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Many current treatment options for lung inflammation and thrombosis come with unwanted side effects. The natural omega-3 fatty acids (O3FA) are generally anti-inflammatory and antithrombotic. The O3FA are always administered orally and occasionally by intravenous (IV) infusion. The main goal of this study is to determine if O3FA administered by inhalation of a nebulized formulation mitigates LPS-induced acute lung inflammation in male Wistar rats. Inflammation was triggered by intraperitoneal injection of LPS once a day for 14 days. One hour later, rats received nebulized treatments consisting of egg lecithin emulsified O3, budesonide and Montelukast, and blends of O3 and melatonin or Montelukast or Cannabidiol; O3 was in the form of free fatty acids for all groups except one group with ethyl esters. Lung histology and cytokines were determined in n=3 rats per group at day 8 and day 15. All groups had alveolar histiocytosis severity scores half or less than that of the disease control (Cd) treated with LPS and saline only inhalation. IL-6, TNF-α, TGF-β, and IL-10 were attenuated in all O3 groups. IL-1β was attenuated in most but not all O3 groups. O3 administered as ethyl ester was overall most effective in mitigating LPS effects. No evidence of lipid pneumonia or other chronic distress was observed. These preclinical data suggest that O3FA formulations should be further investigated as treatments in lung inflammation and thrombosis related lung disorders, including asthma, chronic obstructive pulmonary disease, lung cancer and acute respiratory distress like COVID-19.

Lipid pneumonia is pneumonia due to aspiration or inhalation of various oily or fatty substances. It can be divided into exogenous and endogenous depending on the source of the lipids. In endogenous lipid pneumonia (ELP), lipid accumulates in the intra alveoli as a result of obstruction, chronic lung infection/disease, or a lipid storage disorder. This study presents a case of a 47 yearold man with a history of smoking, surgically repaired ventricular septal defect, pulmonary stenosis, and no history of lipid intake. The patient complained of worsened exertional dyspnea and a chronic non-productive cough with no signs and symptoms of infection. The patient was diagnosed with idiopathic endogenous lipid pneumonia after excluding any inflammatory or systemic disease as a possible cause. Open lung biopsy showed lipid-laden macrophages. Corticosteroid was the mainstay therapy with no radiological improvement, eventually death occurred due to pulmonary embolism.

