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Weekly Chest CasesArchive of Old Cases

Case No : 594 Date 2009-03-15

  • Courtesy of Young Jae Seoung, MD, Jeung Sook Kim, MD / Dongguk University Ilsan Hospital, Gyeonggi-do, Korea
  • Age/Sex 44 / M
  • Chief ComplaintOral ulcer
  • Figure 1
  • Figure 2
  • Figure 3

Diagnosis With Brief Discussion

Diagnosis
Paraquat poisoning
Radiologic Findings
Chest HRCT obtained 5 days after the admission shows areas of ground-glass attenuations, predominantly in the subpleural portions of the both lung, and focal patchy consolidations in basal portion of both lower lung. Traction bronchiectasis and linear opacity associated with the consolidation are present in right lower lobe.
Brief Review
From Case 196.

Paraquat (1,1’-dimethyl-4,4’-bipyridylium dichloride) is a widely used herbicide that has toxic effects on the lung, liver and kidneys. Death from paraquat poisoning was primarily caused by progressive pulmonary damage with respiratory failure (1). The toxic effects of paraquat are through to result from oxygen radicals that destroy the cell membrane (2). Organ damage by paraquat depends on the balance between oxygen radicals and tissue levels of oxygen and antioxidants. Organ-specific damage to the lung is caused by both lower concentration of the antioxidants and higher concentration of oxygen within the lung. Early pathologic finding in the lung include thickening of the alveolar walls by edema, hemorrhage, and inflammatory cells. Some of the alveoli fill with fluid and large amount of fibrin (3). Late pathologic findings include pulmonary fibrosis and microcysts (2).
According to Im et al (4), there were three patterns of pulmonary abnormalities seen on the chest radiographs: a) diffuse air-space consolidation, b) diffuse cystic and linear shadows and c) focal interstitial opacities containing small cysts. During the first 7 days after ingestion, the preponderant radiologic abnormality was diffuse consolidation. Cystic (2-9mm) and linear opacities then appeared within the consolidated lung during the next 7 days, and this pattern was the preponderant finding after 2 weeks. Beyond 1 month, a focal honeycombing of the lung was the principal abnormality. Meanwhile, according to Lee et al (5), the predominant finding within the first 7 days was areas of ground-glass attenuation. The initial areas of ground-glass attenuation changed into areas of consolidation associated with bronchiectasis and areas of irregular lines. The initial areas of consolidation became more highly attenuated with bronchiectasis or areas of irregular lines on follow-up CT scans.
Please refer to
Case 196, Case 356,
References
1. Bismuth C, Garnier R, Band FJ, Muszynski J, Keyes C. Paraquat poisoning: an overview of the current status. Drug Saf 1990;5:243-251.
2. Thurlbeck WM, Thurlbeck SM. Pulmonary effect of paraquat poisoning. Chest 1976;69:276-280.
3. Bullivant CM. Accidental poisoning by paraquat: report of two cases in man. Br Med J 1966;1:1272-1273.
4. Im JG, Lee KS, Han MC, Kim SJ, Kim IO. Paraquat poisoning: Findings on chest radiography and CT in 42 patients. AJR 1991;157:697-701.
5. Lee SH, Lee KS, Ahn JM, Kim SH , Hong SY. Paraquat poisoning of the lung: Thin-section CT findings. Radiology 1995;195:271-274.
Keywords
Lung, Inhalation and aspiration disease, Drug complication,

No. of Applicants : 88

▶ Correct Answer : 10/88,  11.4%
  • - Seoul National University Hospital , Korea (South) Kwang Nam Jin
  • - Shinsegye Rad Clinic, Daegu , Korea (South) Gi Beom Kim
  • - MIR , United States Clint Jokerst
  • - Soonchunhyang university Bucheon hospital , Korea (South) Minhee Lee
  • - EWHA WOMANS MOKDONG UNIVERSITY HOSPITAL , Korea (South) YOOKYUNG KIM
  • - Soon chun hyang university hospital BUCHEON , Korea (South) Yang ji-yeon
  • - Yashoda Super Speciality hospital , India Ramesh Pandey
  • - NTUH , Taiwan Kuei-pin Chung
  • - Armed Force Capital Hospital , Korea (South) Dae Kun Oh
  • - Seoul Nationial University Bundang Hospital , Korea (South) Hee Seok Choi
▶ Correct Answer as Differential Diagnosis : 18/88,  20.5%
  • - PingTung Christian Hospital ,China Medical University ,Taiwan,R.O.C. , Taiwan Jun Jun Yeh
  • - POPOVO HOSPITAL , Bulgaria VLADISLAV RUSINOV
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - MD SKNMC & GH,Pune,Maharashtra, INDIA , India Sushant Bhadane
  • - Samsung Medical Center , Korea (South) Hye Sun Hwang
  • - ROHINI Scan Center. Ambattur, Chennai , India Umapathi Mahesh
  • - IRSA La Rochelle France , France Denis Chabassiere
  • - Hospital Sotiria, Athens, Greece , Greece Vasilios Tzilas
  • - Hangang Sacred Heart Hospital , Korea (South) Eil Seong Lee
  • - Changhua Christian Hospital , Taiwan Chia-Fu Tsai
  • - NASA SCANS , India RAKESH BHATIA
  • - Beaulieu clinic Geneva , Switzerland gilles GENIN
  • - Hanmaeum Hospital , Korea (South) Kwon Hyoung Kim
  • - GHSR , Reunion Regis Labroye
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - Vital Imaging Centre, Mumbai,India , India Ganesh Agrawal
  • - Yonsei University college of medicine Severance Hospital , Korea (South) Hua Sun Kim
  • - UZ GASTHUISBERG , Belgium Johan COOLEN
▶ Semi-Correct Answer : 2/88,  2.3%
  • - CHRU Lille , France Benjamin Damarey
  • - The Armed Forces HamPyeong Hospital , Korea (South) Bae Geun Oh
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