(Chest. 2003;124:398-400.)
© 2003
American College of Chest Physicians
Electron Microscopic Findings in BAL of a Fire-eater After Petroleum Aspiration*
Olaf Burkhardt, MD;
Hans-Joachim Merker, MD;
Mehdi Shakibaei, PhD and
Hartmut Lode, MD
* From the Department of Chest and Infectious Diseases (Dr. Burkhardt and Professor Lode), Hospital Heckeshorn; and the Institute of Anatomy (Professors Merker and Shakibaei), University Hospital Benjamin Franklin, Free University Berlin, Berlin, Germany.
Correspondence to: Hartmut Lode, MD, Department of Chest and Infectious Diseases, Chest Hospital Heckeshorn, Zum Heckeshorn 33, D-14109 Berlin, Germany; e-mail: haloheck{at}zedat.fu-berlin.de
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Abstract
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Hydrocarbon pneumonitis, known also as fire-eater pneumonia, always develops after aspiration of low-viscosity, volatile hydrocarbides. Despite the presence of clear-cut indicators for an infection, it is considered to be an acute pseudoinfectious lung disease. In this article, we report on a relatively rare clinical picture of a 30-year-old man after accidental petroleum 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 occurrence of macrophages (40%) with numerous lipoid inclusions that exhibited all morphologic signs of an activation as well as neutrophil granulocytes (33%), lymphocytes (21%), and eosinophils (6%). Despite a large and necrotizing infiltration of the right lower lobe, the clinical course was uneventful with complete recovery.
Key Words: BAL • hydrocarbon pneumonitis • petroleum aspiration • pulmonary mycosis • transmission electron microscopy
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Introduction
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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 petroleum aspiration by fire-eating. Special attention is paid to the electron microscopic findings in the BAL specimen, since such results have not been described yet in scientific literature. From these findings, additional information on the pathogenesis of hydrocarbon pneumonitis might be derived.
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Case Report
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A 30-year-old Brazilian music-hall entertainer was admitted to the emergency department of a Berlin hospital with the following symptoms: dyspnea, cough, hemoptysis, chest pain, and a body temperature of 39.7°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 occurred 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, on the right side, a marginal angular pleural effusion (Fig 1
, left, A, and center, B). The cell blood count revealed elevated WBCs (13,800/µL) with a left shift. A striking finding was an increase of the C-reactive protein by 34 mg/L and an increase of creatinine-kinase by 170 U/L. Serum electrolytes, hepatic and renal function findings, as well as arterial blood gas measures, were normal. Conservative therapy was initiated, which included 1.5 g of cefuroxime IV tid, 320 mg of gentamicin IV qd, and 20 mg of prednisolone equivalent IV tid. After 5 days, the clinical symptoms had improved but the temperature was still 39°C. The WBC count had increased to 20,600/µL, 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 system, especially on the right side. Signs of bronchial purulence were not observed. The material for the demonstration of pathogens was taken from segment 10 on the right side by means of a protected specimen brush and BAL; however, pathogens, ie, bacteria, mycobacteria or fungi, could not be demonstrated, either microscopically or by culturing. Light microscopic inspection of the cell smear taken from the BAL material (Fig 2
, top left, A), which had been stained with Giemsa solution, revealed 40% alveolar macrophages, 21% lymphocytes, 33% neutrophils, and 6% eosinophil granulocytes. Immunotyping of the lymphocytes yielded a CD4/CD8 ratio of 2.4. Additionally, the BAL material was investigated in the electron microscope.
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Figure 1.. Left, A: CT after petroleum aspiration showed infiltration in the right lower lobe of the lung, partly with air inclusions. Center, B: Chest radiography after petroleum aspiration showed also infiltration in the right lower lobe and a marginal angular pleural effusion. Right, C: Three months after petroleum aspiration, chest radiography showed only small scarred residues of the previous inflammation.
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Figure 2.. Top left, A: Light microscopic inspection of the cell smear from the BAL showed alveolar macrophages, lymphocytes, neutrophil and eosinophil granulocytes (Giemsa solution, original x 100). Top right, B: Section of a macrophage with numerous inclusions that contain homogeneous material of average electron density. Striking is the great number of processes at the cell surface. The other areas of the cytoplasm exhibit a large number of cell organelles (Giemsa solution, original x 9,000). Bottom left, C: Neutrophil granulocyte with two cut nuclear segments, a Golgi apparatus and some electron-dense granules in the vicinity. The left side of the micrograph shows a microorganism (cross-section) with a cytoplasmic nucleus and a two-layered capsule; the inner part is of low electron density, and the outer part is thinner and of high electron density (Giemsa solution, original x 12,000). Bottom right, D: Sections of microorganisms, probably representing cross-section and longitudinal section of yeast cells. The center shows a cytoplasmic area with cell organelles, a two-layered capsule at the outside; its inside exhibits a low electron density, and its outside exhibits a high electron density (Giemsa solution, original x 24,000).
