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Exogenous Lipoid Pneumonia. Clinical and Radiological Manifestations

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Exogenous Lipoid Pneumonia. Clinical and Radiological Manifestations View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector Respiratory Medicine (2011) 105, 659e666 available at www.sciencedirect.com journal homepage: www.elsevier.com/locate/rmed REVIEW Exogenous lipoid pneumonia. Clinical and radiological manifestations Edson Marchiori a,b,*, Gla´ucia Zanetti b,c, Claudia Mauro Mano a,d, Bruno Hochhegger b,e a Fluminense Federal University, Rio de Janeiro, Brazil b Federal University of Rio de Janeiro, Rio de Janeiro, Brazil Received 19 August 2010; accepted 1 December 2010 Available online 23 December 2010 KEYWORDS Summary Exogenous lipoid Lipoid pneumonia results from the pulmonary accumulation of endogenous or exogenous lipids. pneumonia; Host tissue reactions to the inhaled substances differ according to their chemical characteris- Computed tomography; tics. Symptoms can vary significantly among individuals, ranging from asymptomatic to severe, Aspiration pneumonia; life-threatening disease. Acute, sometimes fatal, cases can occur, but the disease is usually Bronchoalveolar lavage; indolent. Possible complications include superinfection by nontuberculous mycobacteria, Lung diseases pulmonary fibrosis, respiratory insufficiency, cor pulmonale, and hypercalcemia. The radiolog- ical findings are nonspecific, and the disease presents with variable patterns and distribution. For this reason, lipoid pneumonia may mimic many other diseases. The diagnosis of exogenous lipoid pneumonia is based on a history of exposure to oil, characteristic radiological findings, and the presence of lipid-laden macrophages on sputum or BAL analysis. High-resolution computed tomography (HRCT) is the best imaging modality for the diagnosis of lipoid pneu- monia. The most characteristic CT finding in LP is the presence of negative attenuation values within areas of consolidation. There are currently no studies in the literature that define the best therapeutic option. However, there is a consensus that the key measure is identifying and * Corresponding author. Rua Thomaz Cameron, 438, Valparaiso, CEP 25685.120, Petro´polis, Rio de Janeiro, Brazil. Tel.: þ55 (24) 22492777; fax: þ55(21)26299017. E-mail addresses: [email protected] (E. Marchiori), [email protected] (G. Zanetti), [email protected] (C.M. Mano), [email protected] (B. Hochhegger). c Rua Coronel Veiga, 733/504. Centro, CEP 25655-504, Petro´polis, Rio de Janeiro, Brazil. Tel.: þ55(24)22429156. d Rua Dr. Paulo Alves, 110/802 E. Inga´, CEP 24210-445, Nitero´i, Rio de Janeiro. Brazil. e Rua Joa˜o Alfredo, 558/301, CEP 90050-230, Porto Alegre, Brazil. 0954-6111/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.rmed.2010.12.001 660 E. Marchiori et al. discontinuing exposure to the offending agent. Treatment in patients without clinical symp- toms remains controversial, but in patients with diffuse pulmonary damage, aggressive thera- pies have been reported. They include whole lung lavage, systemic corticosteroids, and thoracoscopy with surgical debridement. ª 2010 Elsevier Ltd. All rights reserved. Contents Definition and classification . ...........................................................660 Etiopathogenesis and pathophysiology . .....................................................660 Clinical findings . .....................................................................661 Diagnosis . ...........................................................................661 Clinical history ...................................................................661 Bronchoalveolar lavage .............................................................661 Chest radiograph . ...............................................................662 Computed tomography .............................................................662 Histopathology ...................................................................663 Complications . .....................................................................664 Treatment ...........................................................................664 Natural history and outcome . ...........................................................664 Conflict of interest statement . ...........................................................665 References ..........................................................................665 Definition and classification Chronic constipation is a frequent symptom in the pedi- atric population. Mineral oil is also used in children for partial 12,13 Several pulmonary complications may be caused by the small bowel obstruction by Ascaris lumbricoides. aspiration of different substances into the airways and However, it must be remembered that infants and small