대한흉부영상의학회 Korean Society of Thoracic Radiology

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Weekly Chest CasesCases by Disease Category

Case No : 1178 Date 2020-05-18

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  • Courtesy of Hee Kang, MD / Kosin University Gospel hospital
  • Age/Sex 35 / M
  • Chief ComplaintDyspnea
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5

Diagnosis With Brief Discussion

Diagnosis
Chemical pneumonitis caused by nitric acid inhalation
Radiologic Findings
Fig 1. A chest radiography shows multifocal ill-defined nodular and patchy opacities in both lung.
Fig 2-5. Chest CT images with lung window setting show ill-defined patchy areas and centrilobular nodules of ground glass opacity along the bronchovascular bundle with upper lung zone predominance. There is small amount of pneumomediastinum.

Fig 6. A chest radiography 3 days after treatment of corticosteroid shows clearance of the previously noted diffuse ill-defined patchy or nodular opacities in both lung.

Brief Review
This patient had a previous history of dyspnea and was admitted with severe dyspnea following exposure to nitric acid in his work environment.

Inhalation injuries occur as a result of toxic absorption and may cause asphyxiation, local irritation, or allergic reactions. Irritant gases when inhaled in high concentrations injure the respiratory tract by causing acute inflammation. The main site of injury depends on the solubility of the gases; more soluble gases like ammonia exert maximal effect on the proximal respiratory tract, while less soluble gases like nitric acid fumes exert greater effect on the distal airway.

Nitric acid is a commonly used strong acid agent used in metal refining, cleaning, electroplating and other industrial applications. It generates oxides of nitrogen, including nitric oxide (NO) and nitrogen dioxide (NO2), which cause chemical pneumonitis when inhaled.

The clinical presentation of nitric acid inhalation injury depends on the duration and intensity of exposure. Within the first several hours, mild cases may stay asymptomatic. After a latency of 3-24 hours, the first typical symptoms of pulmonary edema may appear resulting in acute respiratory failure. However, in severe exposure cases diffuse alveolar damage can develop.
Please refer to
Case 893, Case 1089,
References
1. Kao SL et al. Acute lung injury after inhalation of nitric acid Eur J Emerge Med 2008;15(6):348
2. Ha JW et al. A case of chemical pneumonitis caused by nitric acid fume inhalation Tuberculous and Respiratory Diseases 2004;56(6): 670
3. Hur GY et al. A case of chemical pneumonitis after occupational nitric acid inhalation Korean Jour of Medicine 2006;71(5):562
4. Jayalakshmi TK et al. Acute lung injury following exposure to nitric acid Lung India 2009;26(4):149
Keywords
lung, inhalation, chemical pneumonitis,

No. of Applicants : 84

▶ Correct Answer : 34/84,  40.5%
  • - Niigata University , Japan ATSUSHI UEHARA
  • - Chungbuk National University Hospital , Korea (South) YEONGTAE PARK
  • - , Korea (South) HYEYOUNG CHOI
  • - Affilitated Hospital of Jining Medical college , China JIANG SHENG HUA
  • - , Japan SHIN-ICHI CHO
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - St. Lukes International Hospital , Japan DAISUKE YAMADA
  • - , Korea (South) JIN YOUNG LEE
  • - Oita University, Faculty of Medicine , Japan FUMITO OKADA
  • - Chonbuk National University Hospital , Korea (South) JUNGHWAN KIM
  • - Hamamatsu University Hospital , Japan HAYATO NOZAWA
  • - National Center for Global Health and Medicine , Japan MASATOSHI HOTTA
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - , Korea (South) YEONSOO KIM
  • - The University of Tokyo Hospital , Japan RYO KUROKAWA
  • - Chonbuk National University Hospital , Korea (South) YOUNGKWANG LEE
  • - University of Tsukuba Hospital , Japan HIROAKI TAKAHASHI
  • - Osaka City General Hospital , Japan SHU MATSUSHITA
  • - Dae Jin Medical Center , Korea (South) JIYOUNG CHOI
  • - Ajou University Hospital , Korea (South) HYERIN KIM
  • - Chonbuk National University Hospital , Korea (South) KUM JU CHAE
  • - Asan Medical Center , Korea (South) JIHOON KIM
  • - Kitano Hospital , Japan SATOSHI IKEDA
  • - , Korea (South) SUNGEUN YUN
  • - Fortis hospital , Mohali , India SHALEEN RANA
  • - University of Tsukuba Hospital , Japan SODAI HOSHIAI
  • - Chonbuk National University Hospital , Korea (South) SOL KI KIM
  • - , Japan SOTA MASUOKA
  • - Chonbuk National University Hospital , Korea (South) MINJEE KIM
  • - , Korea (South) CHOI SOOYOUNG
  • - , India SUSHANT JOSHI
  • - Chonbuk National University Hospital , Korea (South) YOUNG JU SONG
  • - , Japan YUMI MAEHARA
  • - iran university , Iran MOHAMAD REZA AYOUBPOUR
▶ Correct Answer as Differential Diagnosis : 26/84,  31.0%
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - Showa University Fujigaoka Hospital , Japan KYOKO NAGAI
  • - Mayo Clinic , United States AKITOSHI INOUE
  • - CH de la Cote Basque , France PAUL ARDILOUZE
  • - Samsung Medical Center , Korea (South) CHOHEE KIM
  • - Chonnam National University Hospital , Korea (South) MOON GYEONG IL
  • - Cabinet Capricorne, clinique sainte-clotilde , Reunion FABIEN HO
  • - Sikkim Manipal Institute of Medical Sciences, Gangtok , India HARIPRASAD SUDARSAN
  • - Yeungnam University Medical Center , Korea (South) JONGSOO PARK
  • - Gifu University Hospital , Japan Yo Kaneko
  • - Seoul Veterans Hospital , Korea (South) JI HOON NOH
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey MERIC TUZUN
  • - Chungbuk National University Hospital , Korea (South) MIHYEON PARK
  • - Other , Korea (South) MINSU KIM
  • - University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
  • - Seoul Veterans Hospital , Korea (South) JANG SEONG WON
  • - TB centre kasaragod. , India rikhy krishnan
  • - Toranomon Hospital , Japan KAORU SUMIDA
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - , Japan KAZUMA TERAUCHI
  • - Private sector , Greece VASILIOS TZILAS
  • - Hamamatsu University Hospital , Japan YUKI HAYASHI
  • - Diagnose.me (BV) / Royal Perth Hospital , Australia YURANGA WEERAKKODY
  • - Chonnam National University Hwasun Hospital , Korea (South) WONGI JEONG
  • - the first affiliatited hospital of nanjing medical univercity , China HAI XU
  • - Jiangsu province hospital , China WANGJIAN ZHA
▶ Semi-Correct Answer : 3/84,  3.6%
  • - IRSA LA ROCHELLE , France JEAN LUC BIGOT
  • - The University of Tokyo Hospital , Japan MOTO NAKAYA
  • - Holy Family Hopsital , India RAJESH GOTHI
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