View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector Respiratory Medicine CME 4 (2011) 75e78 Contents lists available at ScienceDirect Respiratory Medicine CME journal homepage: www.elsevier.com/locate/rmedc Case Report Nocardia and Mycobacterium fortuitum infection in a case of lipoid pneumonia Ashfaq Hasan a,b, T.L.N. Swamy b,* a Department of Respiratory Medicine, Owaisi Hospital and Research Centre, Hyderabad, India b Department of Pulmonology, Care Hospitals, Banjara Hills (Road No.1), Hyderabad-500034, A.P., India article info abstract Article history: Exogenous lipoid pneumonia is a potential problem with any form of oil aspiration. The association of Received 11 August 2010 Mycobacterium fortuitum with lipoid pneumonia is a rare occurrence and ascribed to as yet-unknown Accepted 2 September 2010 interplay between the oil in the pulmonary parenchyma and the waxy Mycobacterial cell wall. We describe a case of lipoid pneumonia due to “oil aspiration”, complicated by infection with Mycobacterium Keywords: fortuitum as well as Nocardia, in an individual with no obvious immune deficiencies. Lipoid Ó 2010 Published by Elsevier Ltd. Nocardia Mycobacterium 1. Introduction revealed sparse crackles in the right inframammary area and also bilaterally in the infrascapular areas. Lipoid pneumonia is a chronic inflammatory reaction of the The total leucocyte count was 16.9 Â 103 (Neutrophils 80%), and lungs to the presence of lipid substances. It is of two types, exog- the Erythrocyte Sedimentation Rate (ESR) 60 mm. Human Immu- enous and endogenous. The endogenous variety is due to release of nodeficiency Virus (HIV) test was negative. The chest radiograph lipids from lysis of lung tissue on account of tumor, drugs, radiation, showed bilateral basal patchy consolidation, much more prominent etc. Exogenous lipoid pneumonia results from the aspiration of on the right side (see Fig.1). A Computerized Tomographic (CT) scan vegetable, animal, or most commonly mineral oils. The presence of of the chest showed dense consolidation with an airbronchogram a lipoid environment seems to favour Mycobacterium fortuitum in the right middle lobe and alveolar infiltration in left lingula and infection. We present such a case with exogenous lipoid pneu- both the lower lobes (see Fig. 2). These showed a moderate degree monia associated with Mycobacterium fortuitum infection super- of heterogenous post-contrast enhancement. Multiple nodular added with Nocardia infection. opacities were also observed in both lungs. Sputum showed acid- fast bacteria (grade 3þ) on direct staining. 2. Case history Since it was thought that tuberculosis could not by itself explain the radiological abnormalitydparticularly the nodular- d A 60-year-old male presented to the outpatient department ity the consolidated area was targeted with a CT guided trans- with fever of four days duration, and cough with scanty expecto- thoracic needle aspiration. Cytological features of granulomatous fl ration. The patient, a non-smoker, had been involved in running in ammation were seen. The stains were positive for fat globules a paper-manufacturing unit until eight years ago. Three years ago (see Fig. 3). Acid-fast bacilli were noted, along with the charac- fi he had been treated for pulmonary tuberculosis of the right middle teristic delicate gram-positive weakly acid-fast laments of fi lobe (Brock’s syndrome), and he had completed the complete Nocardia (see Fig. 4). Culture of both the sputum and the ne- course of anti-tubercular therapy with good compliance. needle aspirate grew Mycobacterium fortuitum which eventually fl fl One month ago, the patient accidentally drank coconut oil showed sensitivity to ethambutol, spar oxacin, o oxacin, cap- d stored in a drinking water bottle and had a choking episode fol- reomycin and amikacin and resistance to streptomycin, iso- lowed by cough that lasted a few days. General examination was niazide, rifamycin, pyrazinamide and clofazimine. mostly unremarkable, and there was no obvious clubbing or The patient, who had already been started on the standard four- superficial lymphadenopathy. Physical examination of the chest drug anti-tubercular therapy plus sulphonamides, was commenced on ofloxacin, amikacin and clarithromycin. Pyrazinamide was withdrawn. At the end of eighteen months, the patient had shown * Corresponding author. Tel.: þ91 9849808430. complete clinical and radiological recovery (see Fig. 5), and treat- E-mail address: [email protected] (T.L.N. Swamy). ment was discontinued. 