Background : Pneumothorax is a clinical condition which can cause respiratory distress. It can have as its origin traumatic causes or even classified as spontaneous, mainly related to diseases of the lung parenchyma. Lipoid pneumonia is rarely described in dogs , and it is characterized by globules of lipid in the alveolar spaces. Endogenous lipoid pneumonia (EnLP) occurs when lesions on pulmonary cells release cholesterol and other lipids in the alveoli. There is no clinical approach established for EnLP in veterinary patients. The aim of this report is to describe a case of a young Maltese dog, with recurrent spontaneous pneumothorax in which EnLP was diagnosed Post mortem. Case : A 2-year-old sexually intact male Maltese dog was evaluated for restrictive dyspnea. Clinicopathologic findings included cyanotic, muffled chest auscultation with hypersonic thoracic percussion. Chest x-ray demonstrated an increase in pleuropulmonary radio transparency and a floating-looking heart, indicating pneumothorax. Complete blood counts and biochemical panel results were normal. Dirofilaria immitis antigen test results were negative. Computed tomography demonstrated slightly hyper-expanded pulmonary fields, with slightly enlarged reticular marking with areas of mild multicentric panlobular emphysema and a fracture on the sixth left rib. The treatment was focused on improving the breathing pattern through sedation, supplementation with oxygen, and thoracentesis. Owing to the reserved prognosis of the case, the unknown etiology of the recurrent pneumothorax, and the clinical worsening of the patient, the owner opted for euthanasia. Necropsy displayed multiple, circular whitish areas in the lungs, distributed over the surface of all lobes. Histopathological examination revealed pulmonary tissue with the subpleural micronodular foci, multifocal to coalescent, with a moderate accumulation of foamy intra-alveolar macrophages, occasionally multinucleate, associated with cholesterol crystals compatible with endogenous lipid pneumonia. Discussion : The patient presented with clinical signs and physical examination characteristics of pneumothorax at the first visit. After the pneumothorax diagnosis, and clinical stabilization of the patient. No predisposing factor for the formation of the pneumothorax was identified as the radiography revealed only bronchitis and blood tests were normal, the patient was thus discharged after 24 h, with the recommendations for observing the breathing pattern. Initially, spontaneous pneumothorax was suspected. The antibiotics were administered since bacterial pneumonia, although not confirmed on chest x-ray, is the main cause of pneumothorax in dogs is lung parenchyma disease. With the worsening of the clinical condition of the patient, CT was performed and did not demonstrate any findings that would justify the presence of pneumothorax. Despite the placement of the chest tube for facilitating the management of thoracentesis, there was no stabilization of the condition, enhancing the frequency of centesis procedures, which led to the decision to euthanize. The microscopic examination of the pulmonary alterations was decisive for the diagnostic conclusion. The visualization of the accumulation of foamy intra-alveolar macrophages, occasionally multinucleate, associated with cholesterol crystals, was responsible for the diagnosis of EnLP. This condition is rarely described in dogs and as in the present report, it is a non infectious inflammatory condition, characterized by intra- or extracellular globules of lipid in the alveolar spaces. In the present report, although it was not possible to determine the etiology of EnLP, we can conclude that although rare, it can affect dogs and can generate severe clinical repercussions.

Objectives Clinical manifestations of lipoid pneumonia (LP) vary depending on the causative agents or underlying causes. The aim of the present study was to investigate the clinical and radiological features of LP, classified according to etiologic agents. Methods The clinico-radiological characteristics of LP patients were retrospectively compared among groups: exogenous versus idiopathic and squalene versus omega-3-acid ethyl esters (O-3-AEE) versus idiopathic. Idiopathic group was defined as LP with no proven or reported etiological evidence. Results Twenty-two patients met the diagnostic criteria for LP: squalene (9 [41%]), O-3-AEE (6 [27%]), olive oil (1 [5%]), and idiopathic (7 [32%]). Compared with the exogenous group, the idiopathic group showed a higher recurrence rate; higher frequencies of bronchial anthracofibrosis (BAF) and bronchoalveolar lavage (BAL) lymphocytosis; and a higher rate of crazy-paving pattern and lower rate of consolidation on computed tomography scan. In three-group tests, compared with the O-3-AEE group, the squalene group exhibited a significantly higher percentage of neutrophils and a higher rate of right middle lobe (RML) involvement. Conclusions In comparison with the exogenous group, the idiopathic group demonstrated BAL lymphocytosis, higher rates of recurrence and BAF, and a higher rate of crazy-paving pattern. Compared with the O-3-AEE group, the squlaene group showed a higher percentage of BAL neutrophils and predominant RML involvement.

Cholesterol pneumonia or endogenous lipid pneumonia (ELP) is a rare disease that can occur in the context of a systemic disease or following a bronchial obstruction. It is characterized by a wide range of diverse symptoms and various disease course. The present report introduces a young woman diagnosed with adult onset still disease three years ago, who has been referred with macrophage activation syndrome (MAS). She underwent biopsy due to dyspnea and a crazy paving pattern in HRCT of the lungs, leading to the diagnosis of lipoid pneumonia based on the interstitial lymphocytic inflammation and cholesterol granulomas. So far, there has been no report indicating MAS associated with cholesterol pneumonia. This is the second Case Reporting ELP in the adult onset still disease.

