Gravity-Dependent
Pneumonia
of
,
Yves
Sibille,
61-year-old
man
purulent
sputum.
smoking.
He
bricklayer
lesions
and
with
mm
was
1990; 98:1253-54)
bilateral
The
fine
lung
percent
capacity
of predicted).
for carbon
elevated
film
reduced
tests
were
as
a kiln
pulmonary
silicate
(ILO
crackles
were
blood
gas analysis
64 mm
vital
Hg
rate,
the
38
horizontal
demonstrated
which
opacities
tomography
logic
diology
Belgium.
Reprint
Yvoir,
FIGURES
Section,
Department
excluded
(29
monary
aspiration.
diffusion
alveolar
treatment
with
for
Chest
presence
x-ray
a more
the
Department,
requests:
Belgium
1 (above)
University
Dr. Sibille,
Hospital
Cliniques
ofMont-Godinne,
UCL
Mont
Godinne,
and
tRaYvoir,
5180
negative.
sis.
disorders
The
worsened.
Therefore,
and
the
He was
One
month
spontaneous
biopsies
chest
with
the
patient’s
without
he
was
films
steroid
revealed
lungs
and
noted
therapy
significantly
definitive
readmitted
left pneumothorax
and
was then
performed.
chest
patient’s
level
condition
discharged
and
the
horizontal
pul-
on empiric
in both
empiric
later,
manometry
started
x-ray
infiltration
of
pneumoniand
treatment,
Control
cyto-
markers
bronchodilatators
this
alveolar
disappearance
and
Seruni
was
al-
computed
associated
patient
antibiotics,
diffuse
proved.
lung
and
by
of bacteriologic
was
Despite
admission.
dense
with a
chest
of the
confirmed
Result
esophageal
condition
of pseudo-
Medicine,
2).
physiotherapy.
an
disclosed
for systemic
diseases
and hypersensitivity
tis were absent.
Contrast
examination
(71
for
and
mobilization
was
ofsputum
L
mm/h.
of Internal
(Fig
analysis
L
values.
lobes
veolar
initiated
*Pjlmonary
upper
2.79
except
tipper
in the two lower
lung fields
level (Fig 1). Lateral
decubitus
roentgenograms
0.81
limits
40
confirmed
PaCO2,
ofpredicted
normal
A).
two
opacities
of
single-breath
corrected
to 44 percent
within
in the
alveolar
was
a FEy,
The
monoxide
category
and
capacity
with
sedimentation
on admission
years
end-inspiratory
bases.
Arterial
predicted)
was
Blood
ten
pseudotumors
forced
of
for
to have
PaO,,
percent
volume
;*
tumors
with
dyspnea
and
a 30 pack-year
history
worked
known
air showed
Hg.
presented
He had
had
On admission,
heard
over both
on room
with Lipoid
M.D.*
(Chest
A
in a Patient
Van den Plas, M. D. ;* Jean-Paul
Triga!x,
M. D. ;t
Van Beers,
M. D. ;t Luc Delaunois,
M. D. F. C. C.
Olivier
Bernard
and
Infiltrates
at
was
imdiagno-
because
thoracoscopy
of
with
2 (right).
CHEST
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21620/ on 06/18/2017
I 98 I 5 I NOVEMBER,
1990
1253
Exogenous
Diagnosis:
Examination
vacuoles
of lung
within
multinucleated
sis was also
suggested
lipoid
pneumonia
biopsy
alveolar
samples
showed
macrophages
and
empty
interstitial
giant cells. Moderate
interstitial
fibronoted.
These
pathologic
features
strongly
an exogenous
lipoid
pneumonia.
