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Images in Thorax
Unexpected identification of bilateral masses in an asymptomatic heavy smoker
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  1. Elisa Garlassi1,
  2. Giulio Rossi2,
  3. Andrea Bedini2,
  4. Luca Richeldi1
  1. 1University of Modena & Reggio Emilia, Modena, Italy
  2. 2Policlinico Hospital of Modena, Modena, Italy
  1. Correspondence to Luca Richeldi, Centre for Rare Lung Disease, Policlinico Hospital, University of Modena & Reggio Emilia, Modena 41124, Italy; luca.richeldi{at}unimore.it

https://doi.org/10.1136/thx.2009.130500

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    A 47-year-old male heavy smoker who was an ex-intravenous drugs user presented with gallstones; a preoperatived chest radiograph showed hazy opacity in the right lower lobe. Chest CT revealed in the lower posterior lobes two almost symmetrical areas of consolidation with fat attenuation values (−50 Hounsfield units, figure 1). A broncholaveolar lavage did not provide pathological findings. A transthoracic core needle biopsy showed the pattern of chronic exogenous lipoid pneumonia, with numerous lipid-laden macrophages (figure 2). Upon further investigation, the patient revealed that he had been taking 200 ml of mineral oil daily for 5 years to treat chronic constipation related to methadone treatment.

    Figure 1
    Figure 1

    CT scan of the chest with the lung window showing two almost symmetrical areas of consolidation in the lower posterior lobes; surrounding parenchyma was characterised by ground-glass opacities with interlobular septal thickening, suggesting a ‘crazy-paving’ pattern.

    Figure 2
    Figure 2

    Transthoracic biopsy (performed using an 18-gauge needle as the guide and a 20-gauge gun to obtain the core) showing the round-to-oval vacuolar spaces representing lipid vacuoles that are washed out during tissue processing (H&E stain, ×400 magnification).

    Learning points

    • Lipoid pneumonia can be totally asymptomatic even in heavy smokers and even when lipoid masses are considerable in size.1

    • Although the diagnosis of lipoid pneumonia is uncommon, it still needs to be considered in adults without anatomical abnormalities predisposing to aspiration.2

    • The finding of a lung mass surrounded by a crazy-paving pattern on chest CT with density values indicating the presence of fat tissue (Hounsfield units within the −60 to +10 range) should trigger minimally invasive bioptic techniques that may be diagnostic, avoiding surgical approaches.

    • Triggers for exogenous lipoid pneumonia are usually not recognised as risk factors by patients and as such are not reported.

    References

    1. ↵
      1. Spickard A 3rd.,
      2. Hirschmann JV
      . Exogenous lipoid pneumonia. Arch Intern Med 1994;154:686–92.
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    2. ↵
      1. Gondouin A,
      2. Manzoni P,
      3. Ranfaing E,
      4. et al
      . Exogenous lipid pneumonia: a retrospective multicentre study of 44 cases in France. Eur Respir J 1996;9:1463–9.
      OpenUrlAbstract/FREE Full Text

    Footnotes

    • Competing interests None.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed.