Diagnostic value of bronchoalveolar lavage in fat embolism syndrome--a case report

Abstract

On the basis of the studies of autopsy cases and experimental animals, the pulmonary pathological findings of fat embolism syndrome (FES) have been reported to be (1) fat globules in the alveolar capillaries and the alveoli, (2) intra-alveolar hemorrhage, (3) alveolar edema and (4) foci of secondary infection. However, reports on lung biopsy in FES are rare, and no report has mentioned bronchoalveolar lavage (BAL) in FES. We experienced a case of FES, in which BAL was diagnostic. A 23 year-old man traffic accident victim was brought to our hospital by ambulance. His consciousness was clear and skeletal X-ray films revealed multiple fractures of the right femur, left tibia and left fibula. Direct traction of bilateral lower extremities was done. He remained stable subjectively, but anemia and thrombocytopenia progressed gradually in spite of blood transfusion. On the 4th hospital day severe hypoxemia, diffuse pulmonary infiltrates and petechiae in bilateral axillary lesions appeared, and FES was strongly suspected. O2 inhalation by face mask and high dose methylprednisolone administration was started. The hypoxemia improved, but pulmonary infiltrates worsened. For differential diagnosis, bronchoscopy and BAL was done on the 7th hospital day. Bronchoscopy revealed much fresh blood in the left main, upper lobe and lower lobe bronchus but no bleeding point was found. BAL fluid was bloody. The Sudan III stain and Berlin blue stain revealed several fat globules and numerous hemosiderin-laden macrophages. The presence of intra-alveolar fat globules and intra-alveolar hemorrhage was proved and definite diagnosis of FES was established.