Based on the data currently available in literature, the factors inducing acute lung injury resulting from the increasingly widespread use of e-cigarettes (vaping) (EVALI) were analysed. Although the number of traditional smokers in the population has been declining, vaping may be dangerous to health due to the substances contained in various e-cigarette liquids and cause acute respiratory failure during various forms of pneumonitis. In addition to tetrahydrocannabinol (THC), cannabidiol (CB) and other opioids, the major injuring factors include standard ingredients of e-liquid, such as propylene glycol, vegetable glycerine, colouring dyes, and flavouring agents. Vaping-associated lung injury impairs the alveolar-capillary barrier and distribution of respiratory volume manifesting the features of atelectasis, which is particularly pronounced in lipoid pneumonia. Due to critical gas exchange disorders, ICU treatment is required in an increasing number of patients. The management is essentially based on steroid and antibiotic therapy; whenever the ventilator is needed, the principles of lung-protective ventilation should be strictly followed. If mechanical ventilation fails, ECMO should be considered.

A 1-year-old female ferret was presented with an acute history of severe respiratory distress. Abnormal clinical signs noted during the initial physical examination were hypothermia, dehydration, pale mucous membranes, tachypnea, and severe dyspnea. Thoracic radiographs revealed pleural effusion, an enlarged cardiac silhouette, and areas of lung consolidation. Both blood and thoracic fluid were hyperproteinemic and hypergammaglobulinemic. Antibiotic, corticosteroid, and diuretic supportive treatment provided temporary improvement. After the initial positive response to treatment, the ferret's condition progressively deteriorated until the owners decided to euthanize the patient 15 days after initial presentation. Gross necropsy results revealed 5 mL of serosanguinous fluid within the thoracic cavity, cardiomegaly, and consolidated lungs that had a patchy, pale golden tissue pattern. The histologic diagnosis was endogenous lipid pneumonia. Findings suggest that endogenous lipid pneumonia can be associated with severe respiratory disease in ferrets.

Lipoid pneumonia is an unusual form of lung disease resulting from the accumulation of lipids in the alveoli, where they provoke a foreign body reaction with associated inflammation and sometimes local fibrosis. The lipids may be endogenous or exogenous in origin, and the clinical mechanisms and circumstances differ accordingly. Exogenous lipoid pneumonia occurs when animal, vegetable, or mineral oils are aspirated or inhaled into the lungs, provoking a foreign body reaction with chronic inflammation. Typical symptoms are cough and breathlessness. The chest radiograph and CT may show interstitial thickening, with areas of consolidation that may coalesce into a mass (paraffinoma) which simulates carcinoma. Bronchoalveolar lavage and biopsy show lipid-laden macrophages. In endogenous lipoid pneumonia the lipids are derived from surfactant and cholesterol released from decaying cells distal to bronchial obstruction.

Objectives The aim of this report is to describe the lung biopsy findings in vaping-associated pulmonary illness. Methods Lung biopsies from eight patients with vaping-associated pulmonary illness were reviewed. Results The biopsies were from eight men (aged 19-61 years) with respiratory symptoms following e-cigarette use (vaping). Workup for infection was negative in all cases, and there was no evidence for other etiologies. Imaging showed diffuse bilateral ground-glass opacities in all patients. Most recovered with corticosteroid therapy, while one died. Lung biopsies (seven transbronchial, one surgical) showed acute lung injury, including organizing pneumonia and/or diffuse alveolar damage. Common features were fibroblast plugs, hyaline membranes, fibrinous exudates, type 2 pneumocyte hyperplasia, and interstitial organization. Some cases featured a sparse interstitial chronic inflammatory infiltrate. Although macrophages were present within the airspaces in all cases, this feature was not prominent, and findings typical of exogenous lipoid pneumonia were absent. Conclusions The histopathology of acute pulmonary illness related to e-cigarette use (vaping) is characterized by acute lung injury patterns, supporting the contention that vaping can cause severe lung damage.

