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Lipoid Cell Pneumonia: Report of a Case
Lipoid Cell Pneumonia: Report of a Case JOSEPH M. MILLER, M.D. and MILTON GINSBERG, M.D.Ft. Howard, Maryland
A moderate degree of interest in lipoid cell pneumonia has been reflected in a number of reports in the literature to which we desire to add the following case. V.H.B. (R-27,1l8), a 60 year old white male was admitted to the Veterans Administration Hospital on July 2, 1949, with a history of recurrent hemoptysis for about one month. A cough, productive of about 120 cc, of purulent sputum a day , which did not contain blood grossly, was present in June, 1949. A moderate degree of weakness, anorexia and pain in the right side of the thorax and the loss of a small amount of weight were associated with the cough. A mucopurulent exudate was present in both ears and the tympanic membranes were scarred and retracted. Loud wheezes which disappeared on coughing were present over the upper lobe of the right lung. A systolic murmur over the apex of the heart and a harsh systolic aortic murmur were present. The blood pressure was 126/90. The roentgenogram of .the chest (Flgure 1) showed an irregular infiltration in the right lung field extending out from the hilum. A second roentgenogram taken about two weeks later was the same. Blood counts, Eagle flocculation and urinalysis were normal. Numerous examinations of the sputum were negative for acid fast bacilli, fungi, parasites and neoplastic cells. Bronchoscopy on July 15 showed a slightly thickened carina and a marked degree of inflammation about the or1fice to the upper lobe of the right lung. Bronchial washings were negative for fungi, parasites and neoplastic cells. Bronchoscopy on August 2 showed chronic inflammation of the right bronchial tree and a localized area of thickened tissue about three em. below the carina on the medial wall of the left main bronchus. Biopsy from this area showed normal bronchial mucosa. Cough during the period of stay in the hospital was slight and productive. The temperature remained normal. The patient was discharged on August 30 with a diagnosis of fibrosis of the upper lobe of the right lung due to an undetermined cause. When seen as an out-patient on September 30, the patient stated that he was well. The patient was admitted again to the hospital on October 4, 1950. A productive cough with occasional hemoptysis had been present for about six weeks . Pain in the chest had been present for about six weeks. The roentgenogram of the chest showed a scattered infiltration in the upper lobe of the right lung (Flgure 2). The roentgenologist thought that the lesion now might be a carcinoma. Bronchoscopy on October 13 showed chronic inflammation of the right bronchial tree. Bronchial washings from the upper lobe of the right lung revealed cells interpreted as being normal bronchial mucosa. Since the diagnosis in this individual was still in doubt, an exploratory thoracotomy was done. A firm, rubbery mass was found in the upper lobe of the right -Department of Surgery, Veterans Administration, Fort Howard, Maryland. Reviewed in the Veterans Admlnlstration and published with the approval of the Chief Medical Director. The statements and conclusions published by the authors are the result of their own study and do not necessarily reflect the opinion or policy of the Veterans Administration. 452
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Figure 1: Roentgenogram of chest on July 21, 1949, showing irregular infiltration in right lung.-Figure 2: Roentgenogram of chest on November 17, 1950, showing Increase in area of Infiltration in right lung . - Figure 4: Roentgenogram of chest on April 20, 1951, showing post-operative result.
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454
MILLER AND GINSBERG
Aprll,1953
lung. Extension to the middle or the lower lobe or to the mediastinum had not occurred. The procedure of choice seemed lobectomy which was done. Microscopic examination of the specimen showed severe chronic inflammation. Extensive bronchiectasis with lipoid cell pneumonia was found (Figure 3). When the diagnosis was determined, the patient was questioned about the use of oU. He stated that he had sustained a rupture of both tympanic membranes as the result of blast from the explosion of a shell in World War I and that bUateral chronic otitis media had followed. Pain and the gradual onset of deafness were noted. OUy medication of various types had been put into both aural canals for many years. The postoperative course was uneventful. The patient was discharged from the hospital on December 22. The patient was seen on subsequent visits on January 22 and AprU 20, 1951, when the roentgenogram of the chest was normal (Figure 4). He was completely asymptomatic and had returned to his regula); occupation.
