LIPOID PNEUMONIA SEEN IN PATIENT WITH HISTORY OF PURGING

Abstract

SESSION TITLE: Medical Student/Resident Imaging Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Lipoid pneumonia is seen when mineral oil (commonly used for constipation) is aspirated [1]. Two responses are noted: (1) an inflammatory response with regional edema and intra alveolar hemorrhage; these patients acutely present with cough, fever, and dyspnea, or (2) a “paraffinoma” with aspirated oils encapsulated by fibrous tissues; these patients present asymptomatically with mass seen on imaging [2]. Most patients who develop lipoid pneumonia have risk factors for aspiration. CASE PRESENTATION: Patient is a 61-year-old female with known history of Hepatitis C, anxiety, self-described “obsessive-compulsive disorder”, homebound for eight years, and no recent physician visits, brought in by Emergency Medical Services after patient was standing from chair and heard a loud “snap”. On interview, patient remarked that she consistently “eats healthy” and took “natural” supplements for her “constipation”. On arrival, the patient's vital signs were within normal limits, afebrile, saturating 99 percent on room air. Patient was cachectic appearing with bitemporal wasting and four out of five strength globally. She exhibited pressured speech and tangential thought. Lungs were clear to auscultation bilaterally. Patient was found to have pathologic fracture of left femur on Computed Tomography (CT) imaging and underwent open reduction and internal fixation. Chest X-Ray revealed a right middle lobe or lingular opacity concerning for aspiration or a questionable pneumonia. Further imaging of chest with a noncontrast CT showed fat attenuation and patchy areas of consolidation in the mid to lower lungs bilaterally, compatible with lipoid pneumonia. In-patient psychiatry diagnosed the patient as hypomanic and noted that she exhibited multiple signs of anorexia nervosa including limited oral intake and excessive purging. Patient was otherwise asymptomatic throughout hospital course. DISCUSSION: This presentation is unique in that the patient had been taking mineral oil supplements for purging in addition to emesis; emesis of these oil particles and subsequent aspiration were the cause of her development of lipoid pneumonia. While aspiration of food particles is common, aspiration of organic oils is quite rare. It is important remember that patients with body dysmorphic disorder can use laxatives as a form of purging. All patients that exhibit signs of purging are at great risk for aspiration pneumonitis and pneumonia. CONCLUSIONS: The patient’s presentation and CT findings suggests a “paraffinoma” rather than inflammation with hemorrhage. While typical paraffinomas are skin conditions characterized by granulomatous and fibrotic reactions in subcutaneous fats, interestingly, the same reactions can take place in the lung resulting in above CT findings. Reference #1: Spickard, A., & Hirschmann, J. V. (1994). Exogenous lipoid pneumonia. Archives of internal medicine, 154(6), 686-692. Reference #2: Betancourt, S. L., Martinez-Jimenez, S., Rossi, S. E., Truong, M. T., Carrillo, J., & Erasmus, J. J. (2010). Lipoid pneumonia: spectrum of clinical and radiologic manifestations. American Journal of Roentgenology, 194(1), 103-109. DISCLOSURES: No relevant relationships by George Apergis, source=Web Response No relevant relationships by Karthik Bharadwaj, source=Web Response No relevant relationships by Doris Zavaro, source=Web Response