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Weekly Chest CasesArchive of Old Cases

Case No : 747 Date 2012-02-20

  • Courtesy of Daun Lee, Hyun Ju Seon, Yun-Hyeon Kim / Chonnam National University Hospital
  • Age/Sex 64 / F
  • Chief ComplaintDyspnea
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5
  • Figure 6
  • Figure 7
  • Figure 8

Figure 1. Initial

Diagnosis With Brief Discussion

Diagnosis
Exogenous lipoid pneumonia (confirmed by open lung biopsy)
Radiologic Findings
Initial HRCT images (Fig. 1-2) show multiple patchy and nodular areas of ill-defined ground-glass attenuation and consolidation with mixed smooth intralobular/interlobular septal thickening in both lungs, especially in both lower lungs with somewhat posterior predominance. Mediastinal window setting images (Fig. 3-4) show areas of fat attenuation within consolidation in the posterior lung on each side. Follow up HRCT images (Fig. 5-6) after two months show increased extent of ground-glass attenuation with decreased attenuation of previous consolidative lesions and progressed internal fine reticulation associated smooth intralobular interstitial thickening (crazy-paving lesions) in both lungs with somewhat posterior predominance. Follow up mediastinal window setting images (Fig. 7-8) show several reactive hyperplastic enlargements of lymph nodes in mediastinum and both hila.
Brief Review
Exogenous lipoid pneumonia is a pulmonary disorder resulting from chronic aspiration or inhalation of animal, vegetable, or petroleum-based oils or fats. Predisposing factors such as structural abnormalities of the pharynx, esophageal disorders (achalasia, Zenker diverticulum, hiatus hernia, and reflux), neurologic defects, and chronic illness are common. However, in many cases, no predisposing condition is found.
Symptoms include cough, mild fever, shortness of breath, and chest discomfort.
Chest radiographs are usually nonspecific, demonstrating bilateral lower-lobe air-space opacities, mixed alveolar and interstitial opacities, and occasionally poorly marginated focal mass-like lesions that mimic pulmonary neoplasms. If a large amount of lipid has been aspirated, high-resolution CT usually reveals consolidation that is characteristically low in attenuation (-35 to -75 HU), indicating the presence of lipid deposition. However, exogenous lipoid pneumonia can also manifest as geographic ground-glass attenuation; this appearance is most common in patients with chronic mineral oil aspiration. An appearance of ground-glass opacity associated with interlobular septal thickening and intralobular lines (crazy paving) has also been reported. This crazy-paving pattern reflects intraalveolar and interstitial accumulation of lipid-laden macrophages and hyperplasia of type II pneumocytes in the alveolar lining. Centrilobular opacities may also be seen. However, because inflammation or fibrosis may accompany the presence of the lipid material, the CT attenuation of the consolidation need not be low. In some patients, necrosis and cavitation may be present. Diagnosis can be difficult, since many patients do not recall a history of ingestion or inhalation of mineral oil substances. Bronchoalveolar lavage, transbronchial biopsy, or open lung biopsy combined with a history of oil ingestion and radiographic studies are usually diagnostic.
References
1. Sonia L. Betancourt, Santiago Martinez-Jimenez, Sntiago E. Rossi, Mylene T. Truong, Jorge Carrillo, Jeremy J. Erasmus, Lipoid Pneumonia: Spectrum of Clinical and Radiologic Manifestations. AJR 2010; 194:103
2. Santiago E. Rossi, Jeremy J. Erasmus, Mariano Volpacchio, Tomas Franquet, Teresa Castiglioni, H. Page McAdams, Crazy-Paving pattern at Thin-Section CT of the Lungs: Radiologic-Pathologic Overview. RadioGraphics 2003; 23:1509
3. W. Richard Webb, Nestor L. Muller, David P. Naidich, High-resolution CT of the Lung 4th edition
Keywords
lung, iatrogenic,

