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Weekly Chest CasesArchive of Old Cases

Case No : 639 Date 2010-01-24

  • Courtesy of Lee Ki Yeol / Korea University, Ansan Hospital
  • Age/Sex 70 / F
  • Chief ComplaintIncidentally found abnormality on the chest radiograph in routine health check up.
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Diagnosis With Brief Discussion

Diagnosis
Exogenous lipoid pneumonia
Radiologic Findings
Chest radiograph demonstrates focal consolidation in RML.
The crazing paving appearance showing patch areas of ground glass opacity with inter- and intra-septal thickening and focal consolidations is seen in RML on HRCT scans.
Poorly defined small centrilobular nodules are also noted in RML. On PET-CT, focal area of increased FDG uptake is seen in the right lower lung zone. On the follow-up chest radiograph after 40 days, there is no definite interval change of focal increase opacity in RML. She had a history of repeated ingestion of shark liver oil (squalene).
Brief Review
Exogenous lipoid pneumonia is a rare disorder caused by the aspiration or inhalation of mineral, vegetable. or animal oils present in food, radiographic contrast media, or oil-based medications into the lung. Squalene, produced from shark liver oil, is used in some Asian countries as a folk remedy.
Mineral oils, and similar substances, do not irritate the pharyngeal mucosa; therefore, they do not stimulate the gag reflex.
Patients particularly at risk for exogenous lipoid pneumonia include those with risk factors for aspiration such as swallowing dysfunction, episodes of loss of consciousness, and extremes of age.
On chest radiographs, lipoid pneumonia has been shown to have many different manifestations. Most series do not differentiate between acute and chronic presentations. The previous study described lipoid pneumonia due to squalene ingestion as having areas of ground glass opacity, consolidation, and poorly defined small nodules.
On CT, exogenous lipoid pneumonia may be diagnosed when areas of fat attenuation are present within a pulmonary opacity. However, in some cases of lipoid pneumonia, fat attenuation is not evident on CT because the fat attenuation values are averaged with surrounding inflammatory exudates. Other CT findings of lipoid pneumonia include ground glass opacities, thickened intralobular septae, and small cystic areas. Thin section CT findings in relatively asymptomatic patients with exogenous lipoid pneumonia include diffuse ground glass opacities, multifocal airspace consolidation, and interstitial opacities.
Right middle lobe and both lower lobes are commonly involved. Complete recovery or partial clearance of these lesions can be seen after cessation of squalene ingestion.
On PET-CT, similar to inflammatory and infectious lung diseases, lipoid pneumonia may be a false-positive case of F-18 FDG uptake.

Lung, right middle lobe, needle biopsy(H&E X 400): Foamy macrophages and chronic inflammatory cells(arrows) are noted.
References
1. Baron SE, Haramati, LB, Rivera VT. Radiological and clinical findings in acute and chronic exogenous lipoid pneumonia. J Thorac Imaging 2003;18:217-224
2. Lee JY, Lee KS, Kim TS, et al. Squalene-induced extrinsic lipoid pneumonia: serial radiologic findings in nine patients. J Comput Assist Tomogr 1999; 23:730-735
3. Franquet T, Gimenez A, Bordes R, et al. The crazy-paving pattern in exogenous lipoid pneumonia: CT-Pathologic correlation. AJR 1998;170:315-317
4. Laurent F, Philippe JC, Vergier B, et al. Exogenous lipoid pneumonia: HRCT, MR, and pathologic findings. Eur Radiol 1999;9:1190-1196
5. Babak Mokhlesi, David Angulo-Zereceda, Vahid Yaghmai, et al. False-positive FDG-PET scan secondary to lipoid pneumonia mimicking a solid pulmonary nodule. Ann Nucl Med 2007;21:411-414
6. Florence Tahon, Yves Berthezene. Exogenous lipoid pneumonia with unusual CT pattern and FDG positron emission tomography scan findings. Eur Radiol 2002;12:171�173
Keywords
Lung, Inhalation and aspiration disease,

No. of Applicants : 87

▶ Correct Answer : 9/87,  10.3%
  • - Osaka University , Japan Osamu Honda
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - hospital de clinicas de porto alegre , Brazil ana zanardo
  • - Hospital M de Deus , Brazil Thiago Bento da Silva
  • - All India Institute of Medical Sciences , India Jitesh Ahuja
  • - SMG-SNUH boramae medical center , Korea (South) Kwang Nam Jin
  • - Hopital du SacrCoeur , Canada Abraham Bohadana
  • - Beaulieu clinic Geneva , Switzerland gilles GENIN
  • - SEOUL NATIONAL UNIVERSITY , Korea (South) LEE HEE
▶ Correct Answer as Differential Diagnosis : 11/87,  12.6%
  • - University of British Columbia , Canada Amr Ajlan
  • - PingTung Christian Hospital ,China Medical University ,Taiwan,R.O.C. , Taiwan Jun JunYeh
  • - KKUH , Saudi Arabia Manar EL Essawy
  • - Youngdong Hospital , Korea (South) Sang Min Lee
  • - All India Institute of Medical Sciences , India Ashish Gupta
  • - Soonchunhyang university hospital, Bucheon , Korea (South) Hyelin Kim
  • - Hotel-Dieu Montreal , Canada nicolas gautier
  • - Homs National Hospital , Syria Rami Abou Zalaf
  • - Hospital Sotiria, Athens, Greece , Greece Vasilios Tzilas
  • - Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
  • - All India Institute of medical sciences , India Justin Moses
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