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Pulmonary puzzle

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From the question on p 359

After much discussion at the lung cancer multidisciplinary team meeting, the question was jokingly asked “what is he putting down his tracheostomy?” It transpired that the patient suffered with a dry throat from his tracheostomy. Ten years previously he read in “CLAN” (the newsletter of the National Association of Laryngectomee Clubs) that liquid paraffin would solve this. Every night before he went to bed he lay on his back and his wife put three drops of liquid paraffin down his tracheostomy. He went on to explain that he was now getting the paraffin directly from the manufacturer as they had stopped supplying it for medical use some years earlier.

The histology was reviewed confirming a diagnosis of exogenous lipoid pneumonia. He was immediately advised to stop using the paraffin. On follow-up his cough gradually resolved but his chest radiograph remained unchanged. Due to a lack of established treatment options for his condition and his significant co-morbidity, further intervention was deemed inappropriate.

Exogenous lipoid pneumonia results from the inhalation of oil-based substances. Mineral oil depresses the cough reflex favouring aspiration and causes include oil-based laxatives and nasal drops.1 Occupational exposure has been described in furniture factories2 and steel mills.3 Paraffin-induced lipoid pneumonia as an occupational hazard of fire-eaters has also been described,4 a condition which has been coined “fire-eater’s pneumonia” or “fire-eater’s lung”.

Cough, weight loss and dyspnoea are the most common symptoms. Radiological features vary from consolidation to nodules and ground-glass opacities. Treatment consists of removal of the offending substance. The use of corticosteroids and partial resection of the lung have been described.2 Whole lung lavage has been used as a treatment for endogenous lipoid pneumonia for Niemann-Pick disease5 but its use in exogenous cases is yet to be established.

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