FIGURE 3: Area of lipoid cell pneumonia. Comment
Being an obscure condition presenting a picture of low grade pulmonary infection, lipoid cell pneumonia is difficult to recognize. A high index of suspicion, in a patient with an unusual shadow on the roentgenogram of the chest, should serve to keep the condition in mind. The history should include questions about the administration of oU in the various orifices communicating with the respiratory tract, particularly in the chronically ill and the aged. A history of nasal disease for which intranasal medication was given, the presence of oral pathologic conditions permitting aspiration and the presence of dysphagia will aid in making a diagnosis. The condition has a slow course which mayor may not be
Vol.XXIn
LIPOID CELL PNEUMONIA
455
attended by symptoms. Fat or macrophages containing fat may be isolated from the sputum. Nathanson, Frenkel and Jacobi 1 were able to make a diagnosis of lipoid cell pneumonia by aspiration of the affected area of lung and finding fat in the aspirated cells by microscopic examination. Bchnelder- reports that the roentgenogram is characteristic in that the lesion extends peripherally, atelectatic phenomena are absent and hilar adenopathy is not seen. SUMMARY
Lipoid cell pneumonia is an unusual lesion which may be confused with carcinoma of the lung. A patient with this condition caused by repeated instillation of oily medication for bilateral otitis media wit~ perforation of ear drums is reported. RESUMEN
La neumonla lipoidea es una lesi6n rara que puede ser confundida con el carcinoma del pulm6n. Se comunica un caso de esa afecci6n que fu~ causado por las instllaciones repetidas de medicamentos aceitosos para pertoractones con otitis medta bilaterales de los t1mpanos. RESUME
La pneumonle hulleuse est une leston qui n'est pas trequente et peut se contondre avec Ie cancer du poumon. Les auteurs rapportent l'observation d'un malade qui s'est trouve dans ce cas; la pneumonie hulleuse avait pour cause des instillations repetees d'hulle a la suite d'une perforation d'une otite moyenne bllatlrale des tympans. REFERENCES
1 Nathanson, L., Frenkel, D. and Jacobi, M.: "Diagnosis of Lipoid Pneumonia by Aspiration BiOpsy," Arch. Int. Med ., 72 :627, 1943. 2 SChneider, L.: "Pulmonary Hazard of the Ingestion of Mineral Oil in the Apparently Healthy Adult," H.E.J.M., 240:284, 1949.
A moderate degree of interest in lipoid cell pneumonia has been reflected in a number of reports in the literature to which we desire to add the following case. V.H.B. (R-27,1l8), a 60 year old white male was admitted to the Veterans Administration Hospital on July 2, 1949, with a history of recurrent hemoptysis for about one month. A cough, productive of about 120 cc, of purulent sputum a day , which did not contain blood grossly, was present in June, 1949. A moderate degree of weakness, anorexia and pain in the right side of the thorax and the loss of a small amount of weight were associated with the cough. A mucopurulent exudate was present in both ears and the tympanic membranes were scarred and retracted. Loud wheezes which disappeared on coughing were present over the upper lobe of the right lung. A systolic murmur over the apex of the heart and a harsh systolic aortic murmur were present. The blood pressure was 126/90. The roentgenogram of .the chest (Flgure 1) showed an irregular infiltration in the right lung field extending out from the hilum. A second roentgenogram taken about two weeks later was the same. Blood counts, Eagle flocculation and urinalysis were normal. Numerous examinations of the sputum were negative for acid fast bacilli, fungi, parasites and neoplastic cells. Bronchoscopy on July 15 showed a slightly thickened carina and a marked degree of inflammation about the or1fice to the upper lobe of the right lung. Bronchial washings were negative for fungi, parasites and neoplastic cells. Bronchoscopy on August 2 showed chronic inflammation of the right bronchial tree and a localized area of thickened tissue about three em. below the carina on the medial wall of the left main bronchus. Biopsy from this area showed normal bronchial mucosa. Cough during the period of stay in the hospital was slight and productive. The temperature remained normal. The patient was discharged on August 30 with a diagnosis of fibrosis of the upper lobe of the right lung due to an undetermined cause. When seen as an out-patient on September 30, the patient stated that he was well. The patient was admitted again to the hospital on October 4, 1950. A productive cough with occasional hemoptysis had been present for about six weeks . Pain in the chest had been present for about six weeks. The roentgenogram of the chest showed a scattered infiltration in the upper lobe of the right lung (Flgure 2). The roentgenologist thought that the lesion now might be a carcinoma. Bronchoscopy on October 13 showed chronic inflammation of the right bronchial tree. Bronchial washings from the upper lobe of the right lung revealed cells interpreted as being normal bronchial mucosa. Since the diagnosis in this individual was still in doubt, an exploratory thoracotomy was done. A firm, rubbery mass was found in the upper lobe of the right -Department of Surgery, Veterans Administration, Fort Howard, Maryland. Reviewed in the Veterans Admlnlstration and published with the approval of the Chief Medical Director. The statements and conclusions published by the authors are the result of their own study and do not necessarily reflect the opinion or policy of the Veterans Administration. 452
~ ~
S
~
~
o
I.:EJ
~
nO~E1
nO~E2
nO~4
Figure 1: Roentgenogram of chest on July 21, 1949, showing irregular infiltration in right lung.-Figure 2: Roentgenogram of chest on November 17, 1950, showing Increase in area of Infiltration in right lung . - Figure 4: Roentgenogram of chest on April 20, 1951, showing post-operative result.
