Lipoid Pneumonia: a Silent Complication of Mineral Oil Aspiration

Lipoid Pneumonia: A Silent Complication of Mineral Oil Aspiration

Hari P. R. Bandla, MD*; Scott H. Davis, MD*; and Nancy Eddy Hopkins, PhD‡

ABSTRACT. Introduction. Chronic constipation is a constipation. Pediatrics 1999;103(2). URL: http://www. common symptom in pediatrics, and physicians often use pediatrics.org/cgi/content/full/103/2/e19; bronchoalveolar mineral oil to treat chronic constipation in children. Min- lavage, constipation, exogenous lipoid pneumonia, lipid- eral oil, a hydrocarbon, may not elicit a normal protective laden macrophages, mineral oil. cough reflex and may impair mucociliary transport. These effects can increase the likelihood of its aspiration and subsequent impaired clearance from the respiratory ABBREVIATIONS. RUL, right upper lobe; CXR, chest x-ray; BAL, tract. We report a case of a child with neurodevelopmen- bronchoalveolar lavage; ELP, exogenous lipoid pneumonia. tal delay with chronic constipation and a history of chronic mineral oil ingestion presenting as asymptomatic hronic constipation, a common symptom in exogenous lipoid pneumonia (ELP). pediatrics, accounts for 3% of referrals to Case History. A 6-year-old white boy with a history teaching hospital clinics and 10% to 25% of of developmental delay was found to have an infiltrate in C 1,2 his right upper lobe on a chest radiograph obtained dur- referrals to pediatric gastroenterology practices. ing evaluation for thoracic scoliosis. The patient had a Liquid paraffin, or mineral oil, is a hydrocarbon that long history of constipation with daily use of mineral oil. physicians often use to treat chronic constipation in He was fed by mouth and had occasional episodes of children and adults. It is a tasteless, indigestible liq- coughing and choking during feeding. He was asymp- uid that is poorly absorbed from the gastrointestinal tomatic at presentation and physical examination was tract and acts as a stool softener by decreasing the unremarkable. The patient was advised to stop adminis- reabsorption of water from the intestinal lumen.3 tration of the mineral oil and was treated empirically However, other properties such as its low volatility with antibiotics during a 3-month period. At follow-up and high viscosity may contribute to undesirable examination the patient continued to be asymptomatic, side effects. Mineral oil may not elicit a normal pro- with the radiologic persistence of the infiltrate. Diagno- tective cough reflex4 and may impair normal muco- sis of lipoid pneumonia was made by diagnostic bron- 5 choscopy with bronchoalveolar lavage (BAL). The exog- ciliary transport. These effects can increase the like- enous origin of the lipid in the BAL fluid was confirmed lihood of its aspiration and subsequent impaired by gas chromatography/mass spectrometry. clearance from the respiratory tract. We report a case Discussion. The clinical presentation of ELP is non- of a child with neurodevelopmental delay, chronic specific and ranges from the totally asymptomatic patient constipation, and a history of chronic mineral oil with incidental radiologic finding, like our patient, to the ingestion who presented with an infiltrate in the patient with acute or chronic symptoms attributable to right upper lobe (RUL) as an incidental finding on a pneumonia, pulmonary fibrosis, or cor pulmonale. Bron- chest radiograph (CXR). choscopy with BAL can be successful in establishing the diagnosis of ELP by demonstration of a high lipid-laden macrophage index. Treatment of ELP in children is gen- CASE REPORT erally supportive, with the symptoms and roentgeno- A 6-year-old white boy with a history of developmental delay graphic abnormalities resolving within months after and a seizure disorder was found to have an infiltrate in his RUL stopping the use of mineral oil. on a CXR obtained during an orthopedic evaluation for thoracic Conclusion. Lipoid pneumonia as a result of mineral scoliosis. He had no signs or symptoms of respiratory disease at oil aspiration still occurs in the pediatric population. It that time. He was treated with one 10-day course each of amoxi- cillin with clavulanic acid and cefazolin during a 2-month period. can mimic other diseases because of its nonspecific clin- The patient continued to be asymptomatic, but a follow-up CXR ical presentation and radiographic signs. In patients with showed persistence of the infiltrate and the patient was referred to swallowing dysfunction and pneumonia, a history of our center for further evaluation. The patient had a long history of mineral oil use should be obtained and a diagnosis of constipation with daily use of mineral oil. He was fed by mouth ELP should be considered in the differential diagnoses if and had occasional episodes of coughing and choking during mineral oil use has occurred. Our case points to the need feeding. for increased awareness by the general pediatricians of Physical examination was unremarkable except for findings the potential hazards of mineral oil use for chronic related to his chronic neurologic and orthopedic problems. The CXR (Fig 1) showed a dense alveolar infiltrate in the anterior and posterior segments of his RUL. These findings were unchanged from those noted on the initial CXR taken 3 months earlier. The From the *Department of Pediatrics, Tulane University School of Medicine, patient was started on an empiric treatment with clarithromycin New Orleans, Louisiana; and the ‡Department of Chemistry, Millsaps and advised to stop administration of the mineral oil. Laboratory College, Jackson, Mississippi. evaluation included a normal complete blood count and differen- Received for publication Jul 13, 1998; accepted Sep 21, 1998. tial, a stool specimen negative for ova and parasites, a negative Reprint requests to (S.H.D.) Department of Pediatrics SL-37, 1430 Tulane IgG titer for Mycoplasma pneumoniae, and a normal total IgE. A Ave, New Orleans, LA 70112. purified protein derivative skin test was negative. At follow-up PEDIATRICS (ISSN 0031 4005). Copyright © 1999 by the American Acad- evaluation, 1 month after discontinuation of mineral oil use, he emy of Pediatrics. continued to be asymptomatic, and a repeat CXR at that time http://www.pediatrics.org/cgi/content/full/103/2/Downloaded from www.aappublications.org/newse19 PEDIATRICSby guest on September Vol. 10328, 2021 No. 2 February 1999 1of4 choscopy with bronchoalveolar lavage (BAL) was performed. Bronchoscopic findings included normal airway anatomy except for mild erythema around the posterior segmental bronchus of the RUL. BAL was done in this segment and the recovered fluid was milky white in appearance, with fat globules floating on the surface. Oil red O staining of BAL fluid demonstrated high numbers of lipid-laden macrophages (Fig 3) with an index of 2806 and free droplets of extracellular oil. Viral, bacterial, fungal, and mycobacterial studies on the BAL specimen were negative. To confirm the exogenous origin of the lipid, BAL fluid and a sample of the patient’s mineral oil were analyzed by gas chromatography/mass spectrometry. The analysis demonstrated identical retention time and the same mass spectrum between the BAL fluid and the patient’s mineral oil sample (Fig 4). The mass spectrum of the BAL was matched to a library of lipid standards including the mass spectrum of the patient’s mineral oil using commercial spectrum identification software. This computer analysis indicated a 99.99% likelihood that the BAL sample matched that of the patient’s mineral oil. Three months after the bronchoscopic examination, the patient was in his usual state of health without any respiratory symptoms and the infiltrate persisted on CXR. Because the patient was asymptomatic and the pathology was focal, no further specific therapeutic interventions were done. Periodic follow-up at 6-month intervals was recommended.

