Exogenous Lipoid Pneumonia Due to Aerosolized Essential Oils: An Unusual Source of Chronic Pneumonia Mimicking Neoplasm

A 72-year-old man presented with progressive shortness of breath and increasing consolidation. Extensive workup eventually led to the diagnosis of lipoid pneumonia, attributed to an unusual source of inhaled aerosolized essential oils in a commercially available breath freshening spray. This case illustrates the clinical and radiologic manifestations of exogenous lipoid pneumonia from an unreported entity and highlights the value of interdisciplinary discussion, detailed analysis of every imaging study, proper pathologic sample preparation, and the limited value of functional imaging in this condition. Keywords: PET/CT, Biopsy/Needle Aspiration, Thorax, Lung, Inflammation, Observer Performance © RSNA, 2025.

Unmasking the mimic: lipoid pneumonia imitating primary lung cancer - a case report series of a diagnostic challenge

Introduction

Lipoid pneumonia is a rare inflammatory disease characterized by an abnormal deposition of lipids in the alveoli. It may manifest as pulmonary consolidation, simulating primary lung cancer on radiological imaging and an increased uptake on fluorine-18-fluorodeoxy-D-glucose (FDG) positron-emission tomography (PET)/computed tomography (CT). The confirmed diagnosis can be achieved only by microscopic examination of cytological or histological samples.

Methods

This paper describes eight cases at a single center from 2016 to 2024 of lipoid pneumonia mimicking primary lung cancer and its risk factors. Samples were collected thanks to multidisciplinary evaluations using CT and FDG-PET/CT. The histopathological diagnoses were obtained with endobronchial ultrasound (EBUS), fine needle aspiration biopsy (FNAB), or, as a last resort, surgical resection.

Results

Our cohort of patients confirms that lung masses with fat density and irregular margins are lipoid pneumonia's most common findings. However, it can also present as a solid mass with no fat density. This condition must always be appropriately evaluated through a multidisciplinary approach, especially when excluding a neoplastic origin.

Conclusion

In this paper, we present the largest case series of lipoid pneumonia mimicking primary lung cancer from a single center reported in the literature so far. This case series highlighted the critical role of a multidisciplinary approach, including radiologists and pathologists, in differentiating lipoid pneumonia from malignancy to ensure optimal patient management.

Immunological Effects of Electronic Cigarette Use: A Review of Current Evidence

Electronic cigarettes (EC) have emerged as a popular alternative to traditional tobacco products, but their impact on immune function has raised significant health concerns. This review explores the immunological effects of EC exposure, focusing on innate and adaptive immune responses. Electronic cigarette aerosol (ECA) induces widespread inflammation. These changes compromise immune cell function, impairing neutrophil chemotaxis, phagocytosis, and oxidative burst while increasing macrophage and dendritic cell recruitment and activation. ECA also disrupts epithelial barriers, increasing susceptibility to bacterial and viral infections. Studies show enhanced biofilm formation in bacteria such as Staphylococcus aureus and Streptococcus pneumoniae and impaired antiviral responses against pathogens like influenza A and SARS-CoV-2. Additionally, EC exposure modulates adaptive immunity, affecting T and B cell function and increasing systemic inflammatory markers. The long-term consequences of these immunological disruptions include heightened risks for chronic inflammatory diseases, respiratory infections, and potentially autoimmune conditions. The widespread adoption of EC, particularly among younger users, poses a growing public health challenge. As the popularity of vaping continues to rise, these immunological disruptions could result in increased healthcare burdens in the future, with higher rates of infections, chronic inflammatory diseases, and immune system-related disorders among those who begin using e-cigarettes at a young age. Understanding the full scope of EC-related health risks is essential for informing public health policies and protecting future generations from the potential long-term effects of vaping.

Rare cause of chronic cough in a young healthcare worker - A case of exogenous lipoid pneumonia!

Exogenous lipoid pneumonia (ELP) is a rarely reported entity caused by aspirating or inhaling fat or oil-containing substances. Clinically, patients present with subacute to chronic-onset non-specific symptoms such as cough, fever, breathlessness, and general malaise. In addition, lobar or multifocal interstitial and parenchymal infiltrates on chest imaging can mimic any other infectious etiology. Diagnosis of lipoid pneumonia is often missed or delayed in many cases and requires a high index of clinical suspicion. We report a case of a 36-year-old nursing officer who presented with a cough and right-sided pneumonia on chest imaging. She was being treated empirically with antitubercular therapy without any clinical response to the treatment. ELP was diagnosed after carefully evaluating the radiological findings, reviewing the clinical history, and finding supportive evidence of lipid-laden alveolar macrophages in her broncho-alveolar lavage fluid. It is vital to uphold a heightened clinical suspicion for non-infectious etiologies in non-resolving pneumonia and investigate the patient thoroughly before resorting to empirical treatments.

Lipid-laden macrophage index as a marker of aspiration in children, is it reliable? A scoping review

INTRODUCTION

A diagnostic pathway to detect aspiration is challenging and usually requires a multidisciplinary approach and a variety of tests. Lipid-laden macrophage index (LLMI) was first described in 1985 by Corwin and Irwin as a promising tool to detect aspiration. Information in the literature as well as physicians' opinions about the clinical value of the LLMI remains controversial.

