Hydrocarbon pneumonitis.

Hydrocarbon pneumonitis, known also as fire-eater pneumonia, always unfolds after aspiration of low-viscosity, volatile hydrocarbides. Despite the mien of clear-cut indicators for an infection, it is considered to be an acute pseudoinfectious lung disease. In this article, we report onward a relatively rare clinical picture of a 30-year-old man after accidental mineral tar aspiration. In addition to the usual clinical and instrumental examinations, we also performed, for the first time, electron microscopic investigations of the BAL specimen. A striking finding was the proceeding of macrophages (40%) with numerous lipoid inclusions that exhibited all morphologic signs of an activation as well as neutrophil granulocytes (33%) lymphocyte (21%) and eosinophils (6%) Despite a large and necrotizing infiltration of the right lower lobe, the clinical course was eventless with complete recovery.

guide words: BAL; hydrocarbon pneumonitis; rock oil aspiration; pulmonary mycosis; transmission electron microscopy

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Low-viscosity volatile hydrocarbides cause acute pneumonitis that may be life threatening. (1) In the following article, we report a case of hydrocarbon pneumonitis of a 30-year-old man after mineral tar aspiration by fire-eating. Special attention is paid to the electron microscopic findings in the BAL specimen, since like results have not been described still in scientific literature. From these findings, additional information in succession the pathogenesis of hydrocarbon pneumonitis might be derived.

CASE REPORT

A 30-year-old Brazilian music-hall entertainer was admitted to the strait department of a Berlin hospital with the following symptoms: dyspnea, cough hemoptysis, chest pain, and a corpse temperature of 39.7[degrees]C. The patient was normotensive, the heart rate was 120 beats/min, and the respiratory rate was 26 breaths/ min. His general condition was poor. He reported that the symptoms had occurr while fire-eating. CT and chest radiography revealed infiltrations in the right lower lobe of the lung and to the left in retrocranial direction, partly with air inclusions and, forward the right side, a marginal angular pleural effusion (Fig 1 left A, and center B) The small room blood count revealed elevated WBC (13,800/[micro]L) with a left shift. A striking finding was an increase of the C-reactive protein from 34 mg/L and an increase of creatinine-kinase on 170 U/L. Serum electrolytes, hepatic and renal function findings, as well as arterial kin gas measures, were normal. Conservative therapy was initiated, which included 15 g of cefuroxime IV tid, 320 mg of gentamicin IV qd and 20 mg of prednisolone equivalent IV rid. After 5 days, the clinical symptoms had improved still the temperature was still 39[degrees]C The WBC reckon had increased to 20,600/[micro]L, as had the C-reactive protein to 337 mg/L The patient was then transferred to our hospital. After interrupting antibiotic therapy for 24 h bronchoscopy was performed. The macroscopic finding was an inflamed, hyperemic bronchial classification especially on the right side. Signs of bronchial suppuration were not observed. The material for the demonstration of pathogens was taken from portion 10 on the right side by way of means of a protected specimen brush and BAL; however, pathogens, ie, bacteria, mycobacteria or fungi, could not be demonstrated, either microscopically or by means of culturing. Light microscopic inspection of the small room smear taken from the BAL material (Fig 2 top left A), which had been stained with Giemsa solution, revealed 40% alveolar macrophages, 21% lymphocyte 33% neutrophils, and 6% eosinophil granulocytes. Immunotyping of the lymphocyte yielded a CD4/CD8 ratio of 24 Additionally, the BAL material was investigated in the electron microscope.

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Ultrastructural Morphology

Electron microscopic inspection revealed macrophages (Fig 2 top right, B) that showed typical signs of an activation, like as increased process formation, increased phagocytotic activity, a large amount of organelles, and general increase in size. They differed from the usual mononuclear enclosed spaces of a normal BAL, especially in united specific feature: the cytoplasm showed numerous membrane-bordered homogeneous inclusions of average to lower electron density. These inclusions may be interpreted in limits of lipoid-containing vacuoles. In addition to these macrophages, typical lymphocyte and granulocytes were characterized from cut nuclear segments and a certain quantity of inclusions of varying electron density (Fig 2 bottom left C) Another surprising feature of the BAL smear, as seen in the electron microscope, was the transaction of elongated, ramifying structures with an inner capsule of little electron-dense material and a thinner exterior coat of high electron density (Fig 2 bottom right, D) The cytoplasm in the center showed the usual small cavity organelles. Based on these morphologic findings and in view of the preceding antibiotic therapy and the absence of bacteria, we interpreted these mode of buildings as fungi.

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