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Ultrastructural Morphology
Electron microscopic inspection revealed macrophages (Fig 2
, top right, B) that showed typical signs of an activation, such as increased process formation, increased phagocytotic activity, a large amount of organelles, and general increase in size. They differed from the usual mononuclear cells of a normal BAL, especially in one specific feature: the cytoplasm showed numerous membrane-bordered homogeneous inclusions of average to lower electron density. These inclusions may be interpreted in terms of lipoid-containing vacuoles. In addition to these macrophages, typical lymphocytes and granulocytes were characterized by cut nuclear segments and some 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 occurrence of elongated, ramifying structures with an inner capsule of little electron-dense material and a thinner outer coat of high electron density (Fig 2
, bottom right, D). The cytoplasm in the center showed the usual cell organelles. Based on these morphologic findings and in view of the preceding antibiotic therapy and the absence of bacteria, we interpreted these structures as fungi.
Development of the Case
Since pathogens could not be clearly demonstrated, especially not in serologic investigations, we continued antibiotic treatment with 1 g of meropenem IV tid for 7 days and, subsequently, with an oral dose of 400 mg moxifloxacin qd for 2 weeks. Antiphlogistic therapy with a systemic corticosteroid and inhalation with fluticasone, as well as sufficient doses of analgesics, completed our treatment regimen. It led to defervescence 5 days after the patient’s admission to our hospital. The initially severe restriction of lung function became normal during clinical treatment (maximum vital capacity, 2.22 L vs 3.81 L), as did the inflammatory parameters in the blood. The patient could be discharged as cured approximately 4 weeks after his petroleum aspiration. Two months after his discharge from our hospital, radiography was performed, showing only small scarred residues of the previous inflammation (Fig 1 , right, C).
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Discussion
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Our clinical findings largely correspond to the described picture of hydrocarbon pneumonitis.1
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3
4
Our patient showed the typical clinical symptoms, such as dyspnea, cough, hemoptysis, chest pain, and high temperature immediately after petroleum aspiration. Radiograph examination of the chest as well as CT 1 day after petroleum aspiration revealed lung consolidations and incipient formation of pneumatoceles, ie, well-defined cavitary nodules.5
Conservative antiphlogistic and antibiotic therapy led to a rapid decrease of the described symptoms, accompanied by an obvious improvement of the patient’s general condition; however, a striking finding was the persistent high temperature and the increase of all inflammatory parameters in the blood despite the administration of broad-spectrum antibiotics. Using the two qualitatively and quantitatively best bronchoscopic methods (protected specimen brush and BAL), we were not able to demonstrate any pathogens, either microscopically or in culture, which would have confirmed the diagnosis of pseudoinfectious lung disease.6
In contrast, electron microscopic inspection of the BAL specimen revealed two interesting findings. One peculiarity was the occurrence of macrophages with lipoid-containing inclusions that exhibited all morphologic signs of an activation.7
The occurrence of lipoid vacuoles indicates an increased phagocytotic activity of macrophages that leads to an increased release of cytokines by macrophages, which in turn can trigger an increased and prolonged inflammatory reaction. The second interesting finding refers to the ultrastructural demonstration of structures we interpreted as fungi. We believe that we were dealing with a fungus colonization and not with a pulmonary mycosis, especially since all other culture and serologic tests for fungi and fungus antigens yielded negative results. This one special case is, of course, insufficient to decide to what extent a secondary fungal colonization is characteristic of hydrocarbon pneumonitis, and whether or not it plays a role in the prolongation of this inflammatory reaction. It could, of course, also have occurred accidentally, especially after the preceding antibiotic therapy. Further investigations are necessary to be able to decide whether this is a diagnostic feature. Another question to be clarified is the specificity of the electron microscopic picture of this fire-eater’s lung lavage, especially in view of the diagnosis of aspiration of petroleum or other low-viscosity, volatile hydrocarbides, for example after occupational accidents.
Received for publication September 26, 2002.
Accepted for publication January 27, 2003.
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References
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- Gentina, T, Tillie-Leblond, I, Birolleau, S, et al (2001) Fire-eater’s lung: seventeen cases and review of the literature. Medicine 80,291-297[CrossRef][Medline]
- Brander, PE, Taskinen, E, Stenius-Aarniala, B Fire-eater’s lung. Eur Respir J 1992;5,112-114[Abstract]
- Borer, H, Koelz, AM Fire eater’s lung (hydrocarbon pneumonitis). Schweiz Med Wochenschr 1994;124,362-367[Medline]
- Ewert, R, Kern, F, Mutze, S, et al Aspiration of petroleum by a "fire-eater." Pneumologie 1995;49,388-390[Medline]
- Franquet, T, Gomez-Santos, D, Gimenez, A, et al Fire eater’s pneumonia: radiographic and CT findings. J Comput Assist Tomogr 2000;24,448-450[CrossRef][Medline]
- Haas, C, Lebas, FX, Le Jeunne, C, et al Pneumopathies caused by inhalation of hydrocarbons: apropos of 3 cases. Ann Med Intern 2000;151,438-447
- Burkhardt, O Immunoelectron microscopic investigations of lymphocytes [doctoral thesis] 2001 Freie Universität Berlin. Berlin, Germany:
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Abstract
Introduction