OBJECTIVES

To assess the clinical value and possible limitations of LLMI as a diagnostic marker for detecting aspiration in children.

METHODS

Based on the available literature we thought to answer the following questions: 1. Is there a reliable cutoff value of LLMI to detect aspiration? 2. What are the limitations of LLMI? We queried 8 electronic databases: Medline, Embase, CINAHL, Cochrane, Global Health, Web of Science, Africa Wide Information, and Global Index Medicus. Studies were selected based on established study criteria. Search was limited to publications in English language including human and animal studies. Authors reviewed 2900 articles and identified 21 relevant to the studied subject.

RESULTS

Research reveals different proposed cutoff values for aspirators ranging from 85 to 200 macrophages. LLMI reliability has several limitations including: inter- and intraobserver variability among pathologists scores, inability to differentiate between exogenous and endogenous lipid content, inconsistencies in the definition of the term "aspiration" in various publications. Also, studies in animal models have shown that the nature of the disease, frequency of aspiration, and the time frame when bronchoalveolar lavage (BAL) is performed, could all contribute to the overlap in LLMI in aspirators versus non-aspirators.

DISCUSSION

Our research demonstrates the limitations of LLMI in distinguishing between aspirators and non-aspirators. We believe based on these findings that airway teams should audit their local data as to the value of BAL in detecting aspiration in their patient population.

Lipoid Pneumonia Secondary to Diesel Aspiration: An Occupational Hazard

Lipoid pneumonia is defined as a type of pneumonia that occurs as a result of inhalation of either endogenous or exogenous lipid-containing products in the lungs. We present the case of a 55-year-old male patient who presented with chief complaints of cough with blood-tinged sputum, right-sided chest pain, dyspnea, and fever for two days. The patient gave a history of working as a mechanic in an automobile garage and reported an episode of accidental aspiration of diesel during diesel siphoning at the workplace. A chest X-ray and computed tomography (CT) scan of the chest were done, which revealed right-sided lower lobe consolidation. The patient was admitted and started on intravenous antibiotics, corticosteroids, and inhaled bronchodilators, along with oxygen support. A bronchoscopy was done, which revealed the presence of thick mucoid secretions in the right lower lobe bronchus. The patient was discharged after 10 days with stable vitals and was advised to have regular follow-ups to monitor for any long-term pulmonary complications.

Lipid Pneumonia Mimicking Lung Cancer in a Middle-Age Woman

Lipid pneumonia is exceedingly rare, with only a few reported cases to date. A 46-year-old woman with a history of left breast cancer underwent a left-modified radical mastectomy, adjuvant chemotherapy, and radiotherapy. Despite no known exposure to lipids, she presented with chronic non-productive cough and general malaise. Follow-up chest computed tomography revealed progressive ground-glass opacities in the left lower lung, initially suspected to be lobar bronchioloalveolar carcinoma. Surgical intervention was performed for both diagnostic and therapeutic purposes, confirming the lesion as lipid pneumonia upon pathological examination, revealing the presence of foamy histiocytes.

Endogenous lipid pneumonia in a ringed seal (Pusa hispida subsp. ochotensis)

An adult female ringed seal died suddenly and was subsequently examined for diagnostic purposes. The animal's lungs demonstrated mild non-collapsibility and multifocal white to yellow patches. Histopathological examination revealed multifocal pulmonary histiocytosis. Alveoli were filled with numerous foamy macrophages cytoplasm and scattered multinucleated giant cells containing cholesterol clefts. The foamy cytoplasm of the macrophages stained with oil red O stain. Further, lipid droplets within the cytoplasm were detected by electron microscopy. To the author's knowledge, this is the first case report describing the histochemical staining and electron microscopic findings associated with endogenous lipid pneumonia in ringed seal.

Predicting ventilator-associated pneumonia in elderly patients requiring mechanical ventilation through the detection in tracheal aspirates

OBJECTIVE

In this study, we evaluated the clinical utility of tracheal aspirates α-amylase (AM), pepsin, and lipid-laden macrophage index (LLMI) in the early diagnosis of ventilator-associated pneumonia (VAP) in elderly patients on mechanical ventilation.

METHODS

Within 96 hours of tracheal intubation, tracheal aspirate specimens were collected from elderly patients on mechanical ventilation; AM, pepsin, and LLMI were detected, and we analyzed the potential of each index individually and in combination in diagnosing VAP.

RESULTS

Patients with VAP had significantly higher levels of AM, pepsin, and LLMI compared to those without VAP (P < 0.001), and there was a positive correlation between the number of pre-intubation risk factors of aspiration and the detection value of each index in patients with VAP (P < 0.001). The area under a receiver operating characteristic (ROC) curve (AUC) of AM, pepsin, and LLMI in diagnosis of VAP were 0.821 (95% CI:0.713-0.904), 0.802 (95% CI:0.693-0.892), and 0.621 (95% CI:0.583-0.824), the sensitivities were 0.8815, 0.7632, and 0.6973, the specificities were 0.8495, 0.8602, and 0.6291, and the cutoff values were 4,321.5 U/L, 126.61 ng/ml, and 173.5, respectively. The AUC for the combination of indexes in diagnosing VAP was 0.905 (95% CI:0.812-0.934), and the sensitivity and specificity were 0.9211 and 0.9332, respectively. In the tracheal aspirate specimens, the detection rate of AM ≥ cutoff was the highest, while it was the lowest for LLMI (P < 0.001). The detection rates of AM ≥ cutoff and pepsin ≥ cutoff were higher within 48 hours after intubation than within 48-96 hours after intubation (P < 0.001). In contrast, the detection rate of LLMI ≥ cutoff was higher within 48-96 hours after intubation than within 48 hours after intubation (P < 0.001). The risk factors for VAP identified using logistic multivariate analysis included pre-intubation aspiration risk factors (≥3), MDR bacteria growth in tracheal aspirates, and tracheal aspirate AM ≥ 4,321.5 U/L, pepsin ≥ 126.61 ng/ml, and LLMI ≥ 173.5.