DISCUSSION Mineral oil is commonly prescribed for the treatment of constipation in children and adults. Annu- ally, 2 million to 3 million people are prescribed Fig 1. cathartics and laxatives by physicians in the United Chest radiograph shows a dense alveolar infiltrate in the 7 anterior and posterior segments of the right upper lobe. States. These estimates do not include self-medica- tion, because mineral oil can be purchased without prescription. Consequently, mineral oil can be a com- revealed no change in the infiltrate. A computed tomographic mon household product and children are at addi- scan of the chest done at this time showed a dense infiltrate in the anterior and posterior segments of the RUL without any hilar tional risk from accidental ingestion. Because of its lymphadenopathy, volume loss, mass, or airway compression (Fig high viscosity, mineral oil depresses the cough reflex 2). A 24-hour esophageal pH probe was negative for gastroesoph- facilitating aspiration even in normal persons, and ageal reflux. A modified barium swallow showed a disordered patients with swallowing dysfunction are at an ad- oral phase of swallowing with poor labial seal, drooling, anterior loss of the bolus, difficulty in manipulating the bolus, and diffi- ditional increased risk. In adults, 25% of cases of culty in propelling the bolus posteriorly. exogenous lipoid pneumonia (ELP) have been re- In view of the persistent radiologic opacity, a diagnostic bron- ported in normal individuals without any predispos-

Fig 2. Computed tomography scan of the chest shows the dense alveolar infiltrate in the anterior and posterior segments of right upper lobe.

