European Journal of Radiology, 16 ( 1993) 2 17-220

0 1993 Elsevier Scientific Publishers Ireland Ltd. All rights reserved. 0720-048X:93/$06.00

EURRAD 00389

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Chest radiographic findings in childhood lipoid pneumonia following aspiration of animal fat

S.H. Annobil”, A.O. Ogunbiyib and B. Benjamin”

aDepartment of Child Health and bDepartment of Radiology, College of Medicine, King Saud University, Abha Branch, Abha. Saudi Arabia

(Received 30 January 1992; accepted after revision 15 December 1992)

Key words: Thorax, infants and children; Thorax, lipoid pneumonia; Pneumonia, aspiration

Abstract

The pulmonary radiological manifestations of lipoid pneumonia following a cultural practice of forced feeding of rendered animal fat (ghee) in 24 Saudi children are described. The age range is 15 days to 1 I years with 68% of cases being in infancy. The chest radiographic appearances en- countered could be grouped into four broad patterns, viz, bilateral multilobar consolidations (BMLC) in 50% (12 cases), bilateral perihilar infiltrates (BPHI) with or without associated lobar consolidation in 21% (five cases), right perihilar infiltrates (RPHI) in 21% (five cases) and unilateral right multilobar consolidation (RMLC) 8% (two cases). The pneumoniae were non-resolving acute or chronic lung consolidations despite the usual an- timicrobial chemotherapy. Associated nodular dense opacities (granulomas) were seen in the lower lobes of four of the 12 cases in the first group. Complications, seen also in this first group, included chronic collapse consolidation, fibrosis and death in three cases. In communities where the traditional practice of infant feeding with ghee exists, these pulmonary radiological patterns, although in some cases indistinguishable from those of bacterial pneumoniae, should raise the suspicion of ghee administration with consequent early diagnosis and energetic management to avert prolonged morbidity and potential death.

Introduction

Lipoid pneumonia has occurred in children following the administration of oily medications such as mineral oil [l-4], cod liver oil [5] and milk [6]. Traditional prac- tices which involve the administration of oil-based substances to children may be associated with the risk of lipoid pneumonia [7]. In Saudi Arabia, animal fat (ghee) which is obtained from goat milkfat is given to the newborn and infants, in the belief that it establishes regular bowel habit, eases cough and colds and also pro- motes their general well being. The children are forced fed with the ghee or in a few cases given by the nasal route with the infant in the recumbent posture. In this position, the ghee is often aspirated presenting as lipoid pneumonia, or manifest later as recurrent chest infec- tions not responding to anti-microbial therapy [S-9].

The purpose of this paper is to highlight the pulmonary radiological patterns seen in 24 Saudi children resulting from ghee-induced lipoid pneumonia and their outcome.

Correspondence to: Dr S.H. Annobil, Department of Child Health, College of Medicine, King Saud University, P.O. Box 641, Abha, Saudi Arabia.

Patients and Methods

A prospective study was carried out on all children admitted to a referral hospital, Asir Central, Abha, Saudi Arabia with proven ghee induced lipoid pneumonia during a 3.5-year period, from January 1988 to June 1991. The study group comprised 10 girls and 14 boys, 68% of the group being infants. Detailed histories were obtained including route of administration of the ghee, the age at which it was first given to the infant or child and the main clinical features. Chest radiographs were taken on admission, then at two weekly intervals for the first 3 months and then monthly at the follow up out-patient clinics. The diagnosis of lipoid pneumonia was confirmed by the demonstration of fat by oil red 0 stain on aspirates obtained after an overnight fasting from bronchoalveolar lavage (BAL) in 22 patients and by open biopsy in two.

Results

The common clinical manifestations in the group in- cluded fever in 76%, cough in 88% and tachypnoea in

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TABLE 1 TABLE 2

Pattern of pulmonary distribution in 24 children with lipoid pneumonia.

Distribution of lobar involvement in the four groups of lipoid pneumonia.