children often object vigorously to ingest the oil, resulting in airspaces. Lipoid pneumonia (LP) is an uncommon condition 14 that results from the pulmonary accumulation of fatlike gagging that precipitates aspiration. compounds of animal, vegetable or mineral origin.1,2 It can Different substances called pyrofluids are used by “fire- be classified into endogenous and exogenous forms. eaters” (performers that “swallow” or “spit” fire). The most In endogenous form, also called “cholesterol” or common is the petroleum-derivative kerdan, characterized by “golden” pneumonia, the fatlike materials are derived from its reduced viscosity and rapid diffusion throughout the bron- 3,4 chial tree. After flame blowing, the fire-eater takes a deep the lung itself. It usually develops when lipids that nor- 8 mally reside in the lung tissue e most commonly cholesterol breath, and can aspirate the kerdan remaining in the mouth. and its esters e are released from destroyed alveolar cell It is noteworthy that fire-eater pneumonitis has morpho- walls distal to an obstructive airway lesion or from lung logical, radiographic and clinical profiles entirely different tissue damaged by a suppurative process, or due to lipid from chronic lipoid pneumonia. The history of accidental storage diseases.3,5,6 aspiration during “fire-eating” demonstrations is character- The exogenous form can be classified into acute and istic. Symptoms occur in the first 12 h after aspiration, and chronic. Chronic exogenous LP results from long-term, include chest pain, dyspnea, cough, fever, and hemoptysis. recurrent inhalation exposure to oil, while the acute form is The disease has, in most of cases, a favorable evolution. The HRCT usually shows bilateral lung consolidations, often secondary to accidental aspiration of a large quantity of 8 lipid material over a short period of time.7,8 associated with cavitary lesions (pneumatoceles). Other less commonly reported causes of LP include: aspiration of milk,15,16 poppy seed oil,3 and egg yolk16; Etiopathogenesis and pathophysiology occupational exposure to paraffin (paraffin droplets released by machines) in cardboard crockery factories17; oil Exogenous LP is caused by the inhalation of oils present in blasting in industries; use of spray paint18; contact with food, radiographic contrast media, or oil-based medica- plastic paint19; aspiration of oils used in industry as lubri- 1,9 tions such as laxatives. Traditional oil-based popular cants and cutting fluids, in either fluid or spray form, for medicines are used to treat various diseases in children, turning, milling and grinding operations3; cleaning of new 10 and are often associated with respiratory diseases. In cars protected by paraffin, using hot water generated by adults, most cases result from the use of oil-based laxatives compressed air jets20; cleaning oil-containing vats; (olive oil, cod liver oil and paraffin oil) for the treatment of siphoning diesel fuel19,21; smoking blackfat tobacco, a Ken- constipation, followed by the nasal instillation of oily tucky product coated with oil and petroleum jelly to flavor 3,11 products for chronic rhinopharyngeal diseases. and moisturize the leaf6; accidental aspiration of vaseline Exogenous lipoid pneumonia 661 used in the placement of nasogastric tubes22; longstanding pneumonia usually presents with chronic cough, sometimes use of petroleum jelly (Vaseline, Vicksä) at bedtime23; productive, and dyspnea.40 Less common problems include aspiration of spray lubricant WD-40 (very popular oil spray, chest pain, hemoptysis, weight loss, and intermittent fever. for home use)24; excessive use of lip balm (Chap Stick, Physical examination of the chest may be normal or may a lipstick that contains petrolatums and lipids) and of present dullness to percussion, crackles, wheezes, or rhonchi.6 flavored lip gloss6; and facial application of petrolatum for Most cases of lipoid pneumonia shows a discrepancy in erythrodermic psoriasis.25 Some authors also described the severity between the radiological and clinical findings. development of LP secondary to suicide attempt by mineral Patients are often asymptomatic with extensive imaging oil immersion.21,26 findings, which are discovered incidentally on routine chest Factors that increase the risk of exogenous LP include radiographs.2,6,28 extremes of age; anatomical or structural abnormalities of the Extrathoracic symptoms, such as vomiting, stomach pharynx and esophagus, such as Zenker diverticulum, gastro- pain, dysphagia, vertigo and fainting, are occasionally esophageal fistula, hiatal hernia, gastroesophageal reflux, described in the literature.8 The presence of hypertrophic achalasia; psychiatric disorders; episodes of loss of osteoarthropathy has been reported in a five-year-old child consciousness; neuromuscular disorders
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