SPR Unknown # 90 -- FINAL

Kiery Braithwaite, MD

Emory University and Children’s Healthcare of Atlanta

Ellen Patrick, MD

Emory University and Children’s Healthcare of Atlanta

Daniel Torrez, MD

Emory University and Children’s Healthcare of Atlanta


Publication Date: 2013-06-29

History

8 month old Hispanic male presented with cough, increased work of breathing, and non-bilious emesis. Patient also has failure to thrive. Patient had just two weeks previously been admitted to our facility for fever and tachypnea, and was treated for pneumonia after an abnormal chest radiograph. Patient’s past medical history includes full term birth and a hospitalization at 3 months of age, at an outside facility, for 4 days for pneumonia. There is also a history of colic, which the family treats by giving their son olive oil by mouth. No known travel history.

Findings

Chest radiograph demonstrates bilateral perihilar air space opacities. CT scan of the chest revealed extensive bilateral alveolar air space disease, involving primarily the posterior portions of bilateral lower lobes, but to a lesser extent the right middle lobe and lingula. No bronchiectasis.

Diagnosis

LIPOID PNEUMONIA

Discussion

In our particular patient, the lack of improvement in the chest radiograph despite antibiotics, combined with the CT findings suggested lipoid pneumonia as a possible etiology. Further questioning of the parent’s, through a Spanish interpreter, confirmed that they had been giving their son olive oil by mouth. A subsequent bronchoscopy with bronchioalveolar lavage demonstrated normal anatomy with lipid laden macrophages (>100/HPF), establishing the diagnosis of lipoid pneumonia. A subsequent modified barium swallow was negative for aspiration.

Lipoid pneumonia results from the aspiration of animal fat, vegetable or mineral oils. Oils are non irritating and do not incite a gag reflex, and thus can be easily silently aspirated, even in normal children. The most common presenting symptoms in children include cough, mild fever, and progressive dyspnea.

Prior studies have demonstrated that administration of olive oil and butter are common traditional home therapies in many cultures, including Saudi Arabia, southern India, Mexico, and Brazil. They are most commonly given intranasally for nasal congestion, and by mouth for colic, fussiness, or abdominal complaints. Other oils, including mineral oil and squalene oils (shark derivative) are more common in Western and Asian cultures.

Severity of the inflammatory reaction is related to the type of oil aspirated, animal fat inciting the most severe inflammatory response, followed by vegetable oils, and then mineral oil. Imaging of the chest with plain films typically demonstrates bilateral air space consolidation. CT typically demonstrates bilateral air space disease, often with air bronchograms, with areas of fat attenuation, areas of ground glass attenuation, and less commonly crazy-paving. Pleural fluid and lymphadenopathy are less common, although small effusions can sometimes be seen. The findings of fat attenuation is certainly helpful, but not always present, possibly due to volume averaging, as was the case in our patient. The lower lobes are almost always involved, predominantly posteriorly. In one study in 17 children who aspirated mineral oil, the lower lobes were abnormal in all children, followed by, in descending order the right upper lobe, right middle lobe, lingula, and finally the left upper lobe.

Bronchoscopy with bronchoalveolar lavage will reveal lipid-laden macrophages. Lung biopsy, although more invasive, has also been reported. Treatment is generally supportive, with cessation of the offending agent.

Files

References

  1. Hugosson CO, Riff EJ, Moore CCM, Akhta M, Tufenkeji HT. Lipoid pneumonia in infants: a radiological-pathological study. Pediatr Radiol 1991; 21: 193-197.
  2. Zanetti G, Marchiori E, Gasparetto TD, Escuissato DL, Souza AS. Lipoid pneumonia in children following aspiration of mineral oil used in the treatment of constipation: high resolution CT findings in 17 patients. Pediatr Radiol 2007; 37: 1135-1139.
  3. Hoffman LR, Yen, EH, Kanne JP, Effmann EL, Gibson RL, Van Niel CW. Lipoid pneumonia due to Mexican folk remedies. Arch Pediatr Adolesc Med 2005; 159: 1043-1048.
  4. Baron SE, Haramati LB, Rivera VT. Radiological and clinical findings in acute and chronic exogenous lipoid pneumonia. J Thorac Imaging 2003; 18(4): 217-224.

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