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Pneumonia, pneumothorax, and emphysema following ingestion of kerosene
PNEUMONIA, PNEUMOTHOgAX, AND EMPHYSEMA FOLLOWING INGESTION OF KEROSENE EDWIN PAUL SC0T!r, M.D. LOUISVILLE, ~ u
manifestations following the accidental ingestion of p ULMONARY kerosene are rather common in young children. Waring, ~ in 1933, Nunn and Martin, 2 in 1934, and Lesser, Weens, and McKey,s in 1943, have concluded from clinical or experimental studies that the pulmonary n~lanifestations are due to aspiration rather than to absorption from the gastrointestinal tract. Lesser, Wrens, and ~V[cKey3 reported thirty-three children with kerosene poisoning, two of whom developed fluid in addition to pulmonary consolidation. In one patient the fluid disappeared spontaneously and in the other surgical drainage was required for the empyema. It is the purpose of this communication to report an unusual complication following the accidental ingestion ~ kerosene, namely, pneumonia, pneumothorax, and emphysema of the so{t tissues of the chest. A 2-year-old white male child was a d m i t t e d to t h e C h i I d r e n ' s F r e e H o s p i t a l Dec. 22, 1941, with a h i s t o r y of h a v i n g i n g e s t e d ~rom one to two ounces of kerosene a b o u t two h o u r s prior to admission. B e f o r e b r i n g i n g him to the hospital h i s p a r e n t s gave h i m some c r e a m which caused h i m to vomit. P h y s i c a l e x a m i n a t i o n on a d m i s s i o n revealed a well-developed a n d wetl-nourlshed comatose white male child who a p p e a r e d a c u t e l y ill. There was a s t r o n g odor of kerosene a b o u t the face. T h e r e were n u m e r o u s m o i s t rgdes h e a r d t h r o u g h o u t the l u n g fields, b u t t h e r e was no d e m o n s t r a b l e c h a n g e to the p e r c u s s i o n note. A s i d e f r o m considerable d i s t e n t i o n of t h e abdomen, the r e m a i n d e r of t h e p h y s i c a l e x a m i n a t i o n was n o t remarkable. T h e rectal t e m p e r a t u r e was 99.6 ~ F., w i t h r e s p i r a t i o n s of 48 per m i n u t e . :Because of his a p p a r e n t p u h n o n a r y edema, he was given a n iramediate cont i n u o u s i n f u s i o n of 50.0 c.c. of 20 p e r cent glucose followed by 10 per cent glucose in distilled water. I n additiort h e w a s given o x y g e n continuously, a n d caffeine sodiobenzoate was a d m i n i s t e r e d as a s t i m u l a n t . :k saline e n e m a followed b y a rectal tube w a s used to relieve t h e a b d o m i n a l distentlon. N o g a s t r i c lavage was performed. The blood c o u n t on a d m i s s i o n revealed a red blood cell count of 4,950,000 per cubic m i l l i m e t e r w i t h h e m o g l o b i n of t 3 Gm. p e r 100 c.c. a n d a white blood eel1 count of 22,500 p e r cubic m i l l i m e t e r w i t h 7~i per cent p o l y m o r p h o n u c l e a r leucocytes a n d 26 p e r cent l y m p h o e y t e s . E x c e p t f o r a mild g l y c o s u r i a which w a s t h o u g h t to be due to t h e i n t r a v e n o u s glucose, t h e u r i n a l y s i s was negative. W i t h i ~ two h o u r s the child w a s conscious. T h e n e x t m o r n i n g , even t h o u g h his t e m p e r a t u r e h a d r i s e n to 103.2 ~ F., he was very alert a n d a b l a n d diet w a s taken well. F r o m the D e p a r t m e n t of Pediatrics. U n i v e r s i t y of Louisville School of Medicine, service of Dr. J a m e s W. Bruce. 31
52
THE
_4.
JOURNAL
OF PEDIATI~ICS
F i g . 1.
F i g , 2.
B.
