Dr.Sruthi Auresh Dr.Sajith Kesavan (Paed Pulmonology)
(DR Greeshma pediatric Intensivist ) Dr.C.Jayakumar
AIMS, Kochi
Two month old male child from Maldives, 3rd child of non-consanguineous parentage presented with history of recurrent episodes of lower respiratory tract infections since neonatal period, requiring intravenous antibiotics and once diagnosed as covid pneumonia at 1 month of age, now presented with complaints of high grade fever and cough of 3 days duration.
Following which he was admitted at a local hospital and treated as lower respiratory tract infection with intravenous antibiotics and nebulized bronchodilators.
With worsening of respiratory distress and increasing oxygen requirement he was referred for further evaluation and management.
At admission to ER ba was sick looking and tachypnoeic, not maintaining room air saturation (91% )
Chest auscultation revealed bilateral wheeze.
Blood investigations showed lymphocytic counts with negative inflammatory markers. Chest X-Ray showed right upper and middle zone opacities.
Figure 1: Chest X-Ray showing right upper and middle zone opacities.
He was started on Inj.Piperacillin and tazobactam. Blood culture grew Klebsiella pneumonia. Primary immunodeficiency workup and ECHO were within normal limits. He was further investigated as his condition was not improving and CT chest showed bilateral extensive consolidation (right>left) with areas of low density within possibly lipid .Thus a suspicion of exogenous lipoid pneumonia arose.
Figure 2 : CT chest before lavage.
Bronchoscopy was thus done which showed normal anatomy. Bronchoalveolar lavage obtained a milky white wash. BAL cytopathology revealed lipid laden macrophages (Oil Red O stain positivity). Thus a diagnosis of lipoid pneumonia was considered.
Parents now revealed the practice of forceful ingestion of one spoon of olive oil the ba owing it to being a cultural practice. Serial segmental lobar lung lavage was done until clear wash was obtained. Repeat CT chest after lavage showed improvement.
Figure 3 : CT chest after lavage.
Swallow study showed oesophageal dysphagia but was found to be fit for oral stimulation with restricted quantity. Repeat CT chest after 1 year of age showed normal findings.
Lipoid pneumonia :
Lipoid pneumonia can be classified into exogenous and endogenous.
Exogenous lipoid pneumonia is caused aspiration or inhalation of lipid-containing products.
This ba was subjected to forceful ingestion of one spoon of olive oil daily since birth in view of it being nutritious.
Lipoid pneumonia is largely a diagnosis of exclusion. It can mimic several diseases; therefore, history plays a crucial role in the diagnosis given there is no specific clinical feature linked to the disease.
There is no standard of care for the treatment of lipoid pneumonia. Many case reports show improvement with corticosteroids given their anti-inflammatory nature. Whole lung lavage has also been mentioned as curative.
Carry home message: Our aim should thus be not just to treat the disease in front of us but to figure out the “why” behind it which will help us prevent the disease recurrence in the future.