Group Pulmonary distribution Number %

I

II

III

IV

Bilateral multilobar 12 50 consolidation (BMLC)

Right multilobar 2 8

consolidation (RMLC) Bilateral perihilar 5 21

infiltrates (BPHI) (a) Three with lobar consolidation (b) Two without lobar consolidation Right perihilar 5 21

infiltrates (RPHI)

Total 24 100

64%. Bilateral scattered crepitations were present in 92% and 56% of the patients presented with recurrent chest infections. The radiological presentation was worse than the clinical findings. Chest radiographs characteristical- ly demonstrated four broad groups (Table 1). The most common distribution was bilateral multilobar con- solidations (BMLC) in 12 patients (50%), four of which had a striking associated nodular pattern of granulomas (Fig. la,b). In 21% of the children, there were bilateral perihilar infiltrates (BPHI) with or without lobar con- solidations. A further 21% had right perihilar infiltrates (RPHI) with lobar consolidations. The remaining two children had unilateral right multilobar consolidations (RMLC). The detailed lung involvement in each group

A Twelve children with bilateral multilobar involvement (BMLC) Right lung RUL 9 RML 1 RLL 9 Left lung LUL 3 Lingula 1 LLL 10

B Two children with right multilobar involvement (RMLC) Right lung RUL 1 RML 2 RLL I

C Five children with bilateral perihilar infiltrates (BPHI), three of whom had lobar consolidations

Right lung RUL 1 RML 1 RLL I

D Five children with right perihilar infiltrates (RPHI) Right lung RUL 5

Abbreviations: RUL, right upper lobe; LUL, left upper lobe; RML, right middle lobe; LLL, left lower lobe; RLL, right lower lobe.

was further evaluated (Table 2). Some patients from the group with BMLC and one patient with RPHI with right upper lobar consolidation, showed dense homo- geneous consolidation with expanded lobes accompanied by bulging of the fissures.

a b

Fig. 1. (a) Chest radiograph of one of the patients in Group I Dense homogeneous consolidations in right upper and middle lobes. Expanded right upper lobe with bulging transverse fissure. Nodular opacities (granulomas) in the right lower lobe. Consolidations in both left mid and lower zones. (b) Lateral chest radiograph of the same patient showing discrete dense nodular opacities in the right lower lobe. (c) Chest radiograph of the same patient after 8 months of treatment. Complete resolution of all the lung consolidative changes shown in Fig. la. Note the prominent thymus shadow.

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Follow-up

Four patients were sent back to the respective hospitals which referred them for confirmation of the diagnosis and were subsequently lost to our follow up. These were three patients with BMLC and one patient with RMLC. The children were initially given various courses of antibacterial and antifungal agents for presumed infective pneumoniae with no significant im- provement. Together with supportive measures, all the children received prednisolone (2 mg/kg per day) for variable periods. In the remaining nine with BMLC, 2 months was the shortest period and 12 months the longest (average of 6 months) for attainment of com- plete radiological resolutions (Fig. lc). There were three deaths in the study and all were from this group, occurr- ing at 2 weeks, 4 weeks and 2 years, respectively after diagnosis. Two of the three had undergone left lower and right middle lobectomies. In the only case with RMLC to be followed up, it took 11 months to achieve complete radiological resolution. Finally, of those with bilateral and right perihilar infiltrates with and without lobar consolidations, 50% showed clearance of radiological changes in 6 weeks while the remaining half also resolved completely between 8 weeks and 6 months (average of 4 months).

Discussion

The earliest reports of mineral oil aspiration in children were by Laughlen [3] and others [ 1,2,4,5]. Most of these cases were diagnosed at autopsy. Since then, other substances including milk [6] and baby oil [lo] have been incriminated. Various traditional customs, in- volving administration of oil-based substances including ghee, have also produced infantile and childhood lipoid pneumonia [7-91.

Among the factors which facilitate oil aspiration are failure of oil to stimulate the cough reflex [4] and the in- hibition of the mucociliary action necessary for the removal of the exogenous agent from the tracheo- bronchial passages [ 111. The aspirated animal fat is hydrolysed by lung lipases and the released fatty acids are highly toxic and produce severe inflammatory reac- tion [4]. Mineral and vegetable oils on the other hand are emulsified but not hydrolysed and may cause little reaction in adults, but in children this may lead to acute, widespread aspiration pneumoniae [4]. Wagner et al.