CONCLUSION

The detection of AM, pepsin, and LLMI in tracheal aspirates has promising clinical utility as an early warning biomarker of VAP in elderly patients undergoing mechanical ventilation.

Extrinsic lipoid pneumonia due to chronic polyethylene glycol consumption: A case report

Extrinsic lipoid pneumonia (ELP) results from the aspiration of lipid-containing substances. Tissue or cell histopathology after Oil-Red-O staining can confirm the diagnosis, which requires proper tissue handling and preparation during bronchoscopy. Here, we report a case of ELP in a quadriplegic patient with a long history of dysphagia and polyethylene glycol consumption. Computed tomography (CT) of the chest revealed multiple, progressively enlarging, fat-attenuated, nodular pulmonary lesions. Bronchoscopy with bronchoalveolar lavage (BAL) and a transbronchial forceps biopsy confirmed the diagnosis of lipoid pneumonia. We discuss the clinical, radiological, and pathological features of ELP and highlight the preparatory steps required for obtaining a successful diagnosis.

A rare case of lipoid pneumonia mimicking lung malignancy on radiological imaging: A case report

Lipoid pneumonia is a rare benign lung disease pathologically characterized by the presence of lipids in the alveoli. It may mimic lung malignancy on radiological imaging. In this case report we present a case of lipoid pneumonia that radiologically manifested as a lung mass and summarize the typical investigation findings and the management of the disease from the literature review to serve as a reminder of and refresh our knowledge of this rare disease entity.

A case of drug-induced organizing pneumonia caused by amikacin liposome inhalation suspension

Inhaled liposomal antimicrobials are known to cause hypersensitivity pneumonitis. Amikacin liposome inhalation suspension (ALIS) is a promising novel antimicrobial agent against refractory Mycobacterium avium complex infections. The frequency of drug-induced lung injury caused by ALIS is relatively high. To date, no reports of ALIS-induced organizing pneumonia diagnosed by bronchoscopy are available. We report a case of a 74-year-old female patient presenting with non-tuberculous mycobacterial pulmonary disease (NTM-PD). She was treated with ALIS for refractory NTM-PD. Fifty-nine days after starting ALIS, the patient developed a cough, and her chest radiographs indicated deterioration. She was diagnosed with organizing pneumonia based on pathological findings of the lung tissues obtained by bronchoscopy. After switching from ALIS to amikacin infusion, her organizing pneumonia improved. It is difficult to distinguish between organizing pneumonia and an exacerbation of NTM-PD based on chest radiography alone. Therefore, it is essential to perform an active bronchoscopy for diagnosis.

The effect of therapeutic bronchoalveolar lavage in combination with glucocorticoids on children with acute exogenous lipoid pneumonia

BACKGROUND

Exogenous lipoid pneumonia (ELP) is a rare disease caused by the inhalation of oily materials in the alveoli with the pathological characterization by the presence of laden-lipid macrophages in the respiratory specimens. At present, the treatment norm for ELP has not well defined, and so the aim of this study is to evaluate the effect of bronchoalveolar lavage in combination with glucocorticoids on children with ELP.

METHODS AND MATERIALS

We retrospectively reviewed 17 children with a confirmed history of exogenous oily materials aspiration, admitted to the First Affiliated Hospital of Guangzhou Medical University from June 2012 to December 2021. Clinical features, blood investigations, tomographic evaluations, therapeutic bronchoalveolar lavage and glucocorticoids use were carried out at the beginning of therapy and throughout a follow-up period.

RESULTS

The included children are the median age of 2 years. Fever, dypnea and tachypnea were the most common symptoms. The most common radiological features were airspace consolidations (15, 93.75%). Chest CT scans showed areas of consolidation with air bronchogram (15, 93.75%), poorly defined centrilobular nodules (13, 81.25%), areas of ground-glass attenuation (11, 68.75%) and 'crazy-paving' pattern (6, 37.5%) in the both lower, right middle lung lobes. Neutrophil percentage of peripheral blood and bronchoalveolar lavage fluid exhibited a significantly higher than the normal range. After treatment with multiple bronchoalveolar lavages and local administration of budesonide during the hospital stay, taken by oral prednisolone (1 ~ 2 mg/kg) after discharge, all of children became asymptomatic and presented normal radiological imagings in the follow-up period.

