Asian Cardiovasc Thorac Ann 1999;7:324-325
© 1999 Asia Publishing EXchange Pte Ltd
Pulmonary Hydatid Cyst and Endogenous Lipoid Pneumonia
Levent Elbeyli, MD,
Ayten Filiz, MD,1,
Bülent Tunçözgür, MD,
Yalçin Kepekci, MD,2,
Re
at Kervancio
lu, MD,3
Department of Thoracic Surgery
1 Department of Chest Disease
2 Department of Internal Medicine
3 Department of Radiodiagnostics Gaziantep University School of Medicine Gaziantep, Turkey
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For reprint information contact: Levent Elbeyli, MD Tel: 90 342 336 5400 Fax: 90 342 336 5505 email: elbeyli{at}alpha.bim.gantep.edu.tr Department of Thoracic Surgery, Gaziantep University School of Medicine, Gaziantep, Kolejtepe 27070, Turkey.
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Abstract
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Lipoid pneumonia associated with pulmonary hydatid cyst in a 20-year-old male is described. On the basis of clinical and radiological findings suggestive of pulmonary hydatid cyst, a thoracotomy was performed. Histopathology of the resected right upper lobe indicated hydatid cyst and lipoid pneumonia.
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Introduction
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Lipoid pneumonia may be caused by exogenous or endogenous factors or it may be idiopathic.1 Exogenous lipoid pneumonia can result from aspiration of vegetable or animal oil from food, mineral oil, or radiographic contrast medium. Endogenous lipoid pneumonia is usually associated with lipid-storage diseases, pulmonary alveolar proteinosis, or obstructive pneumonitis.2 Although bronchial obstructive lesions such as carcinoma may also be responsible for endogenous lipoid pneumonia, pulmonary hydatid cyst has not been previously reported as a cause of this condition.1,3 We describe the clinical, radiological, and pathological findings in a case of endogenous lipoid pneumonia associated with a pulmonary hydatid cyst.
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Case Report
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A 20-year-old male Caucasian student was admitted with a history of productive cough and hemoptysis of 2 months duration. His past medical history was unremarkable except for a smoking habit. Physical examination and blood tests were within normal limits. The purified protein derivative of tuberculin test result was 10 mm. Chest radiography showed a 3 x 2.5 cm mass in the right para-hilar area. Computed tomography of the thorax revealed a 3 x 2.5 x 2.5 cm mass with irregular margins located centrally in the anterior segment of the right upper lobe (Figure 1
). Gram-negative diplococci and Gram-positive cocci were found in his sputum and sputum culture grew pneumococci. Sputum studies for acid-fast bacilli and malignant cells were negative. Ultrasonography of the abdomen was normal. Fiberoptic bronchoscopic examination showed a white mobile lesion in the orifice of the anterior segment of the right upper lobe bronchus. A mucosal biopsy analysis was reported as chronic bronchitis. Bronchial lavage showed no abnormal cells.
The radiographic and bronchoscopic findings were suggestive of a benign pathology that was presumed to be a pulmonary hydatid cyst preoperatively. A thoracotomy was performed for diagnosis and treatment. Intra-operatively, expansion of the right upper lobe was noted to be poor. The anterior and apical segments were heparinized. Two-thirds of the right upper lobe was found to be invaded by multiple micronodular lesions and a 3 x 3 cm cystic cavitary lesion was detected. The cystic lesion was macroscopically diagnosed as hydatid cyst; cystectomy and capitonnage were performed. Histological examination of the micronodular lesions was carried out on frozen sections but a definitive diagnosis could not be obtained. Because of diffuse pulmonary parenchymal lesions around the cystic cavity, a standard right upper lobectomy was performed without perioperative com-plications. Further histopathological examination showed lipid-laden macrophages in the central area with lymphocytes, histiocytes, neutrophils, and fibroblasts in the peripheral regions (Figure 2), which indicated lipoid pneumonia in addition to the hydatid cyst and micro-abscesses. On further questioning, the patient denied inhalation of fatty or oily material. He was clinically and radiologically asymptomatic at the 6-month follow-up examination.
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Figure 2. Lung biopsy specimen showing lipid-laden alveolar macrophages consistent with lipoid pneumonia.
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Discussion
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Endogenous lipoid pneumonia is an uncommon lung disorder. It occurs chiefly at sites of chronic inflammation, obstruction, or tissue necrosis; the lipid is derived from necrotic cells.4 Lipid may also be ingested by macrophages and recovered in the sputum.4 The body may produce and retain lipid (mainly cholesterol) within the lungs.4 Although bronchial obstruction is known to cause lipoid pneumonia, its association with a pulmonary hydatid cyst has not been reported previously. In this patient, the clinical and radiological findings were suggestive of hydatid cyst and it was confirmed by histopathology. Retrospectively, we concluded that the cause of the lipoid pneumonia was the cystic membrane that obstructed the right bronchus, which had been seen as a mobile lesion during bronchoscopy.
Computed tomography, showing hypodense areas within the mass, is considered the best imaging modality for diagnosis of lipoid pneumonia.5 Magnetic resonance imaging has not been found to yield any additional findings.5 Histopathological examination of broncho-alveolar lavage, percutaneous needle aspiration material, or a biopsy performed through bronchoscopy or thoracotomy, is reported to be the most accurate method of diagnosis.3 In this patient, radiological findings were suggestive of pulmonary hydatid cyst but there was no evidence of the lipoid pneumonia that was determined histopathologically. Conservative treatment of lipoid pneumonia is usually based on general support.6 There is evidence that glucocorticosteroid may hasten recovery.7 The cause of the disease should be eliminated if possible.
This case suggests that pulmonary hydatid cyst should be considered as an obstructive bronchial lesion that may cause lipoid pneumonia. Bronchoscopy is a useful diagnostic technique but it may be insufficient and histopathological examination may be required for diagnosis.
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References
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Fraser RG, Paré PJA, Paré PD. Aspiration of lipid. In: Diagnosis of disease of the chest. 3rd ed. London: Saunders, 1990:2398.
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Kennedy JD, Costella P, Balikian JP, Herman PG. Exogenous lipoid pneumonia. AJR 1981;136:1145–9.[Abstract/Free Full Text]
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Hendrick DJ. Lipoid (lipoid pneumonia). In: Weatherall DJ, Ledingham JGG, Warell DA, editors. Oxford textbook of medicine USA. Oxford: Oxford Medical, 1996:2837–8.
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Brechot JM, Buy JN, Laaban JP, Rochemaure J. Computed tomography and magnetic resonance findings in lipoid pneumonia. Thorax 1991;46:738–9.[Abstract/Free Full Text]
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Brown AC, Slocum PC, Puttoff SL. Exogenous lipoid pneumonia due to nasal application of petroleum jelly. Chest 1994;105:968–9.[Abstract/Free Full Text]
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Ayvazian LF, Steward DS, Merkel CG, Frederick WW. Diffuse lipoid pneumonitis successfully treated with prednisone. Am J Med 1967;43:930–4.[Medline]
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Abstract
Introduction