Background Nearly one-third of the population worldwide is estimated to have latent tuberculosis infection (LTBI), which represents a vast reservoir for a constant source of tuberculosis (TB) transmission. It has been suggested that cynomolgus macaques are less susceptible to Mycobacterium tuberculosis (M.tb) infection than rhesus macaques, we examined M.tb infection of Chinese cynomolgus macaques. Methods Eight Chinese cynomolgus macaques were infected with M.tb Erdman strain with a small [25 colony forming unit (CFU)] or large dose (500 CFU) via bronchoscopy. The infected animals were monitored for symptoms and examined by chest X-ray, computed tomography (CT), tuberculin skin test (TST), and enzyme-linked immunospot (ELISPOT). Results Based on TST conversion and the specific immune responses to M.tb antigens, all animals were successfully infected. Half of the animals developed active infection and died within 15 months postinfection. The other four animals were grouped with latent M.tb infection because of positive TST but few clinical signs and pathological changes of TB during the course of this study. Interestingly, a challenge with a large dose of M.tb also induced latent infection. Similar to the changes that occur with human TB patients, the animals with active infection exhibited weight loss, cough and typical TB pathological changes, including caseous granulomas, cavities, consolidation, lipid pneumonia, pleural effusion, lymphadenopathy and bacterial burden in lungs and other organs. Conclusions The low dose of M.tb was sufficient to cause both active and latent M.tb infection in cynomolgus macaques of Chinese origin.

Although mucus is a normal product of the tracheobronchial tree, some diseases of the respiratory tract are characterized by unusually thick (inspissated) forms of mucus that accumulate within the airways. These are known as mucus plugs. The pathologic composition of these plugs is surprisingly diverse and, in many cases, correlates with distinctive clinical, radiologic, and bronchoscopic findings. The best-known conditions that involve mucus plugs are allergic bronchopulmonary aspergillosis, plastic bronchitis, and asthma. Other lung diseases occasionally associated with plugs within the airways include Aspergillus tracheobronchitis, hyper-IgE syndrome, exogenous lipoid pneumonia, pulmonary alveolar proteinosis, and chronic eosinophilic pneumonia. In this review, we describe and illustrate the bronchoscopic, pathologic, and imaging findings in respiratory disorders characterized by mucus plugs or plugs composed of other similar materials. Recognition of the characteristic appearance and differential diagnosis of mucus plugs will hopefully facilitate diagnosis and management of these diseases.

Background Use of petroleum-based over the counter remedies such as Vicks VapoRub to alleviate symptoms of rhinitis is common and can be effective, but carries under-appreciated risks of adverse side effects. In this case report we highlight Exogenous Lipoid Pneumonia (ELP), an uncommon condition that results from accumulation of exogenous lipids in the alveoli, as an adverse side effect of long-term Vicks VapoRub use. Case presentation We present the case of an 85-year-old female patient with ELP apparently due to continuous application of Vicks VapoRub® to her nostrils to alleviate chronic rhinitis. She was diagnosed incidentally via chest radiograph and computed tomography (CT) scan done as follow up to finding elevated C-reactive Protein during a routine exam. The CT scan revealed a pulmonary consolidation in the lower lobe of the right lung with fat density combined with low density areas associated with focal ground-glass opacities. The patient was advised to discontinue use of petroleum-based products, and was prescribed intranasal corticosteroids for her rhinitis. Follow up 2 years later showed that the lipid consolidation had diminished in size by approximately 10 %. Conclusion Physicians must be aware that ELP can develop as a result of long-term application of petroleum-based oils and ointments to the nose and discourage such use of these products. Patients who have used petroleum-based products in this way should be screened for ELP. CT scan is the best imaging modality for establishing the diagnosis. The treatment of this condition is not well defined, but, as shown in this case, the size of the lipid mass can decrease after use of petroleum based substances is discontinued. Electronic supplementary material The online version of this article (doi:10.1186/s12901-016-0032-6) contains supplementary material, which is available to authorized users.