CONCLUSION

The most frequently findings in the CT scan of ELP were consolidations and ground-glass attenuation in the both lower and right middle lung lobes. Multiple bronchoalveolar lavages in combination with oral prednisolone for children who had a confirmed history of exogenous oily substances ingestion were an efficient and safe for the clearance of oily materials from the lung and the prevention of fibrosis. This strategy contributed to reducing the damage of ELP in children patients.

Endogenous lipid pneumonia associated with atherosclerosis in a blue-fronted Amazon parrot (Amazona aestiva)

Endogenous lipid pneumonia is a rare inflammatory, non-infectious lung disease characterized by the accumulation of endogenous lipids in alveolar macrophages. It has been associated with bronchial obstruction, chronic lung inflammation, alveolar proteinosis and lipid storage disorders. A 14-year-old female blue-fronted Amazon parrot (Amazona aestiva) presented with intermittent dyspnoea, neurological signs and persistent lipaemia of unknown aetiology. At necropsy, the most relevant gross findings were increased rigidity of the great vessels, lungs with diffuse grey to whitish discolouration of the parenchyma and multifocal small yellowish nodules. Microscopic examination revealed typical lesions of atherosclerosis and severe multifocal accumulation of foamy macrophages filling the parabronchi, which led to a diagnosis of endogenous lipid pneumonia. Although the relationship between dyslipidaemia, atherosclerosis and endogenous lipid pneumonia in birds is not well established, the chronic dyslipidaemia of unknown origin could be involved in the pathogenesis of both the atherosclerosis and the endogenous lipid pneumonia. The present case highlights the need to better understand the relationships between various disorders of lipid metabolism in psittacine birds.

From Beneath the Skin to the Airway Wall: Understanding the Pathological Role of Adipose Tissue in Comorbid Asthma-Obesity

This article provides a contemporary report on the role of adipose tissue in respiratory dysfunction. Adipose tissue is distributed throughout the body, accumulating beneath the skin (subcutaneous), around organs (visceral), and importantly in the context of respiratory disease, has recently been shown to accumulate within the airway wall: "airway-associated adipose tissue." Excessive adipose tissue deposition compromises respiratory function and increases the severity of diseases such as asthma. The mechanisms of respiratory impairment are inflammatory, structural, and mechanical in nature, vary depending on the anatomical site of deposition and adipose tissue subtype, and likely contribute to different phenotypes of comorbid asthma-obesity. An understanding of adipose tissue-driven pathophysiology provides an opportunity for diagnostic advancement and patient-specific treatment. As an exemplar, the potential impact of airway-associated adipose tissue is highlighted, and how this may change the management of a patient with asthma who is also obese. © 2023 American Physiological Society. Compr Physiol 13:4321-4353, 2023.

The implications of Vitamin E acetate in E-cigarette, or vaping, product use-associated lung injury

In the summer of 2019, a cluster of cases were observed with users of battery-operated or superheating devices presenting with multiple symptoms, such as dyspnea, cough, fever, constitutional symptoms, gastrointestinal upset, and hemoptysis, that is now termed e-cigarette, or vaping, product use-associated lung injury (EVALI). The Centers for Disease Control and Prevention reported 2807 cases within the USA leading to at least 68 deaths as of February 18, 2020. The heterogeneous presentations of EVALI make diagnosis and treatment difficult; however, treatment focused on identifying and removal of the noxious substance and providing supportive care. Vitamin E acetate (VEA) is a likely cause of this lung injury, and others have reported other components to play a possible role, such as nicotine and vegetable glycerin/propylene glycol. EVALI is usually observed in adolescents, with a history of vaping product usage within 90 days typically containing tetrahydrocannabinol, and presenting on chest radiograph with pulmonary infiltrates or computed tomography scan with ground-glass opacities. Diagnosis requires a high degree of suspicion to diagnose and exclusion of other possible causes of lung disease. Here, we review the current literature to detail the major factors contributing to EVALI and primarily discuss the potential role of VEA in EVALI. We will also briefly discuss other constituents other than just VEA, as a small number of EVALI cases are reported without the detection of VEA, but with the same clinical diagnosis.

A Rare Case of Post-Primary Tuberculosis Which Was Pathologically Diagnosed as Lipoid Pneumonia

Case Presentation

The patient was a middle-aged housewife who had been using the household spray for a long time, and the main symptoms were cough and sputum production. Chest CT showed lobar ground-glass opacities (GGOs) with small patchy consolidation in the right middle lobe (RML), specifically, lung tissue pathology showed a large number of foamy cells and scattered multinucleated giant cells. The patient received empirical anti-infective treatment, but no clinical improvement was observed. Laboratory tests, including smears and cultures of sputum, blood and bronchoalveolar lavage fluid (BALF), did not provide clear evidence for pathogenic microorganisms. Therefore, the presumptive diagnosis was exogenous LP (ExLP). After 28 days of prednisone treatment, her symptoms improved, but 2 months later, she presented with a worsening cough, and the GGOs had progressed into lobar consolidation. Transbronchial lung biopsy (TBLB) culture showed mycobacterium tuberculosis (MTB), and lung tissue pathology showed granulomatous inflammation. After anti-tuberculosis treatment, the consolidation in the right middle lobe was gradually absorbed, along with a considerable symptom improvement. The final diagnosis of the patient was MTB infection with an endogenous lipoid pneumonia (EnLP)-like presentation.