No. of Applicants : 121

▶ Correct Answer : 45/121,  37.2%
  • - University of British Columbia , Canada Amr Ajlan
  • - Ewha Womans University Hospital , Korea (South) YOOKYUNG KIM
  • - Kyung Hee University Medical center , Korea (North) Myung Won You
  • - Korea university , Korea (South) SUMIN HA
  • - HUEC , Brazil Diogo Pinheiro
  • - DongA University hospital , Korea (South) Jiyoung Kang
  • - Dongnam Institute of Radiological and Medical Sciences , Korea (South) Dae-Wook Yeh
  • - Sunchun university hospital, Bucheon , Korea (South) So Young Bae
  • - kyunghee university medical center , Korea (South) An ji young
  • - chp st martin , France Mariotte benoit
  • - , Canada Andrea Ojanguren
  • - Suncheon Plus Medicine , Korea (South) Park Sang Hyun
  • - UWO , Canada S Lee
  • - clinique de SAVOIE , France, Metropolitan gay-depassier philippe
  • - Chonnam national university hospital , Korea (South) Jang-hyeon Song
  • - Chonnam National University Hospital , Korea (South) Sungmin Moon
  • - Song-do Hospital , Korea (South) Ji-young Yun
  • - Japanese Red Cross Society Himeji Hospital , Japan Yuichiro Kanie
  • - Seoul National University Hospital , Korea (South) YongSub Song
  • - Saga University , Japan Ryoko Egashira
  • - National Jewish Health , United States Jonathan Chung
  • - Hangang sacred heart hospital , Korea (South) You Mie Han
  • - Asan Medical Center , Korea (South) Hye Jeon Hwang
  • - Asan medical center , Korea (South) Hyun Joo Lee
  • - China Medical University ,Taiwan,R.O.C. , Taiwan Jun Jun Yeh
  • - Asan medical center , Korea (South) sang young oh
  • - CHU NANCY , France, Metropolitan LEGOU Francois
  • - KUMC ansan , Korea (South) kihwan kim
  • - CH de la C�te Basque , France Paul ARDILOUZE
  • - bmcri , India sanjeev choudri
  • - Az Osp Santa Maria Terni , Italy angelo carloni
  • - Hanyang Medical Center , Korea (South) Kibo Yoon
  • - Kyung Hee Universitiy Hospital at Gangdong , Korea (South) Seong Jong Yun
  • - Maimonides Medical Center , United States naomi twersky
  • - fmmc , India subas kandimalla
  • - Hanyang University Hospital , Korea (South) Yo Won Choi
  • - IRSA La Rochelle France , France Denis Chabassiere
  • - Bupyong Serim Hospital , Korea (South) Hee Seok Choi
  • - IRCCS Istituto Oncologico - Bari , Italy Carlo Florio
  • - CLCC , France nicolas gautier
  • - Saint Malo , France jean-baptiste Noel
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - Seoul St Mary Hospital , Korea (South) Chae Lim
  • - Korea university , Korea (South) Kun Woo Kang
  • - All India Institute of medical sciences , India Justin Moses
▶ Correct Answer as Differential Diagnosis : 26/121,  21.5%
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - Kyungpook National University Hospital , Korea (South) Jaekwang Lim
  • - Onomichi municipal hospital , Japan Ryotaro Kishi
  • - MASAN , Korea (South) Kim Sang Hyeon
  • - Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
  • - Kurashiki Seijin-byo Center , Japan Akihiro Tada
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - McGill University Health Center , Canada Alexandre Semionov
  • - newmasan hospital , Korea (South) park ji hoon
  • - Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
  • - Travancore Medical College , India Chary D
  • - Fukuyama daiichi Hospital , Japan Mototsugu Saeki
  • - Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
  • - SNUH , Korea (South) Euijin Hwang
  • - Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
  • - Hangang Sacred Heart Hospital , Korea (South) Eil Seong Lee
  • - Ondokuz Mayis University , Turkey Cetin Celenk
  • - Iwate Medical University , Japan Akio Akahane
  • - IRSA , France, Metropolitan BIGOT
  • - CHRU lille , France manuel toledano
  • - A.P.Chest hospital ,hyderabad , India bhaskar kakarla
  • - CHU lyon sud , France matthieu ROUSSET
  • - Radnet Teleradiology Istanbul , Turkey Armagan Sarac
  • - NASA SCANS , India RAKESH BHATIA
  • - Pneumologia Universitaria, Policlinico di Bari , Italy Mario Damiani
  • - Private sector , Greece Vasilios Tzilas
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