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Lipid Pneumonia

Pneumonia Lipoid

Lipid pneumonia is an uncommon clinical entity in which respiratory architecture is impaired, either as a result of aspiration or accumulation of lipids from different sources (exogenous and endogenous, respectively). Respiratory signs and symptoms are nonspecific. Imaging studies and a detailed patient history are vital components of the diagnostic workup.


Presentation

Lipid pneumonia can arise from two pathways: After topical application and/or repeated aspiration of lipids from food and other products containing lipids (exogenous lipid pneumonia), or due to the breakdown of fats into free fatty acids in the bronchial tree (endogenous lipid pneumonia) [1]. Based on the clinical presentation, lipid pneumonia may be further divided into acute and chronic [1] [2]. Acute exogenous lipid pneumonia is most frequently diagnosed in patients who aspirate a significant quantity of lipids (such as vaseline used for topical application or fat-rich mineral, animal or vegetable oils), the majority being elderly individuals in their sixth or seventh decades or children, many of whom have some pre-existing condition that predisposes them to aspiration [1] [3]. Dyspnea, cough, and low-grade fever are main symptoms that appear within the first hour after introduction of lipids into the lungs [1] [2], whereas chest pain, weight loss, and hemoptysis may be seen in more severe cases, when even respiratory failure and death may occur in the absence of adequate management and a delayed diagnosis [4] [5]. Aspiration of smaller contents of fat is mostly asymptomatic, which is typical for chronic forms of the disease, and the diagnosis is often made incidentally, but chronic persistent cough and dyspnea accompanied by weight loss may appear [1]. Endogenous lipid pneumonia has a similar clinical presentation, and it is associated with various conditions - Niemann-Pick disease, infections, non-small cell lung cancers, and pulmonary alveolar proteinosis (PAP) [1].

Cough
  • Aspiration of smaller contents of fat is mostly asymptomatic, which is typical for chronic forms of the disease, and the diagnosis is often made incidentally, but chronic persistent cough and dyspnea accompanied by weight loss may appear.[symptoma.com]
  • Fever (39%), weight loss (34%), cough (64%), dyspnoea (50%) and crepitations (45%) were the most frequent symptoms.[ncbi.nlm.nih.gov]
  • He was fed by mouth and had occasional episodes of coughing and choking during feeding. He was asymptomatic at presentation and physical examination was unremarkable.[ncbi.nlm.nih.gov]
  • Patient 2 was a diebetic who presented with a 4 month history of cough productive of white sputum and worsening shortness of breath. No history of other respiratory illness or any exposure history was obtained.[occupationalasthma.com]
  • The usual presentation occurs with insidious onset and nonspecific respiratory symptoms such as dyspnea and/or cough.[ncbi.nlm.nih.gov]
Chronic Cough
  • Symptomatic patients most frequently present with chronic cough or dyspnea.[dx.doi.org]
  • These symptoms include shortness of breath and chronic cough, which may be productive. Hemoptysis, weight loss, chest pain, and intermittent fevers are seen less commonly.[atsjournals.org]
Dry Cough
  • An established risk factor is the presence of chronic GVHD, in view of the inflammation and progressive fibrosis of the lung tissues that appear in graft disease. 2,9,13,30,35 Fever associated to dry cough and tachypnea, with interstitial infiltrates[medintensiva.org]
Seizure
  • Other features of these cases are: Patient 1 is a 56 year old poorly controlled epileptic, whose mother regularly applied Vicks Vaporub into each nostril during grand mal seizures.[occupationalasthma.com]
Meningism
  • […] incidental post mortem finding associated with debilitating disease Lipid either exogenous (from nasal sprays or inhalation of other lipid containing substances) or endogenous (bronchial obstruction) Case reports 1 year old man with recent history of meningitis[pathologyoutlines.com]