After pre-
cise questioning,
the patient
eral years he sprayed
motor
room to protect
auto bodies
Most
cases
of exogenous
recognized
that for sevoil in a poorly
ventilated
against
rust.
lipoid
pneumonia
(ELP)
are observed
in patients
abusing
oily nose
drops
or
laxative
mineral
oils.”2
Some
cases
have
also been
reported
in workers
exposed
to oil spray
in the steel
industr?
and airplane
engine
maintenance.4
ELP may
be considered
a chronic
foreign
lungs,
usually
with
an
infectious
complication
indolent
occurs.
goes
unrecognized
rarely
reported
Moreover,
since
been
suggested
sputum,
biopsy
laden
It has
because
and
sometimes
radiologic
alveolar,
described.
reported
that
from
the
densities
ties
oil is
assume
manifestations
are
in
the
by
nonspecific
to the
completely
demonstrating
in alveolar
stated
that
CT
the
diagnosis
by detecting
consistent
with fat within
the
spaces
scan
could
low
lung
characteristic
and interstitium.
help
oil-
establish
attenuation
values
lesions.5
However,
in
case, we did not find densities
may be related
to the associated
of negative
interstitial
fibrosis
and silicosis.
The most
striking
feature
of the present
report
is
the influence
of postural
changes
on the distribution
of parenchymal
lung
densities
as evidenced
by CT
supine
and prone
and thus ofgravity,
positions.
on lung
An effect of
density
has
prone
in previously
hydrobeen
with
ARDS
regions
were
position,
cleared
of the
turned
the
posterior
while
clear
gravity-dependent
feature
oflipoid
prone
new
anterior
densi-
areas.
and
infiltrates
pneumonia.
supine
represent
a
CT scan studies
positions
should
help
to
this question.
However,
it is reasonable
to
that in our case, the association
of emphysema
contributed
to the mobility
of these
infiltrates
largely
patients.
in patients
it has
To our knowledge,
marked
gravity-dependency
of
intraparenchymal
lung infiltrates,
such as seen in our
patient,
has never
been
described.
It is uncertain
use
by
supine
almost
appeared
answer
denied
densities
mainly
located
in the dependent
lungs.7
Moreover,
when
these
patients
until
often
of mineral
lung
and has been
of the dependent
were
increasing
lung
compliance.
interstitial
or tumor-like
patterns
have
The diagnosis
of ELP, occasionally
specimen
macrophages
images
in the
body position,
to a gravity-induced
More
recently,
of the lung related
pressure
gradient.6
in the
reaction
the presence
of foamy
macrophages
in
is confirmed
by histologic
examination
of lung
the present
values.
This
areas
static
clinical
course
The
diagnosis
by
been
individuals,
perfusion
whether
common
body
the
been
described
in normal
attributed
to an increased
REFERENCES
1 Lipinski
JK,
Weisbrod
J Can
pneumonitis.
2 Kennedy
lipoid
JD,
Costello
pneumonia.
3 Skorodin
GL,
Assoc
Exogenous
lipoid
31:92-8
JP,
Herman
PE.
Exogenous
136:1145-49
1981;
Chandrasekhar
exogenouslipoid
DE.
1980;
P, Balikian
AIR
MS,
Sanders
Radiol
AJ.
pneumonia.
An
Pathol
Arch
occupational
Lab
Med
cause
1983;
of
107:610-
11
4 Foe
RB,
exposure
5 Wheeler
SS.
Bigham
PS,
Stitik
Diagnosis
6 Rosenblum
patterns
raphy.
7 Langer
position
RS.
to oil spray.
in the
Radiology
normal
1980;
BA,
following
GM,
Klinefelter
by T.
Wellenstein
lung as determined
137:109-16
Mascheroni
D,
patients.
occupational
155:33-4
pneumonia
Mauceri
in ARDS
pneumonia
1954;
FP, Hutchins
oflipoid
U,
M,
Lipid
JAMA
JAMA
DE,
HF,
Siegelman
1981;
et
245:65-6
al.
by computed
Marcolin
R, Gattinoni
L. The
A clinical
study.
1988;
Chest
Density
tomogprone
94:103-
07
1254
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21620/ on 06/18/2017
Roentgenogram
of the
Month (Van den Pies et a!)