~COTT:
PNEIJM,0NIA, P~EUMOTHORAX,
AND EMPHYSEMA
3~
In view of the rise in temperature with an elevated white blood cell eount~ it was thought advisable to administer sulfathiazole~ which was given in a I Gin. ~ s t a t " dose followed by 0.5 Gin. every four hours. Oa December 25~ three days following admission, his temperature became normal and remained so until discharge. An examination Dee. 25.~ ~1941~ revealed emphysema of the soft tissues of the neck and chest and numerous fine erepitant, r'~les throughout the lung fields. A teleroentgenogram of the chest on the following morning revealed a left pneumothorax wlth partial collapse of the left lower lobe. The entire l e f t lung showed a dense, patchy~ hazy process which was markedly increased in the lower lobe. On the right there was an irregular haze except in the cardiophrenie sinus where consolidation was present. Overlying this region was an area of decreased density which measured 3 cm. and was apparently a fluid level. The heart was slightly displaced to the right and slightly enlarged. An extensive soft tissue emphysema over the upper abdome~ and thorax extended to the neck and face. The roentgenogram diagnosis was aspiraLi0n pneumonia~ bilateral pneumothorax with possible bronchopleural fistula on the right~ and soft tissue emphysema (Fig. IA and B). Treatment was symptomatic except for the sulfathiazole medication.
Fig. 3~ On December 29 another roentgenogram revealed the left pneumothorax to be elearing~ "~vith partial re-expansion of the lower lobe. The parenchymal reaction in both lungs had become more homogeneous. The former fluid level on the right had disappeared. The heart was almost in the midline~ and the soft tissue emphysema was less marked (Fig. 2). Following this his emphysema gradually disappeared and the patient made an excellent convalescence. I n spite o~ his normal temperature, sulfathiazole medica-
3~:
THE JOURNAL OF PEDIATRICS
tion was continued until Jan. 3, 1962, at which time the physical and roentgenologi; examinations were interpreted as normal (Fig. 3). He was discharged Jan. 4, 1942. SUMMARY
Pulmonary manifestations following' the accidental ingestion of kerosene are rather common in young children, but ~his is believed to be the first case reported complicated by plleumonia, pneumothorax, and emphysema. REFERENCES 1. Waring, J. I.: Am. J. ~ . So. 185: 325, 1933. 2. Nunn, J. A., and Niartln, F . M . : J . A . M . A . 103: 472, 1934. 3. Lesser, L. I , Weens~ H. S., and ~VlcKey, J . D . : J. PEI)IA'2. 23: 352~ 1943.
manifestations following the accidental ingestion of p ULMONARY kerosene are rather common in young children. Waring, ~ in 1933, Nunn and Martin, 2 in 1934, and Lesser, Weens, and McKey,s in 1943, have concluded from clinical or experimental studies that the pulmonary n~lanifestations are due to aspiration rather than to absorption from the gastrointestinal tract. Lesser, Wrens, and ~V[cKey3 reported thirty-three children with kerosene poisoning, two of whom developed fluid in addition to pulmonary consolidation. In one patient the fluid disappeared spontaneously and in the other surgical drainage was required for the empyema. It is the purpose of this communication to report an unusual complication following the accidental ingestion ~ kerosene, namely, pneumonia, pneumothorax, and emphysema of the so{t tissues of the chest. A 2-year-old white male child was a d m i t t e d to t h e C h i I d r e n ' s F r e e H o s p i t a l Dec. 22, 1941, with a h i s t o r y of h a v i n g i n g e s t e d ~rom one to two ounces of kerosene a b o u t two h o u r s prior to admission. B e f o r e b r i n g i n g him to the hospital h i s p a r e n t s gave h i m some c r e a m which caused h i m to vomit. P h y s i c a l e x a m i n a t i o n on a d m i s s i o n revealed a well-developed a n d wetl-nourlshed comatose white male child who a p p e a r e d a c u t e l y ill. There was a s t r o n g odor of kerosene a b o u t the face. T h e r e were n u m e r o u s m o i s t rgdes h e a r d t h r o u g h o u t the l u n g fields, b u t t h e r e was no d e m o n s t r a b l e c h a n g e to the p e r c u s s i o n note. A s i d e f r o m considerable