Conclusion

The current case highlights that the MTB infection should be considered when pathology shows LP accompanied by scattered multinucleated giant cells.

Impact of vaping on respiratory health

Widespread uptake of vaping has signaled a sea change in the future of nicotine consumption. Vaping has grown in popularity over the past decade, in part propelled by innovations in vape pen design and nicotine flavoring. Teens and young adults have seen the biggest uptake in use of vape pens, which have superseded conventional cigarettes as the preferred modality of nicotine consumption. Relatively little is known, however, about the potential effects of chronic vaping on the respiratory system. Further, the role of vaping as a tool of smoking cessation and tobacco harm reduction remains controversial. The 2019 E-cigarette or Vaping Use-Associated Lung Injury (EVALI) outbreak highlighted the potential harms of vaping, and the consequences of long term use remain unknown. Here, we review the growing body of literature investigating the impacts of vaping on respiratory health. We review the clinical manifestations of vaping related lung injury, including the EVALI outbreak, as well as the effects of chronic vaping on respiratory health and covid-19 outcomes. We conclude that vaping is not without risk, and that further investigation is required to establish clear public policy guidance and regulation.

Hydrocarbon pneumonitis with abscess formation following diesel siphoning

A man in his early 40s presented with a 1-month history of fever after accidental diesel aspiration. He had received treatment with intravenous antibiotics, steroids and supportive care. Contrast-enhanced CT of the thorax revealed a right middle lobe lung abscess and bronchoscopy revealed hyperaemia around the middle lobe bronchus. The abscess was initially managed by drainage using a pigtail catheter and intravenous antibiotics. However, only partial drainage of the abscess was achieved and fever persisted. The cardiothoracic surgery team performed drainage of lung abscess through a right posterolateral thoracotomy. Postprocedure, the patient's symptoms improved and the patient was discharged in good health. This case demonstrates a rare complication of hydrocarbon aspiration pneumonitis and lung abscess. Post acute management of diesel aspiration, patients should be advised to return for medical assessment immediately, should symptoms like persistent fever and chest pain recur or persist as these symptoms may herald the development of post-hydrocarbon-aspiration lung abscess.

Acute exogenous lipoid pneumonia: Unusual presentation as cavitating lung disease with pneumothorax

Acute lipoid pneumonia is quite uncommon and is associated with oily or lipid contents within the alveoli. Exogenous lipoid pneumonia due to kerosene poisoning, manifests with a wide clinical spectrum ranging from subtle chemical pneumonitis to marked severe pulmonary and systemic inflammation. We present an interesting case of an adult male with kerosene poisoning. He manifested with severe cavitating lung disease. In addition, he developed spontaneous pneumothorax. Both cavitating lung disease and pneumothorax are unusual manifestations of acute exogenous lipoid pneumonia and perhaps follow severe lung injury following high volume kerosene exposure.

A 66-Year-Old Man With Subacute Cough and Worsening Dyspnea Previously Diagnosed With COVID-19 Pneumonia

A 66-year-old man presented with subacute cough and worsening dyspnea. Labs were notable for moderate peripheral eosinophilia, and computed tomography (CT) scan demonstrated extensive crazy-paving throughout bilateral upper lung fields. Bronchoalveolar lavage (BAL) revealed macrophages with lipid-filled vacuoles and negative periodic acid-Schiff (PAS) stain. Further history obtained from the patient and family was notable for daily application of commercially available vapor rub to nares and intentional deep inhalation of nebulized fluids containing scented oils. The patient was diagnosed with exogenous lipoid pneumonia through an unusual route of lipid administration.

Idiopathic endogenous lipid pneumonia: A case report of a young Syrian man

Lipid pneumonia is pneumonia due to aspiration or inhalation of various oily or fatty substances. It can be divided into exogenous and endogenous depending on the source of the lipids. In endogenous lipid pneumonia (ELP), lipid accumulates in the intra alveoli as a result of obstruction, chronic lung infection/disease, or a lipid storage disorder.

This study presents a case of a 47 year-old man with a history of smoking, surgically repaired ventricular septal defect, pulmonary stenosis, and no history of lipid intake. He complained of worsened exertional dyspnea and a chronic non-productive cough with no signs and symptoms of infection. The patient was diagnosed with idiopathic endogenous lipid pneumonia after excluding any inflammatory or systemic disease as a possible cause. Open lung biopsy showed lipid-laden macrophages. Corticosteroids were the mainstay therapy with no radiological improvement, eventually death occurred due to pulmonary embolism.

Perioperative Care of Children with Acute Exogenous Lipoid Pneumonia Submitted to BAL/FB

Objective

The present study evaluates the psychosocial care and the bronchoalveolar lavage (BAL)/fiberoptic bronchoscopy (FB) procedure in children with pediatric acute exogenous lipoid pneumonia (ELP) and summarizes the critical points of nursing.

Methods

Data on the psychosocial factors of the patients and clinical information were collected. Participants comprised 41 children within three years of age.

Results

All the children were cooperative with the BAL/FB procedure. The children’s pain scores were between 4–6, and the psychological conditions of the children and caregivers were nervous/anxious upon admission. After the medical staff’s psychological care and health education, the children’s postoperative pain scores were reduced to 0–3, and the psychological state of the caregivers was positive.