Understanding mechanisms of cavitation in tuberculosis (TB) is the missing link that could advance the field towards better control of the infection. Descriptions of human TB suggest that postprimary TB begins as lipid pneumonia of foamy macrophages that undergoes caseating necrosis and fragmentation to produce cavities. This study aimed to investigate the various mycobacterial antigens accumulating in foamy macrophages and their relation to tissue destruction and necrosis. Pulmonary tissues from mice with slowly progressive TB were studied for histopathology, acid‐fast bacilli (AFB) and presence of mycobacterial antigens. Digital quantification using Aperio ImageScope was done. Until week 12 postinfection, mice were healthy, and lesions were small with scarce AFB and mycobacterial antigens. Colony‐forming units (CFUs) increased exponentially. At week 16‐33, mice were sick, macrophages attained foamy appearance with an increase in antigens (P < .05), 1.5 log increase in CFUs and an approximately onefold increase in AFB. At week 37‐41, mice started dying with a shift in morphology towards necrosis. A >20‐fold increase in mycobacterial antigens was observed with only less than one log increase in CFUs and sevenfold increase in AFB. Secreted antigens were significantly (P < .05) higher compared to cell‐wall antigens throughout infection. Focal areas of necrosis were associated with an approximately 40‐fold increase in antigen MPT46, functionally active thioredoxin, and a significant increase in all secreted antigens. In conclusion, mycobacterial antigens accumulate in the foamy macrophages in TB lesions during slowly progressive murine pulmonary TB. Secreted antigens and MPT46 correlated with necrosis, thereby implying that they might trigger the formation of cavities. publishedVersion

Background Exogenous lipoid pneumonia is a rare disease resulting from intra-alveolar accumulation of lipids of mineral, vegetal, or animal origin, that induce a foreign body type of inflammatory reaction in the lungs. Gastroesophageal reflux disease and other esophageal abnormalities have often been associated with this disease. Case presentation We herein report the case of an 83-year-old patient in whom a follow-up chest computed tomography scan, for a lingular consolidation, showed multifocal ground glass and consolidative opacities with areas of low attenuation, suggestive of exogenous lipid pneumonia. The patient had been on piascledine capsules (avocado/soybean unsaponifiables) for 20 years and had a hiatal hernia with documented gastroesophageal reflux disease. After thorough history taking, no other predisposing factors were found. The diagnosis was confirmed using oil red staining of bronchoalveolar lavage showing lipid-laden macrophages and extracellular lipid droplets. Conclusions To our knowledge, this is the first case of ELP secondary to avocado/soybean unsaponifiables in the literature.

Case series summary Exogenous lipid pneumonia with mineralisation of the lung parenchyma was diagnosed in three cats with radiographs, CT and/or bronchoalveolar lavage cytological findings. All three cats had a common clinical history of chronic constipation and long-term forced oral administration of mineral oil. All three cases showed radiographic findings compatible with aspiration pneumonia, with an alveolar pattern in the ventral part of the middle and/or cranial lung lobes. Minor improvement of the radiographic lung pattern in the follow-up studies was seen in two cats, and a miliary ‘sponge-like’ mineralised pattern appeared in the previously affected lung lobes months to years after the diagnosis. In one cat, patchy fat-attenuating areas in the consolidated lung lobes were present on thoracic CT. Cases 1 and 2 showed respiratory signs at the initial presentation, while in case 3 the radiographic findings were incidental and the cat had never exhibited respiratory signs. Relevance and novel information This is the first report to describe dystrophic mineralisation of the lung in exogenous lipid pneumonia and also the first to describe the CT features in cats. Exogenous lipid pneumonia should be included in the differential diagnosis in cases of miliary ‘sponge-like’ mineral opacities in the dependent part of the lung lobes on thoracic radiographs or CT in cats, especially in cases of chronic constipation, previously exposed to mineral oil.