I m
454
MILLER AND GINSBERG
Aprll,1953
lung. Extension to the middle or the lower lobe or to the mediastinum had not occurred. The procedure of choice seemed lobectomy which was done. Microscopic examination of the specimen showed severe chronic inflammation. Extensive bronchiectasis with lipoid cell pneumonia was found (Figure 3). When the diagnosis was determined, the patient was questioned about the use of oU. He stated that he had sustained a rupture of both tympanic membranes as the result of blast from the explosion of a shell in World War I and that bUateral chronic otitis media had followed. Pain and the gradual onset of deafness were noted. OUy medication of various types had been put into both aural canals for many years. The postoperative course was uneventful. The patient was discharged from the hospital on December 22. The patient was seen on subsequent visits on January 22 and AprU 20, 1951, when the roentgenogram of the chest was normal (Figure 4). He was completely asymptomatic and had returned to his regula); occupation.
FIGURE 3: Area of lipoid cell pneumonia. Comment
Being an obscure condition presenting a picture of low grade pulmonary infection, lipoid cell pneumonia is difficult to recognize. A high index of suspicion, in a patient with an unusual shadow on the roentgenogram of the chest, should serve to keep the condition in mind. The history should include questions about the administration of oU in the various orifices communicating with the respiratory tract, particularly in the chronically ill and the aged. A history of nasal disease for which intranasal medication was given, the presence of oral pathologic conditions permitting aspiration and the presence of dysphagia will aid in making a diagnosis. The condition has a slow course which mayor may not be
Vol.XXIn
LIPOID CELL PNEUMONIA
455
attended by symptoms. Fat or macrophages containing fat may be isolated from the sputum. Nathanson, Frenkel and Jacobi 1 were able to make a diagnosis of lipoid cell pneumonia by aspiration of the affected area of lung and finding fat in the aspirated cells by microscopic examination. Bchnelder- reports that the roentgenogram is characteristic in that the lesion extends peripherally, atelectatic phenomena are absent and hilar adenopathy is not seen. SUMMARY
Lipoid cell pneumonia is an unusual lesion which may be confused with carcinoma of the lung. A patient with this condition caused by repeated instillation of oily medication for bilateral otitis media wit~ perforation of ear drums is reported. RESUMEN
La neumonla lipoidea es una lesi6n rara que puede ser confundida con el carcinoma del pulm6n. Se comunica un caso de esa afecci6n que fu~ causado por las instllaciones repetidas de medicamentos aceitosos para pertoractones con otitis medta bilaterales de los t1mpanos. RESUME
La pneumonle hulleuse est une leston qui n'est pas trequente et peut se contondre avec Ie cancer du poumon. Les auteurs rapportent l'observation d'un malade qui s'est trouve dans ce cas; la pneumonie hulleuse avait pour cause des instillations repetees d'hulle a la suite d'une perforation d'une otite moyenne bllatlrale des tympans. REFERENCES
1 Nathanson, L., Frenkel, D. and Jacobi, M.: "Diagnosis of Lipoid Pneumonia by Aspiration BiOpsy," Arch. Int. Med ., 72 :627, 1943. 2 SChneider, L.: "Pulmonary Hazard of the Ingestion of Mineral Oil in the Apparently Healthy Adult," H.E.J.M., 240:284, 1949.