, pneumonia, other respiratory illness, gastroesophageal reflux, or sinusitis. He had a remote smoking history. He worked as a railroad conductor and had occupational exposure to asbestos, as well as to other uncharacterized dusts and fumes. The patient spent most of his life in Washington and California and regularly traveled through the California Central Valley. Other travel history included trips to Southeast Asia, Iceland, and Europe in the remote past. The patient had one dog but no exposure to other animals. His only medication was loratadine, taken daily for allergic rhinitis. He applied petroleum jelly to his nares nightly to moisturize his nasal passages.

A case report of exogenous lipoid pneumonia associated with avocado/soybean unsaponifiables.

BACKGROUND: Exogenous lipoid pneumonia is a rare disease resulting from intra-alveolar accumulation of lipids of mineral, vegetal, or animal origin, that induce a foreign body type of inflammatory reaction in the lungs. Gastroesophageal reflux disease and other esophageal abnormalities have often been associated with this disease. CASE PRESENTATION: We herein report the case of an 83-year-old patient in whom a follow-up chest computed tomography scan, for a lingular consolidation, showed multifocal ground glass and consolidative opacities with areas of low attenuation, suggestive of exogenous lipid pneumonia. The patient had been on piascledine capsules (avocado/soybean unsaponifiables) for 20 years and had a hiatal hernia with documented gastroesophageal reflux disease. After thorough history taking, no other predisposing factors were found. The diagnosis was confirmed using oil red staining of bronchoalveolar lavage showing lipid-laden macrophages and extracellular lipid droplets. CONCLUSIONS: To our knowledge, this is the first case of ELP secondary to avocado/soybean unsaponifiables in the literature.

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.

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.

[Analysis of 12 cases of exogenous lipoid pneumonia confirmed by pathology].

Objective: To study the etiological, clinical, radiological, diagnostic, therapeutic, and prognostic manifestations of exogenous lipoid pneumonia (ELP), and therefore to improve the diagnosis and treatment of this disease. Methods: The clinical data of 12 cases of ELP confirmed by pathology were retrospectively analyzed. Results: The patients consisted of 9 males and 3 females, with an average age of 73.8 years (range, 44 to 100 years). The underlying diseases were variable, including diseases affecting the general condition (multiple organ failure, chronic heart and renal insufficiency, pemphigoid, etc) and conditions with increased risk of aspiration (sequelae of cerebrovascular disease, Alzheimer's disease, advanced stage of nasopharyngeal carcinoma, paralytic ileus, etc). The 12 cases were all caused by Inhalation of mineral oil. Common symptoms included cough, sputum production and dyspnea. ELP had no special physical signs. Inflammation indexes, such as white blood cell, neutrophil percentage, ESR, C reactive protein, procalcitonin, D-Dimer, and blood lipid levels were usually normal. Radiological features of ELP mainly included consolidation, mass or nodules, with a little ground-glass opacity. Some patients had ventilation and/or diffusion dysfunction. The diagnostic methods included CT-guided percutaneous lung biopsy, thoracoscopy, thoracotomy or autopsy. Histopathological findings showed accumulation of large foamy macrophages in the alveolar spaces, with a few lipid deposition and polykaryocytes. The main treatment of ELP was cessation of lipid material contact. One case died of ELP, 6 died of other coexisting diseases, and the rest 6 improved with treatment and were discharged. The survival patients were all stable during a follow-up of 2-4.5 years. Conclusions: ELP was rare and its clinical manifestation was atypical. Its radiological manifestations were indistinguishable from pneumonia, lung cancer, interstitial lung diseases, etc. Pathological examination was the gold standard for diagnosis, and the preferred means of sampling was bronchoscopy. In cases whose diagnosis could not be confirmed by BALF, CT-guided percutaneous lung biopsy might be considered. The most important treatment is cessation of lipid material contact. The prognosis is good.