Conclusion

Psychological care can alleviate families’ adverse emotions and promote treatment cooperation and recovery from the acute ELP.

Lipid metabolism in asthma: Immune regulation and potential therapeutic target

Asthma is a chronic inflammatory disease of the lungs that poses a considerable health and socioeconomic burden. Several risk factors work synergistically to affect the progression of asthma. Lipid metabolism, especially in distinct cells such as T cells, macrophages, granulocytes, and non-immune cells, plays an essential role in the pathogenesis of asthma, as lipids are potent signaling molecules that regulate a multitude of cellular response. In this review, we focused on the metabolic pathways of lipid molecules, especially fatty acids and their derivatives, and summarized their roles in various cells during the pathogenesis of asthma along with the current pharmacological agents targeting lipid metabolism.

Shine like gold and sparkle like glitter: Three cases of lipoid pneumonia

Lipoid pneumonia (LP) is an unwonted, mostly asymptomatic entity which has no classical radiological appearance. It can be endogenous or exogenous depending upon the type of exposure or underlying milieu. It simulates a number of infective and malignant respiratory conditions and can go undiagnosed or delayed leading to morbidity and mortality. We put forward three cases that initially presented as classical pneumonia, but on further assessment and investigations were diagnosed to be LP. All the three cases manifested with symptoms of fever, productive cough and breathlessness. Chest Xray and CT scan were indicative of consolidation. Bronchoalveolar lavage (BAL) evinced lipid laden macrophages that stained positive with fat stains (Sudan IV and Oil Red O). Two cases were endogenous and one was exogenous type. LP, owing to its nonspecific clinical presentation and radiographic signs, needs a high index of suspicion, and a detailed clinical history for accurate diagnosis. Corroboration of lipid laden alveolar macrophages in BAL is the crux to the diagnosis. Hence, clinicians should be cognizant of this condition and rule out LP in cases of non-resolving pneumonia in an appropriate clinical context.

The efficacy and safety of therapeutic lung lavage for exogenous lipoid pneumonia: A systematic review

INTRODUCTION AND OBJECTIVES

Exogenous lipoid pneumonia (ELP) is a lung inflammatory disease with low prevalence and has the feature of external lipid substances presented in the alveoli. Therapeutic lung lavage (segmental bronchoalveolar lavage and whole lung lavage) has been gradually recognized as an important therapy for the disease. There was no comprehensive summary on its efficacy and safety.

METHODS

We searched PubMed, Embase, Cochrane Library, CNKI, Wanfang Database, clinicaltrials.gov, and the references of included studies. After study selection, data extraction and quality assessment, we performed a qualitative description of current data.

RESULTS

We included 90 ELP patients from 25 case reports and 8 case series studies. Eighty-four (93.3%) patients received segmental bronchoalveolar lavage and six (6.7%) patients received whole lung lavage. Eighty-seven (96.7%) patients got clinical improvement after lavages, while three (3.3%) patients had no improvement and eventually died. The follow-up status was reported in 29 patients, of whom 24 patients remained well without any use of drugs and 4 patients remained well with some periods of corticosteroids. One patient endured recurrence. The radiological change was reported in 72 patients, of whom 41 (56.9%) patients had full resolution until the last follow-up. Two studies reported acute pulmonary edema and transient hypoxemia during lavages.

CONCLUSIONS

Therapeutic lung lavage might be an effective and safe therapy with long-term benefits for ELP. Current studies were all case reports and case series with relatively high risk of bias. Prospective controlled studies are needed to explore the actual efficacy, safety, individualized indications, and optimized treatment procedures of therapeutic lung lavage for ELP.

Dose-Dependent Pulmonary Toxicity of Aerosolized Vitamin E Acetate

Electronic-cigarette, or vaping, product use-associated lung injury (EVALI) is a syndrome of acute respiratory failure characterized by monocytic and neutrophilic alveolar inflammation. Epidemiological and clinical evidence suggests a role of vitamin E acetate (VEA) in the development of EVALI, yet it remains unclear whether VEA has direct pulmonary toxicity. To test the hypotheses that aerosolized VEA causes lung injury in mice and directly injures human alveolar epithelial cells, we exposed adult mice and primary human alveolar epithelial type II (AT II) cells to an aerosol of VEA generated by a device designed for vaping oils. Outcome measures in mice included lung edema, BAL analysis, histology, and inflammatory cytokines; in vitro outcomes included cell death, cytokine release, cellular uptake of VEA, and gene-expression analysis. Comparison exposures in both models included the popular nicotine-containing JUUL aerosol. We discovered that VEA caused dose-dependent increases in lung water and BAL protein compared with control and JUUL-exposed mice in association with increased BAL neutrophils, oil-laden macrophages, multinucleated giant cells, and inflammatory cytokines. VEA aerosol was also toxic to AT II cells, causing increased cell death and the release of monocyte and neutrophil chemokines. VEA was directly absorbed by AT II cells, resulting in the differential gene expression of several inflammatory biological pathways. Given the epidemiological and clinical characteristics of the EVALI outbreak, these results suggest that VEA plays an important causal role.

