Presentation
Shortness of breath, dry cough.
Patient Data
Bilateral alveolar infiltrates with air bronchograms and fine reticulations. Very small pleural effusions.
The cardiac silhouette is not enlarged.
Extensive ground glass opacities with intralobular thickening in all lung lobes - "crazy paving" pattern. Small subpleural consolidations in posterolateral aspect of right upper lobe (RUL).
Small bilateral pleural effusion, left greater than right.
Mild mediastinal and bihilar lymphadenopathy.
Extensively calcified atheromatous plaque lining the LAD, LCx, and RCA.
Dilated pulmonary trunk, measuring 35 mm in maximum diameter. Mildly dilated pulmonary arteries.
Small hiatal hernia.
Several tiny hypodense foci scattered in the liver parenchyma, too small to characterize.
Follow-up NCCT chest, 1 month later:
Mosaic attenuation pattern in all pulmonary lobes. Subpleural reticulation.
Full regression of the pleural effusions.
The ground glass opacities have virtually vanished. Persistent subpleural reticulation.
Case Discussion
Weakness and shortness of breath for the past month, dry cough with aggravation of shortness of breath for past 3 days. History notable for sigmoidectomy due to colon cancer. PET-CT done 3 months earlier showed no metastases nor recurrence.
Hgb 9.3 g/dL, baseline ~10 g/dL (known iron deficiency anemia). CRP 97 mg/dL, no leukocytosis.
Mentioned that he was consuming paraffin oil for constipation.
X-ray chest showed bilateral alveolar infiltrates and fine reticulations. CT chest, likewise, showed an extensive crazy paving pattern.
Extensive infectious (serology and urine) panels taken for viruses, bacteria, and fungi, as well as a rheumatoid panel. Bronchoalveolar lavage yielded 10^4 colonies (small amount) of Enterobacter cloacae complex, possibly colonizing the airways, i.e. a contaminant. Received antibiotics and steroids, and put on a nasal hi-flow device. Released after 2 weeks.
A follow-up CT chest done 1 month later showed significant regression of the lung opacities. On the subsequent follow-up CT chest done 2.5 months later, only the subpleural reticulation persisted.
A transbronchial biopsy was obtained from the right lower lobe (RLL) right after the first CT.
Histopathology:
Small fragments of bronchus and adjacent lung tissue showing chronic inflammation, fibrosis and intra-alveolar macrophages.
Immunostains: PAN-CK positive in benign epithelial cells; CD68 positive in macrophages; CMV negative.
Note: part of macrophages containing small clear vacuoles, probably lipid-laden.
The history of paraffin oil consumption, along with the biopsy findings and CT findings, the latter which dwindled down significantly after the patient ceased consuming it, all cemented the diagnosis of exogenous lipoid pneumonia, probably acute on chronic.
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