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Lipoid pneumonia usually presents after chronic recurrent ingestion of oily substances or accidental aspiration during "fire-eating" demonstrations. Massive exposure by near drowning extremely rare and potentially fatal. We present here a case of survival after total immersion in oil in her workplace. A 66-year-old woman who nearly drowned in a vat of vegetable oil was admitted as an emergency case with severe hypoxia after rescue. Chest computed tomography (CT) findings showed bilateral ground-glass opacity, consolidation, and the case fulfilled the criteria for acute respiratory distress syndrome (ARDS). Bronchoscopy and bronchoalveolar lavage performed on admission indicated oil droplets and marked neutrophilia (67%), which made us diagnose ARDS induced by lipoid pneumonia. We commenced treatment with pulsed steroids and strictly managed fluid balance under mechanical ventilation. Despite immediate improvement in oxygenation, the value of extravascular lung water index (EVLWI) measured by the PiCCO system consistently remained over 30 ml/Kg through her clinical course. We concluded that lipoid pneumonia is characterized by prolonged elevatation of pulmonary vascular permeability.

Idiopathic pulmonary fibrosis (IPF) is characterized by radiographically evident interstitial infiltrates predominantly affecting the lung bases and by progressive dyspnea and worsening pulmonary function. Acute exacerbation of IPF is recognized widely as an accelerated phase occurring suddenly in the course of IPF, which leads to a catastrophic outcome. No treatment has proven to be effective so far. We describe two cases of acute exacerbation of IPF which were treated by direct hemoperfusion with a polymyxin B-immobilized fiber column (PMX) after steroid pulse therapy. One patient died on the 21st day after direct hemoperfusion and the other is alive at present. The survivor showed significant improvement of pulmonary oxygenation correlating with a decrease in the neutrophil count, SP-D and KL-6 after direct hemoperfusion with PMX. On the other hand, the non-survivor showed no improvement of pulmonary oxygenation, SP-D and KL-6 despite a decrease in neutrophil count comparable with that of the survivor. Neutrophil count which decreased temporarily after direct hemoperfusion with PMX soon convert to increase in the non-survivor, which is a characteristic difference between two. We reached the conclusions that (1) direct hemoperfusion with PMX absorbs neutrophils and this mechanism is effective to improve pulmonary oxygenation, (2) sometimes neutrophil absorption is not enough to control pulmonary inflammation in patients with acute exacerbation of IPF.

A 65-year-old woman was given emergency admission with fever, cough and dyspnea. Chest computed tomography (CT) findings showed bilateral ground-glass opacity, consolidation, and this case were fulfilled the criteria for acute respiratory distress syndrome (ARDS). We clinically diagnosed the patient as suffering from idiopathic ARDS including acute interstitial pneumonia (AIP) based on the absence of any known causes of ARDS and systemic immunologic diseases. We started treatment with sivelestat sodium and strictly managed fluid balance under mechanical ventilation. We found this treatment quite effective because there were significant improvements in the extravascular lung water index (EVLWI) measured by the PiCCO system and neutrophile elastase value and in oxygenation and the chest radiograph. This is apparently the first case report in the literature that clearly shows the treatment with sivelestat sodium and strict fluid management ended in a favorable outcome, as reducing EVLWI measured by the PiCCO system in an idiopathic ARDS patient.