All up in smoke: vaping-associated lung injury

The electronic cigarette (EC), was initially introduced as a safe alternative to conventional cigarette smoking While initially seemingly innocuous, over 2800 E-cigarette, or Vaping, product use-associated lung injury (EVALI) cases have been reported in the USA, with a spectrum of clinical severity ranging from mild dyspnea to overt respiratory failure In this report we highlight three EVALI cases whom presented with dyspnea and a variety of non-specific symptoms. Diagnostic imaging demonstrated bilateral reticular infiltrates and ground-glass opacities with lymphadenopathy. Clinically, patients failed to respond to empiric antibiotics but improved after initiating steroids. Consistent with prior case series, our patients reported exposure to EC liquids containing tetrahydrocannabinol (THC)/cannabidiols (CBD) additives, suggesting Vitamin E acetate as the potentially harmful constituent. In this case series and review, we not only summarize prior clinical studies that have evaluated the effects of vaping on cardiopulmonary function as well as case reports on EVALI, but also discuss the pathophysiology of vaping and EVALI. It remains unclear not only why some individuals develop EVALI, but why the clinical and pathological presentations vary. EVALI remains a significant public health concern and clinicians must maintain a high index of suspicion for this novel phenomenon.

Pattern of FDG-PET uptake in lipoid pneumonia simulating lung cancer

Lipoid pneumonia presents with a variety of lung abnormalities, particularly mass forming lesions that mimic lung cancers. While ¹⁸F-fluorodeoxyglucose (FDG)-positron emission tomography (PET) is expected to discriminate both diseases, some previous reports showed pseudo-positive FDG uptake in lipoid pneumonia. Here, we report a case of pathologically proven chronic lipoid pneumonia in a 78-year-old Japanese man. Computed tomography (CT) showed multi-lobar mass-forming lesions with a fat-density. PET confirmed the spotty accumulation of FDG in the corresponding fat-density area on CT, suggesting lipoid pneumonia. We reviewed the literature and discussed the FDG uptake patterns in lipoid pneumonia.

Bronchoalveolar lavage: role in the evaluation of pulmonary interstitial disease

INTRODUCTION

Bronchoalveolar lavage (BAL), a noninvasive, well-tolerated procedure is an important diagnostic tool that can facilitate the diagnosis of various lung diseases. This procedure allows the assessment of large alveolar compartments, by providing cells as well as non-cellular constituents from the lower respiratory tract. Alterations in BAL fluid and cells ratio reflects pathological changes in the lung parenchyma. In some cases, clinicians use BAL as a differential diagnosis guide for interstitial lung disease.

AREAS COVERED

In this review, we summarized the diagnostic criteria for BAL in interstitial lung diseases, pulmonary infections, lung cancer and other pathologies such as fat embolism, gastroesophageal reflux and collagen vascular disease. For this review, we have selected scientific papers published in the PubMed database in our area of interest. We aimed to highlight the usefulness of BAL in respiratory pathology.

EXPERT OPINION

Although BAL fluid analyzes has an essential role in the diagnostic work-up of many lung pathologies, it should be performed in selected patients. For accurate results, the BAL technique is very important to be standardized.

Exogenous Lipoid Pneumonia Complicated by Mineral Oil Aspiration in a Patient With Chronic Constipation: A Case Report and Review

Exogenous lipoid pneumonia is a rare and frequently misdiagnosed lung disease. It occurs as an inflammatory reaction secondary to either aspiration or inhalation of lipids. Our patient had a history significant for recurrent pneumonia and the use of mineral oil for chronic constipation. A chest computed tomography showed multifocal consolidative opacities with areas of low attenuation, highly suspicious of exogenous lipid pneumonia. The diagnosis was confirmed with combined bronchoalveolar lavage and transbronchial lung biopsy that showed lipid-laden macrophages consistent with exogenous lipoid pneumonia. After thorough medication review, apart from mineral oil, no other contributing factors were found. A diagnosis of exogenous lipoid pneumonia associated with the use of mineral oil made and successfully managed by stopping the offending agent and supportive antibiotics.

Proceedings from the 2nd Next Gen Therapies for Systemic Juvenile Idiopathic Arthritis and Macrophage Activation Syndrome symposium held on October 3-4, 2019

For reasons poorly understood, and despite the availability of biological medications blocking IL-1 and IL-6 that have markedly improved overall disease control, children with Systemic Juvenile Idiopathic Arthritis (SJIA) are now increasingly diagnosed with life-threatening chronic complications, including hepatitis and lung disease (SJIA-LD). On October 3-4, 2019, a two-day meeting, NextGen Therapies for Systemic Juvenile Idiopathic Arthritis (SJIA) & macrophage activation syndrome (MAS) organized by the Systemic JIA Foundation ( www.systemicjia.org/ ) in Washington, DC brought together scientists, clinicians, parents and FDA representatives with the objectives (1) to integrate clinical and research findings in MAS and SJIA-LD, and (2) to develop a shared understanding of this seemingly new pulmonary complication of SJIA. The current manuscript summarizes discussions and conclusions of the meeting.

Exogenous lipoid pneumonia: when radiologist makes the difference

PURPOSE

To report high-resolution CT (HRCT) findings in our group of patients with exogenous lipoid pneumonia (ELP), confirmed with histopathological findings and clinical-anamnestic data, in order to describe the most common radiological patterns of this rare disorder.