Background: Exogenous lipoid pneumonia is a rare entity, the diagnosis is often missed or delayed. Objective: To investigate the clinical characteristics of exogenous lipid pneumonia in elderly patients, improve the efficiency of early diagnosis and treatment of this disease. Methods: Retrospectively analyzed the clinical information and imaging data of these 2 exogenous lipid pneumonia patients, reviewed related literature. Results: Both of the 2 patients were over 60 with a history of gastrointestinal diseases. The clinical presentation is nonspecific. Chest CT showed many different manifestations. Histopathology analysis revealed the accumulation of lipid carrying macrophages, vacuolar cells and inflammation. A literature review indicated that 25 previous cases of exogenous lipid pneumonia were caused by aspiration. The most common site of the lesion was located in right lung, while mineral oil was the most common substances. We sought to discuss the patient's treatment and the corresponding outcomes. Conclusion: The diagnosis of lipid pneumonia's mainly depends on medical history and histopathological morphology. The standard treatment for exogenous lipid pneumonia was composed of antibiotics, steroid, bronchoscopic lavage and a regular follow-up. Keywords: Exogenous lipid pneumonia, Chest CT, Pathology, Antibiotic, Steroid

The Quaker parrot has been used as a psittacine model to study clinical lipidology and lipid-related disorders. However, while Quaker parrots appear to be anecdotally susceptible to a variety of spontaneous dyslipidemic disorders and lesions caused by excess lipid accumulation, epidemiologic data are lacking. A multicenter retrospective study on 652 pathology submissions (411 necropsies and 243 biopsies) from Quaker parrots was performed by recording the final pathological diagnoses, age, and sex for each bird. The prevalence of lesions associated with lipid metabolism, such as hepatic lipidosis, atherosclerosis, xanthomas, adipose tumors, coelomic steatitis/steatonecrosis, endogenous lipid pneumonia, and acute pancreatic necrosis/pancreatitis, was reported. Multiple logistic regression models were used to characterize the effects of sex and age on these lesions, and the prevalence of hepatic lipidosis and atherosclerosis was compared to those in a random sample of control psittacine birds. The raw prevalence of atherosclerosis and hepatic lipidosis was 5.6% (95% confidence interval [CI], 3.4%–7.8%) and 21.2% (95% CI, 17.2%–25.1%), respectively. While the prevalence of atherosclerosis was similar to other psittacine species, hepatic lipidosis was more common in Quaker parrots. Quaker parrots also showed a unique susceptibility to acute pancreatic necrosis with a prevalence of 12.9% (95% CI, 9.7%–16.1%). Male parrots were found to be more susceptible than females to lipid accumulation lesions ( P = .0024), including atherosclerosis ( P = .018) and hepatic lipidosis ( P < .001). This retrospective study confirms the high susceptibility of Quaker parrots to lipid-related disorders and presents epidemiological data that may be useful to avian clinicians, pathologists, and researchers using Quaker parrots.

We describe lipid pneumonia in 5 of 24 Arctic foxes ( Vulpes lagopus) in association with morbillivirus infection, and lymphoid depletion in 3 of these 5 foxes. Canine distemper virus (CDV) immunohistochemistry yielded positive staining in lung, lymph nodes, spleen, adipose tissue, and renal pelvic urothelial cells in 5 cases. Liver and bone marrow samples collected from these cases tested positive for morbillivirus by reverse-transcription PCR assay. Strains belonged to the CDV Arctic lineage based on sequencing of the hemagglutinin gene followed by phylogenetic analysis. Phylogenetic analysis of the phosphoprotein gene showed that the identified CDV strains were not closely related to any previously documented strains responsible for outbreaks in different animals in other parts of the world.