d i s t e n t i o n of t h e abdomen, the r e m a i n d e r of t h e p h y s i c a l e x a m i n a t i o n was n o t remarkable. T h e rectal t e m p e r a t u r e was 99.6 ~ F., w i t h r e s p i r a t i o n s of 48 per m i n u t e . :Because of his a p p a r e n t p u h n o n a r y edema, he was given a n iramediate cont i n u o u s i n f u s i o n of 50.0 c.c. of 20 p e r cent glucose followed by 10 per cent glucose in distilled water. I n additiort h e w a s given o x y g e n continuously, a n d caffeine sodiobenzoate was a d m i n i s t e r e d as a s t i m u l a n t . :k saline e n e m a followed b y a rectal tube w a s used to relieve t h e a b d o m i n a l distentlon. N o g a s t r i c lavage was performed. The blood c o u n t on a d m i s s i o n revealed a red blood cell count of 4,950,000 per cubic m i l l i m e t e r w i t h h e m o g l o b i n of t 3 Gm. p e r 100 c.c. a n d a white blood eel1 count of 22,500 p e r cubic m i l l i m e t e r w i t h 7~i per cent p o l y m o r p h o n u c l e a r leucocytes a n d 26 p e r cent l y m p h o e y t e s . E x c e p t f o r a mild g l y c o s u r i a which w a s t h o u g h t to be due to t h e i n t r a v e n o u s glucose, t h e u r i n a l y s i s was negative. W i t h i ~ two h o u r s the child w a s conscious. T h e n e x t m o r n i n g , even t h o u g h his t e m p e r a t u r e h a d r i s e n to 103.2 ~ F., he was very alert a n d a b l a n d diet w a s taken well. F r o m the D e p a r t m e n t of Pediatrics. U n i v e r s i t y of Louisville School of Medicine, service of Dr. J a m e s W. Bruce. 31
52
THE
_4.
JOURNAL
OF PEDIATI~ICS
F i g . 1.
F i g , 2.
B.
~COTT:
PNEIJM,0NIA, P~EUMOTHORAX,
AND EMPHYSEMA
3~
In view of the rise in temperature with an elevated white blood cell eount~ it was thought advisable to administer sulfathiazole~ which was given in a I Gin. ~ s t a t " dose followed by 0.5 Gin. every four hours. Oa December 25~ three days following admission, his temperature became normal and remained so until discharge. An examination Dee. 25.~ ~1941~ revealed emphysema of the soft tissues of the neck and chest and numerous fine erepitant, r'~les throughout the lung fields. A teleroentgenogram of the chest on the following morning revealed a left pneumothorax wlth partial collapse of the left lower lobe. The entire l e f t lung showed a dense, patchy~ hazy process which was markedly increased in the lower lobe. On the right there was an irregular haze except in the cardiophrenie sinus where consolidation was present. Overlying this region was an area of decreased density which measured 3 cm. and was apparently a fluid level. The heart was slightly displaced to the right and slightly enlarged. An extensive soft tissue emphysema over the upper abdome~ and thorax extended to the neck and face. The roentgenogram diagnosis was aspiraLi0n pneumonia~ bilateral pneumothorax with possible bronchopleural fistula on the right~ and soft tissue emphysema (Fig. IA and B). Treatment was symptomatic except for the sulfathiazole medication.
Fig. 3~ On December 29 another roentgenogram revealed the left pneumothorax to be elearing~ "~vith partial re-expansion of the lower lobe. The parenchymal reaction in both lungs had become more homogeneous. The former fluid level on the right had disappeared. The heart was almost in the midline~ and the soft tissue emphysema was less marked (Fig. 2). Following this his emphysema gradually disappeared and the patient made an excellent convalescence. I n spite o~ his normal temperature, sulfathiazole medica-
3~:
THE JOURNAL OF PEDIATRICS
tion was continued until Jan. 3, 1962, at which time the physical and roentgenologi; examinations were interpreted as normal (Fig. 3). He was discharged Jan. 4, 1942. SUMMARY
Pulmonary manifestations following' the accidental ingestion of kerosene are rather common in young children, but ~his is believed to be the first case reported complicated by plleumonia, pneumothorax, and emphysema. REFERENCES 1. Waring, J. I.: Am. J. ~ . So. 185: 325, 1933. 2. Nunn, J. A., and Niartln, F . M . : J . A . M . A . 103: 472, 1934. 3. Lesser, L. I , Weens~ H. S., and ~VlcKey, J . D . : J. PEI)IA'2. 23: 352~ 1943.