Dyspnoea after home improvement work

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⇓).