Workup

Because symptoms of lipid pneumonia are non-specific and may mimic various other respiratory diseases (infections, malignancies, autoimmune disorders, etc.), a thorough diagnostic workup is mandatory, as lipid pneumonia is often diagnosed after a significant delay in many patients [6]. Having in mind the fact that auscultation of the lungs may frequently reveal no pathological findings (although wheezing or crepitations can be noted in severe cases), a detailed patient history is perhaps the most important part of the assessment of respiratory symptoms. Recent or chronic use of topical fat-containing creams or drugs or the appearance of symptoms after consumption of fat-rich foods, especially in elderly and children, is a valuable information. Imaging studies, however, are vital in order to distinguish fat accumulation from tumors or focal infections, and plain radiography, but more commonly, computed tomography (CT) are widely recommended early on [2] [3] [4] [6]. Pulmonary opacities are seen after 24 hours in virtually all patients who develop acute symptoms, and their appearance depends on the extent of aspirated or accumulated fat. In most cases, ground-glass or consolidative opacities that are distributed segmentally or within a pulmonary lobe, usually in the middle or lower segments, are typical for lipid pneumonia, whereas pneumatoceles, pneumothorax, pleural effusions and pneumomediastinum may also be encountered, indicating a poorer prognosis [1] [3]. CT of the chest can distinguish lipid structures due to their low attenuation and thickening of the intralobular septa, known as "crazy paving pattern" [2]. Magnetic resonance imaging (MRI) is sometimes employed when CT and radiography yield inconclusive findings, but the use of bronchoalveolar lavage (BAL) or bronchoscopy as a tool to obtain a viable sample for biopsy was necessary for a significant number of patients, and histopathological confirmation of lipid droplets in alveoli and local macrophages serves as a definite method [1] [4] [6].

Pulmonary Infiltrate
  • Two years after discontinuing ⿿baby body oil therapy⿿, a chest CT scan revealed partial regression of pulmonary infiltration.[elsevier.pt]
  • Deposition of mineral oil in the lung may be associated with an asymptomatic, incidentally discovered pulmonary infiltrate ( 4 ), or may lead to severe lung disease and death ( 5 ).[ncbi.nlm.nih.gov]
Reticulonodular Pattern
  • pattern CT characteristically show low attenuation within the consolidated areas ( low attenuation consolidation ) of -100 HU reflecting a fat content (at times the attenuation value may be less i.e. around -30 HU and higher than that of subcutaneous[radiopaedia.org]
  • Other methods used for the diagnosis of lipoid pneumonia include: X-ray Consolidation Irregular mass (lesion/reticulonodular pattern) Chest HRCT/contrast CT Low attenuation with consolidation areas Associated ossific foci are present in the affected region[heydoctor.org]

Treatment

  • Margaret W.Leigh consulted on the treatment plan, critically reviewed the manuscript and contributed to the discussion. Terry L. Noah developed the treatment plan and critically reviewed the manuscript.[doi.org]
  • She had received multiple mineral oil enemas and irrigations as treatment for impacted stools. Mineral oil peritonitis was present on the surface of the bowel adjacent to the stoma and covered large portions of the surface of the liver and spleen.[ncbi.nlm.nih.gov]
  • Treatment [ edit ] Treatment is with corticosteroids and possibly intravenous immunoglobulins.[en.wikipedia.org]
  • Treatment These are the most common treatments recommended for lipoid pneumonia: Corticosteroids Immunoglobulins – intravenous administration. For the symptoms of the exogenous lipoid pneumonia to improve, no treatment is necessary.[heydoctor.org]
  • If treatment is needed, therapeutic bronchoalveolar lavage may remove substantial quantities of lipid from the alveoli; episodes of secondary bacterial infection require antibiotic treatment....[oxfordmedicine.com]

Prognosis

  • The prognosis in this entity is usually good and complications are rare. We report an unusual case of chronic lipid pneumonia complicated with massive haemoptysis who responded to steroid therapy after arterial embolization.[ncbi.nlm.nih.gov]
  • Prognosis It is possible that the endogenous lipoid pneumonia appears prior to other medical conditions, such as the pulmonary alveolar proteinosis.[heydoctor.org]
  • […] are distributed segmentally or within a pulmonary lobe, usually in the middle or lower segments, are typical for lipid pneumonia, whereas pneumatoceles, pneumothorax, pleural effusions and pneumomediastinum may also be encountered, indicating a poorer prognosis[symptoma.com]
  • Prognosis [ edit ] Endogenous lipoid pneumonia and non-specific interstitial pneumonitis has been seen prior to the development of pulmonary alveolar proteinosis in a child. [5] History [ edit ] Laughlen first described lipid pneumonia in 1925 with infants[en.wikipedia.org]
  • Signal characteristics may reflect fat/paraffin content. usually: T1: high to intermediate signal 7 T2: low to intermediate signal 7 Treatment and prognosis Serial radiographs showing stability may be enough in asymptomatic patients with no background[radiopaedia.org]

