Endgames Case review

Dyspnoea after home improvement work

BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i5957 (Published 30 November 2016) Cite this as: BMJ 2016;355:i5957
  1. Alessio Marra, internal medicine resident,
  2. Nicoletta Bottero, internal medicine resident,
  3. Giovanna Leoncini, assistant professor,
  4. Giovanni Murialdo, professor
  1. Department of Internal Medicine, IRCCS AOU San Martino-IST, University of Genova, Genova, Italy
  1. Correspondence to A Marra dott.alessio.marra{at}gmail.com

A 73 year old white man presented to the emergency department after unintentional ingestion of paraffin, which he had used as a paint remover two hours earlier. The episode was followed by cough, and the patient reported self induced vomiting. On admission he was eupnoeic and his respiratory rate, oxygen saturation, blood pressure, heart rate, and skin temperature were normal. The patient was a moderate smoker (15 cigarettes/day), and his history was notable only for a minor stroke two years previously without persistent sensory motor impairment. Physical examination, laboratory tests, and chest radiography were normal. No mucosal lesion was evident on an urgent gastroscopy. He was given vaseline oil and oral antacids. After 18 hours he developed hyperpyrexia (39°C), acute dyspnoea with desaturation (peripheral oxygen saturation 91% while breathing ambient air), and productive cough with blood streaks. A pulmonary examination identified fine crackles at the right lung base. White blood cell count and C reactive protein levels were increased (23×109/L (reference values: 4.5-9.8×109/L) and 216 mg/L (reference value: <5 mg/L) respectively). Contrast enhanced computed tomography (CT) of the chest was performed (fig 1).

Fig 1 Computed tomography scan of the lung

Questions

  • 1. What does the CT scan show and what is the diagnosis?

  • 2. How would you manage this patient?

  • 3. What extrapulmonary complications can arise?

Answers

1. What does the CT scan show and what is the diagnosis?

Short answer

The CT scan shows left pleural effusion and bilateral pulmonary infiltrates with consolidations, mixed with areas of low density involving the right middle lobe and the lingual (fig 2), suggestive of acute lipoid pneumonia. The diagnosis is paraffin ingestion related pneumonia.

Fig 2 CT scan shows bilateral lung consolidation (arrows) and left pleural effusion (*). Areas of low fat attenuation are visible in the context of infiltrates (arrowheads)

Discussion

Multiple areas of reduced tomographic density (Hounsfield Unit (HU) …

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