MATERIALS AND METHODS

In this retrospective study, HRCT of 10 patients with ELP were evaluated by three radiologists. Diagnosis of ELP was made through CT, bronchiolo-alveolar lavage (BAL) and a pneumological examination associated with an accurate medical anamnesis. Five patients had a histologically proven ELP, through lung biopsy. All patients had a chronic exposition to substances made of animal fat or mineral/vegetable oils.

RESULTS

In our cohort of patients with ELP, the following parenchymal patterns were observed: 8/10 patients had lung consolidation with adipose density (attenuation values < - 40 HU); 10/10 patients had multiple areas of ground glass opacity; 6/10 patients had smooth thickening of interlobular septa and ground glass opacities ("crazy-paving" pattern); 2/10 patients presented nodules > 2.5 cm with spiculated margins (tumor-like); 5/10 patients showed reactive lymph nodes enlargement. The oldest lesions were characterized by bronchiectasis and fibrosis around the lipidic consolidations.

CONCLUSION

Pulmonary alterations found in HRCT exams can be confused with other lung diseases (especially lung tumors) and they are always a challenge even for the most experienced radiologist. In our experience, although non-specific, consolidation areas with low HU values and crazy-paving pattern are frequently associated in ELP. These characteristics should alert the radiologist to consider ELP among the possible differential diagnoses, always correlating the results of CT examination with appropriate clinical-laboratory evaluations and an accurate anamnesis.

Vaping-Related Acute Parenchymal Lung Injury: A Systematic Review

The outbreak of vaping-related acute lung injury in the United States, named EVALI (e-cigarette or vaping product use associated acute lung injury), has reignited concerns about the health effects of vaping. Initial case reports of vaping-related lung injury date back to 2012, but the ongoing outbreak of EVALI began in the summer of 2019 and has been implicated in 2,807 cases and 68 deaths as of this writing. Review of the scientific literature revealed 216 patient cases that spanned 41 reports of parenchymal lung injury attributed to vaping. In this review, we detail the clinical, radiographic, and pathologic patterns of lung injury that are attributable to vaping and provide an overview of the scientific literature to date on the effects of vaping on respiratory health. Tetrahydrocannabinol was the most commonly vaped substance, and vitamin E acetate was found in BAL specimens from many affected individuals. However, no specific component or contaminant has been identified conclusively to date as the cause for the injury. Patients present with cough, dyspnea, constitutional symptoms, and GI symptoms. Radiologic and histopathologic findings demonstrate a spectrum of nonspecific acute injury patterns. A high index of suspicion combined with a good history are the keys to an accurate diagnosis. Treatment is supportive; the mortality rate is low, and most patients recover. Corticosteroids have been used with apparent success in patients with severe disease, but more rigorous studies are needed to clarify their role in the treatment of vaping-related lung injury.

A Systematic Literature Review of E-Cigarette-Related Illness and Injury: Not Just for the Respirologist

Following the recent electronic cigarette (e-cigarette) illness outbreak, the current review aimed to collect all related clinical cases for study and analysis and provide a critical synopsis of the proposed injury mechanism. Adhering to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) guidelines, e-cigarette-related clinical cases were identified via Google Scholar and PubMed databases. Additionally, references of published case reports and previous review papers were manually searched, revealing 159 publications presenting e-cigarette-related case reports and 19 reports by the Centers for Disease Control and Prevention. 238 individual cases were identified; 53% traumatic injuries due to e-cigarette explosion or self-combustion, 24% respiratory cases, and 12% poisonings. Additional cases pertained to oral, cardiovascular, immunologic, hematologic, allergic reactions, infant complications, and altered medication levels. Case reports were mainly published between 2016-2019 (78%). The oldest case, a lipoid pneumonia, was published in 2012. The current review showed that e-cigarette-related health effects extend beyond the acute lung injury syndrome, including traumatic, thermal injuries and acute intoxications. Physicians should be aware of the distinct clinical presentations and be trained to respond and treat effectively. Regulators and public health authorities should address the regulatory gap regarding electronic nicotine delivery systems (ENDS) and novel tobacco products.

Exogenous lipoid pneumonia in children: A systematic review

OBJECTIVES

To describe the clinical-radiological-pathological characteristics and treatment outcomes of children with suspected exogenous lipoid pneumonia (ELP).

DESIGN

Systematic review. We searched electronic databases and reference lists published between 1967 and 2018, restricted to non-accidental cases.

RESULTS

Forty-four studies including 489 participants aged 1 day to 17 years from 13 countries were included. Cultural, medical, and behavioural rationale for oil-use was described. The clinical-radiological presentation varied widely. Diagnostic certainty was deemed highest if ELP was confirmed on bronchoalveolar lavage/frozen section lung biopsy with documented extracellular lipid on cytological staining and/or fat analysis. Non-tuberculous mycobacteria infection was identified in six studies: Mycobacterium fortuitum/chelonei, Mycobacterium smegmatis and Mycobacterium abscessus. Treatment comprised supportive therapy, corticosteroids, stopping oil, therapeutic lung-lavage and surgical resection. Outcomes were reported inconsistently.

CONCLUSION

Paediatric ELP resulting from cultural and medical practices continues to be described globally. Preventive interventions, standardized reporting, and treatment efficacy studies for cases not averted, are lacking. Protocol registration: PROSPERO CRD42017068313.