WI, outlined the evolution of lipoid pneumonia through four pathological stages; these are (i) early haemorrhagic pneumonia with acute inflammatory reac- tions; (ii) chronic inflammatory infiltrate of lym- phocytes and plasma cells; (iii) foreign body granuloma formation, progressive fibrosis of alveolar walls and destruction of lung parenchymal architecture and (iv) complete fibrous replacement of lung tissue.

The complications of lipoid pneumonia reported by earlier workers include malignant transformation [ 131, predisposition to secondary bacterial infection or col- onization, sometimes with unusual organisms such as atypical mycobacteria [14] or fungi [ 151. Pseudomonas aeruginosa, Klebsiella pneumoniae and Staphylococcus aureus were some of the pathogens isolated from tracheal aspirations in our study.

De Oliveira et al. [ 161 described the chest roen- tgenographic pattern in mineral oil induced lipoid pneumonia in four children as diffuse pulmonary in- filtrates in two and pulmonary consolidation more on the right lung in the other two. Riff et al. [9] described the radiological picture in eight Saudi infants with ghee lipoid pneumonia as characteristically bilateral interstitial-alveolar infiltrates predominantly involving the central posterior dependent lung segments. In this series, the earliest age of presentation was a newborn of 15 days and the oldest was 11 years, and 68% of them were infants. The histories of the older children also revealed recurrent chest infections, in most cases originating from infancy. The most common radiographic picture was the BMLC equally affecting all the lobes of the right lung; whereas in the left lung, the lower lobes were significantly more involved (Tables 1 and 2). In some, the consolidation was characteristically dense and homogeneous with swelling and expansion of the involved lobes and bulging of the fissures. Four of the 12 cases had characteristic associated nodular dense opacities of granulomas mainly in the right lower lobes. In unilateral RMLC, though this occurred in only two cases, all the lobes of the right lung were equally af- fected. In the BPHI with lung involvement, the lobes of the right lung were also equally affected. On the other hand, in those with RPHI, only the right upper lobe was involved in all five cases. BMLC represented the most severe pattern of ghee lipoid pneumonia. Their radiological resolution took an average of 6 months. The severity was also reflected in the chronic complica- tions of collapse consolidation and fibrosis necessitating surgery and also the three deaths that occurred in this group. This study further showed that those with BPHI and RPHI, with or without associated consolidation had a better prognosis. They demonstrated complete radiological clearance on an average of 4 months with no mortality.

Computed tomography (CT) of the chest had been reported to be helpful in establishing the diagnosis of lipoid pneumonia; because of the property of lipids in showing a typical absorption range of -150 to -60 Hounsfield (H) units relative to water which is zero H units [ 17,181. In patients that we suspect to have lipoid pneumonia from the history and on BAL stains, CT should be done to detect fat globules in the lungs because of the characteristic attenuation values of fat density. The exact diagnosis of lipoid pneumonia re-

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quires detection of the oil droplets either by BAL stain- ing or surgical resection, but with the availability of CT, a non-invasive procedure, the invasive methods might be avoided in the future. Although only three of the children in this study had chest CT scans, this characteristic CT finding was not evident in our patients because they had marked fibrotic lung changes which prevented the fat densities to be detected. Carrillon et al. [ 191 reported a case of an adult in which they mentioned specific magnetic resonance imaging (MRI) findings in lipoid pneumonia due to mineral oil aspiration; which may help in the diagnosis of lung parenchyma infiltrated by lipids but we did not have MRI facilities.

In the presence of any of these described radiological manifestations in a community where the traditional practice is prevalent, ghee administration should be suspected and should lead to early diagnosis and management with consequent prevention of prolonged morbidity and potential mortality. Health education also has an important role to play in making the com- munity aware of the inherent dangers of ghee ad- ministration to children. This will reduce the incidence and prevent the hazards of ghee lipoid pneumonia as portrayed by these radiological patterns.

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