1755-0017/$36.00 Ó 2010 Published by Elsevier Ltd. doi:10.1016/j.rmedc.2010.09.001 76 A. Hasan, T.L.N. Swamy / Respiratory Medicine CME 4 (2011) 75e78 Fig. 3. Fine needle aspiration cytology of lung showing fat globules (arrows) within Fig. 1. Chest radiograph showing right middle lobe consolidation with left mid zonal the macrophages. infiltration. these are hydrolysed into fatty acids by lung lipases). Lipases digest 3. Discussion the lung parenchyma and evoke a vigorous inflammatory response. Vegetable oils can be aspirated during feeding or during emesis and Lipoid pneumonia is of two types: endogenous and exogenous. have a highly variable effect. Several individuals have associated In the endogenous variety there is lysis of lung tissue distal to an esophageal problems predisposing to aspiration. Lipoid pneumonia obstruction by tumor or broncholitis obliterans. Release of lung has no characteristic radiologic appearances but a “Paraffinoma” lipids can also occur in association with chemotherapy, amiodarone can cast a nodular infiltrate chest x-rays or CT films, and may therapy or radiotherapy. Lipid like material is also found in alveolar present as a “hot spot” on Positron Emission Tomography (PET) proteinosis. Exogenous lipoid pneumonia can occur in a variety of scans mimicking malignancy.3 The diagnosis must therefore be unusual settings such as in blackfat tobacco smoking seen in suspected in the setting of the appropriate history with radiological 1 2 Guyana or by exposure to oil mists, but it most often occurs in the infiltration, usually in the basal segments of the lower lobes, the setting of medicinal use of liquid paraffin for chronic constipation superior segment of the lower lobe or the posterior segment of an by accidental aspiration. Oil based nasal drops can also result in upper lobe. Bronchoalveolar lavage or lung histopathology will lipoid pneumonia, but these are less commonly used nowadays for then usually demonstrate lipid laden foamy macrophages with obvious reasons. Mineral oils being relatively inert are less prone to occasional giant cells. True granulomas are unusual. produce alveolar inflammation (this explains the paucity of The association of Nontuberculous Mycobacteria (NTM) with symptoms in some individuals) than animal fats (such as in milk: lipoid pneumonia has been noticed. It is intriguing that Mycobacteria, possessed of the most complex cell wall in nature (that enabled their survival at the interface of water and soil over the millenia), appear to derive sustenance from the lipids as in lipoid pneumonia. This in some way actually appears to increase Fig. 2. Computerized tomography of chest in the lung window, showing right middle Fig. 4. Fine needle aspiration cytology of the lung showing weakly acid-fast filamen- lobe consolidation with airbronchogram and left lingular alveolar infiltration. tous Nocardia (arrow). A. Hasan, T.L.N. Swamy / Respiratory Medicine CME 4 (2011) 75e78 77 As in the case of this patient, the disease can occur frequently in the apparently immunocompetent. As many as 36% of all Nocardial infections have been shown to occur in individuals in whom no obvious immunodeficiency was identified.5 The vast majority (two thirds) of all cases affect the lungs,9 in keeping with the commonest mode of transmission, inhalation.13 Direct inoculation across skin surfaces by thorn-pricks, trauma, and even nosocomial breaches of skin and mucosal surfaces by catheters and surgical procedures can result in disease.14,15 Pulmonary Nocardiosis can present with a wide spectrum of radiologic findings; solitary or multiple pulmonary nodules, masses, cavities, reticulonodular or airspace infiltrates, pleural effusions and subpleural plaques can all occur. Since upper lobe lesions are common it is not unusual to see patients receive several weeks of anti-tubercular therapy before appropriate treatment is begun (in one study the mean period between the onset of symp- toms and diagnosis was twelve months).16 The key to diagnosis is a high index of suspicion in a patient with a non-resolving pleural or pulmonary pathology with the above-mentioned co-morbid- Fig. 5. Chest radiograph repeated after completion of treatment showing complete resolution of the right and left mid zonal lesions. ities; or a lung pathology that is associated with brain (Nocardia has a special affinity for the CNS), skin or other soft tissue lesions. A diagnostic intervention in the setting of an unknown lesion often their pathogenicity. Runyon’s (now outdated) classification of 1959 provides the first clue.16 Nocardiae are not normal colonials of the enabled labs to organize NTM. Rapidly growing Mycobacteria tracheobronchial tree, and therefore a sputum isolate of Nocardia is (RGM), by definition grows relatively quickly in culture, and growth almost always significant.17 The visualization of the characteristic is generally apparent within a week. M. fortuitum the most delicate acid-fast filamentous rods