Effacement of normal lung parenchyma by cavities is an important sequela of pulmonary tuberculosis. Despite its clinical significance, the pathogenesis of tuberculous cavitation is poorly understood, with controversy as to whether the fundamental mechanism involves matrix depletion, lipid pneumonia, or mechanical factors. In this study, a repetitive aerosol infection model using Mycobacterium tuberculosis was used to generate cavities in 20 New Zealand white rabbits. Serial computed tomography was performed to monitor cavity progression over 14 weeks. Three-dimensional reconstructions were compiled for each time point, allowing comprehensive four-dimensional cavity mapping. Terminally, cavities were processed for histopathology. Cavities progressed rapidly from areas of consolidation, and often showed a pattern of explosive growth followed by gradual contraction. Cavities formed preferentially in the caudodorsal lung fields, and frequently were subpleural. Cavitation was associated invariably with necrosis. Histomorphology showed four distinct cavity types that provide mechanistic clues and insight on early cavity development. Our study shows that cavitation is a highly dynamic process with preferential formation at sites of high mechanical stress. These findings suggest a model for the pathogenesis of tuberculous cavitation in which mechanical stress acts on the necrotic granuloma to produce acute tears in structurally weakened tissue, with subsequent air trapping and cavity expansion.

Introduction/Objective Lipoid pneumonia is an uncommon inflammatory lung lesion resulting from the aspiration of endogenous or exogenous oily substances. It has no age or sex preponderance, and its mode of presentation is non- specific. Radiologic imaging findings may mimic that of a malignant lung lesion. Methods We report a case of a 69-year-old female with a history of chronic obstructive pulmonary disease, rheumatoid arthritis and a 30-pack year smoking. She was being followed for an enlarging PET positive spiculated left upper lung nodule. She underwent a CT-guided core biopsy of the lung nodule. Results Biopsy showed histiocytes and multinucleated giant cells with lipid vacuoles and associated marked fibrosis. Review of a percutaneous lung biopsy performed two years prior showed a chronic inflammatory process with associated fibrosis in the presence of nonpolarizable vacuoles, many of which were intracytoplasmic within multinucleate foreign body type giant cells. A re-assessment of the patient with further history taking revealed a longstanding practice of nighttime application of petroleum jelly to nostrils and lips. Together, these findings are consistent with an exogenous lipoid pneumonia. Conclusion Lipoid pneumonia although an entity with limited literature description, should be considered in patients presenting with enlarging lung nodules. Early diagnosis of this lesion ensures appropriate treatment and prevents unnecessary invasive procedures.

Exogenous lipoid pneumonia is an uncommon medical condition resulting from aspiration or inhalation of oily material. Generally, lipoid pneumonia has nonspecific clinical and radiological presentations, and may be misdiagnosed as bacterial pneumonia or lung cancer. We describe an unusual case of exogenous lipoid pneumonia accompanied by peripheral blood and pulmonary eosino philia. A 63-year-old man was admitted with progressively worsening exertional dyspnea and productive cough for 5 days. A chest radiograph showed abnormalities in the lower lobe of the right lung, and a diagnosis of community-acquired pneumonia was made; intravenous antibiotics were administered. However, dyspnea and hypoxia gradually worsened and peripheral blood eosino philia developed. A bronchoscopy was performed and bronchoalveolar lavage fluid analysis showed markedly increased numbers of eosinophils (40%). Subsequently, a comprehensive review of history revealed that he fell asleep with camellia oil in his mouth for 2 weeks to relieve foreign body sensation of the throat. Sputum and bronchoalveolar lavage fluid cytology showed the presence of lipid-laden macrophages. He was diagnosed with lipoid pneumonia and acute eosinophilic pneumonia. Chest radiograph and symptom were rapidly improved after treatment with intravenous methylprednisolone. (Allergy Asthma Respir Dis 2019;7:57-60)