Etiology

  • The etiology of PAP includes genetic, primary (anti-granulocyte-macrophage colony-stimulating factor antibodies) and secondary (oncologic, rheumatologic, infectious, chemical and immunologic) causes.[ncbi.nlm.nih.gov]
  • The etiology of PAP includes genetic, primary (anti‐granulocyte‐macrophage colony‐stimulating factor antibodies) and secondary (oncologic, rheumatologic, infectious, chemical and immunologic) causes.[doi.org]
  • However, the clear right predominance of lesions gave primary support to the aspiration etiology of lesions. Laboratory blood findings (hematology, biochemistry, antibody, tumor markers) were normal.[elsevier.pt]
  • Idiopathic interstitial pneumonias(IIPs) are progressive interstitial lung diseases of unknown etiology with a variety of inflammatory and fibrotic changes.[medphas.kumamoto-u.ac.jp]
  • There is no clear etiological treatment.[medintensiva.org]

Epidemiology

  • The International Journal of Tuberculosis and Lung Disease publishes articles on all aspects of lung health, including public health-related issues such as training programmes, cost-benefit analysis, legislation, epidemiology, intervention studies and[doi.org]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology Lipid pneumonia leads to the appearance of a pale-yellow area on the surface of the lungs. Because of this characteristic appearance, this condition is sometimes presented as “golden pneumonia”.[heydoctor.org]

Prevention

  • "Lipoid pneumonia: An unusual and preventable illness in elderly patients". Canadian Family Physician. 61 (9): 775–777. PMC 4569110. PMID 26371101. "Pulmonary Pathology". Retrieved 21 November 2008.[en.wikipedia.org]
  • (November 6, 2017) Centers for Disease Control and Prevention. CDC Features: Pneumonia can be prevented—vaccines can help. Available online at . Accessed on September 8, 2018. (November 10, 2017) Centers for Disease Control and Prevention.[labtestsonline.it]
  • Use of azathioprine with steroids has been reported in pulmonary fibrosis patients to prevent progression of fibrosis [6,7].[indianpediatrics.net]
  • Optimization of oral hygiene and regular care by a dentist may help prevent development of pneumonia or abscess in patients who repeatedly aspirate.[merckmanuals.com]

References

Article

  1. Betancourt SL, Martinez-Jimenez S, Rossi SE, Truong MT, Carrillo J, Erasmus JJ. Lipoid pneumonia: spectrum of clinical and radiologic manifestations. AJR Am J Roentgenol. 2010;194(1):103-109.
  2. Simmons A, Rouf E, Whittle J. Not Your Typical Pneumonia: A Case of Exogenous Lipoid Pneumonia. J Gen Intern Med. 2007;22(11):1613-1616.
  3. Bell MM. Lipoid pneumonia: An unusual and preventable illness in elderly patients. Can Fam Physician. 2015;61(9):775-777.
  4. Harris K, Chalhoub M, Maroun R, Abi-Fadel F, Zhao F. Lipoid pneumonia: a challenging diagnosis. Heart Lung. 2011;40(6):580-584
  5. Buda P, Wieteska-Klimczak A, Własienko A, et al. Lipoid pneumonia--a case of refractory pneumonia in a child treated with ketogenic diet. Pneumonol Alergol Pol. 2013;81(5):448-452.
  6. Hadda V, Khilnani GC. Lipoid pneumonia: an overview. Expert Rev Respir Med. 2010 Dec;4(6):799-807.

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Last updated: 2019-07-11 21:55