2of4 LIPOID PNEUMONIADownloaded FROM from MINERAL www.aappublications.org/news OIL ASPIRATION by guest on September 28, 2021 Fig 3. Oil red O staining of bronchoalveolar fluid shows the lipid-laden macrophages.

ranges from the totally asymptomatic patient with incidental radiologic finding, like our patient, to the patient with acute or chronic symptoms as a result of pneumonia, pulmonary fibrosis, or cor pulmonale.11 Laboratory tests may show peripheral blood poly- morphonuclear leukocytosis with an elevated eryth- rocyte sedimentation rate. Roentgenographic findings are nonspecific with alveolar consolidation and ground glass opacities being the most frequent pat- tern.8 The distribution of radiologic changes can vary from bilateral abnormalities to focal changes. Computed tomographic scans can measure the density of the parenchymal lesions and can be diagnostic. A negative density between Ϫ150 and Ϫ30 Hounsfield Units is highly suggestive of intrapulmo- nary fat.12 The computed tomography scan performed on our patient was done at another hospital Fig 4. Gas chromatography/mass spectrometry analysis of bron- and density measurements were not done. Open- choalveolar lavage sample compared with standard (patient’s lung biopsy has been used as a diagnostic method,13 mineral oil) shows identical retention time and same mass spec- but carries the disadvantage of being a much more trum between standard and bronchoalveolar lavage sample. invasive procedure. Bronchoscopy with BAL has been reported to be ing factors.8 Once deposited in the alveoli, mineral oil successful in establishing the diagnosis of ELP. The can lead to chronic alveolar and interstitial inflam- macroscopic appearance of BAL with fat globules on mation leading to ELP. the fluid surface and the cytologic demonstration of 14 In a majority of cases, ELP is a result of mineral oil lipid-laden macrophages is consistent with the di- given orally for medicinal purposes. Aspiration is the agnosis of ELP. Kameswaran et al15 reported a series common mechanism, although it has been reported of 24 cases of lipoid pneumonia in children, 22 of after rectal administration as a result of mineral oil which were diagnosed by rigid bronchoscopy with embolization9 and from excessive use of lip balm.10 BAL. Bronchoscopy has the additional advantage of Because mineral oil is a tasteless substance, infants assessment of airway anatomy to rule out other and small children often object vigorously to its oral causes of chronic nonresolving pneumonia. Al- administration, resulting in gagging that precipitates though the demonstration of a high lipid-laden mac- aspiration. Patients with neurologic impairment and rophage index is diagnostic of lipoid pneumonia, an associated swallowing dysfunction are particu- additional diagnostic tests like the chemical analysis larly vulnerable to aspiration, as was the case with of BAL fluid may be necessary to confirm the exog- our patient. The clinical presentation of ELP is non- enous nature of lipid. specific and probably depends on the age of the Infants and children account for a minority of re- patient, the volume of the aspirate, and the chronic- ported cases of lipoid pneumonia. Consequently, the ity of aspiration. Accordingly, the presentation natural history of ELP in children cannot be accu-

Downloaded from www.aappublications.org/newshttp://www.pediatrics.org/cgi/content/full/103/2/ by guest on September 28, 2021 e19 3of4 rately derived from case reports. Elston16 reported a istration, and in developmentally delayed children fatal case of ELP in a 9-month-old girl as a result of with or without swallowing dysfunction. mineral oil aspiration. De la Rocha et al17 reported a 13-month-old infant with accidental aspiration of ACKNOWLEDGMENT mineral oil who had a severe protracted clinical This work was supported by Grant MCJ-229163 from the course with chronic lung disease requiring supple- Maternal and Child Health Bureau. mental oxygen for a 5-month period. Fan and Gra- REFERENCES ham13 reported a 4-month-old infant with respiratory 1. Fleisher DR. Diagnosis and treatment of disorders of defecation in distress and hypoxemia with a history of mineral oil children. Pediatr Ann. 1976;5:700–722 administration at age 2 weeks who improved slowly. 2. Levine MD. 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Downloaded from www.aappublications.org/news by guest on September 28, 2021 Lipoid Pneumonia: A Silent Complication of Mineral Oil Aspiration Hari P. R. Bandla, Scott H. Davis and Nancy Eddy Hopkins Pediatrics 1999;103;e19 DOI: 10.1542/peds.103.2.e19

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