Dear Editor, Hydrocarbon compounds such as petroleum jelly and mineral oil can cause lower respiratory disease named exogenous lipoid pneumonia because of high viscosity and surface tension (1). Acute exogenous lipoid pneumonia occurs after exposure to large amounts of mineral oils. The acute form in children is mostly a consequence of accidental poisoning. (2). Consolidation, nodular lesions, reticular and alveolar-interstitial patterns are the most common findings in the chest X-rays. Lower lobes or right middle lobe commonly get involved, but multifocal and bilateral lesions are shown too (3). The diagnosis of exogenous lipid pneumonia is made by a positive history of mineral oil exposure and radiologic findings in favor of the disease and revealing lipid-laden macrophages on bronchoalveolar lavages (BALs) or sputum specimen. Multiple BALs can remove Lipid-laden macrophages as a leading cause of fibrosis in the alveoli and interstitium (3, 4). We present a rare case of exogenous lipoid pneumonia in a 2.5-year old boy with a history of mineral oil aspiration who admitted to the pediatric intensive care unit because of cyanosis and severe respiratory distress. On physical examination he presented with tachycardia (190 min), tachypnea (80 min), O2 saturation 50%, numerous crackles on auscultation of both lungs. Laboratory findings were leukocytosis with a left shift and increased CRP. A chest X-ray showed diffuse opacities with an alveolar pattern in both lungs (Figure 1). CT scans of the chest revealed bilateral diffuse severe pneumonitis with ground glass and alveolar appearance and crazy paving (Figure 2). Bronchoscopy was done. Mucopurulent secretions aspirated then rinsed with saline. After staining the BAL fluid with Sudan III many lipid laden macrophages (grade IV/IV) were seen. Multiple segmental BAL was done weekly, after that BAL fluid became nearly clear and cell counts reached near the normal range values. CT scan which was done after the forth therapeutic BAL, showed dramatic improvement in both lungs (Figure 3). The patient discharged after one month hospitalization and recommended to return to follow up. Figure 1. Simple Anteroposterior Chest X-Ray Demonstrating Bilateral Opacities, Mostly in the Lower Lobes Figure 2. High-Resolution Computed Tomography Scan of the Chest Demonstrating Alveolar Infiltrate, Mostly in the Lung Bases Figure 3. High-Resolution Computed Tomography Scan of the Chest Showing Dramatic Improvement in Both Lungs After Multiple Segmental BAL The best way to remove the oil is multiple BALs especially in the most severely involved segments (3). According to several surveys, multiple BALs is an effective therapeutic strategy with few risks, and better improvement in the clinical and radiological signs (5). The present study indicates that therapeutic multiple segmental BAL is a successful method in removing intra-alveolar mineral oil with significant resolution of clinical, radiological and laboratory findings.

Electronic cigarette (e-cigarette) use, or "vaping," is gaining widespread popularity as an alternative to conventional cigarettes among adolescents. Little is known of the health risks of e-cigarette use, especially in children and adolescents. We present a Case Report of a previously healthy 18-year-old woman who presented with dyspnea, cough, and pleuritic chest pain after e-cigarette use. She developed respiratory failure with hypoxia and was intubated, and ultimately met diagnostic criteria for acute respiratory distress syndrome. Chest tubes were placed to drain worsening pleural effusions. Computed tomography of the chest revealed dependent opacities in both lung bases, superimposed smooth interlobular septal thickening, and pleural effusions. Bronchoalveolar lavage revealed cellular debris and reactive mononuclear cells, and cell counts were remarkable for elevated mononuclear cells and eosinophilia. After the results of a workup for an infectious etiology came back negative, the patient was diagnosed with hypersensitivity pneumonitis and intravenous methylprednisolone therapy was initiated. After this the patient rapidly improved, was weaned off vasopressor support, and was extubated. This is the first reported case of hypersensitivity pneumonitis and acute respiratory distress syndrome as a risk of e-cigarette use in an adolescent, and it should prompt pediatricians to discuss the potential harms of vaping with their patients. Hypersensitivity pneumonitis, lipid pneumonia, and eosinophilic pneumonia should be included in the differential diagnosis of patients who exhibit respiratory symptoms after the use of an e-cigarette.