|Year : 2018 | Volume
| Issue : 1 | Page : 30-33
A rare cause of pneumothorax: Diesel aspiration pneumonitis
Ajay K Verma1, Anubhuti Singh1, Kislay Kishore2, Surya Kant1
1 Department of Respiratory Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Respiratory Medicine, Command Hospital (Central Command), Lucknow, Uttar Pradesh, India
|Date of Web Publication||24-Jan-2018|
Dr. Surya Kant
Department of Respiratory Medicine, King George's Medical University, Chowk, Lucknow - 226 003, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Chemical pneumonitis refers to the aspiration of an inoculum that is inherently toxic to the lungs. Diesel aspiration is an uncommon cause of chemical pneumonitis, and aspiration leading to pneumothorax is an even rarer occurrence, not having been reported in adults so far. We are reporting a case of a young adult male who developed pneumothorax secondary to accidental diesel aspiration.
Keywords: Aspiration pneumonitis, diesel, pneumothorax
|How to cite this article:|
Verma AK, Singh A, Kishore K, Kant S. A rare cause of pneumothorax: Diesel aspiration pneumonitis. Muller J Med Sci Res 2018;9:30-3
|How to cite this URL:|
Verma AK, Singh A, Kishore K, Kant S. A rare cause of pneumothorax: Diesel aspiration pneumonitis. Muller J Med Sci Res [serial online] 2018 [cited 2020 Sep 25];9:30-3. Available from: http://www.mjmsr.net/text.asp?2018/9/1/30/223923
| Introduction|| |
Accidental diesel aspiration is not uncommon in rural areas of India, where siphonage from tanks and gallons is a common practice. Diesel aspiration leads to chemical pneumonitis, most commonly involving the right middle and lower lobes. This condition is usually self-resolving, and patients improve within 7–10 days. Pneumothorax is a very rare presentation of diesel aspiration and has not been reported in adults so far. Thus, such patients can be mistaken as tuberculosis (TB) or bacterial pneumonia if this important exposure history is missed and patients can be unnecessarily put on anti-tubercular treatment (ATT). We are reporting a case of a young adult male who presented with pneumothorax secondary to accidental diesel aspiration and pneumonitis.
| Case Report|| |
A 16-year-old male student, belonging to a rural background presented to our side with complaints of right-sided chest pain, shortness of breath and dry cough of 1 month duration. On examination, there was decreased air entry on the right side with intercostal drainage (ICD) in situ. The patient gave a history of severe right-sided chest pain 1 month back followed by shortness of breath. He was taken to a local hospital where chest X-ray (CXR) revealed right-sided pneumothorax [Figure 1]. ICD insertion was done, and the patient was started on ATT. Since there was no lung expansion on follow-up chest radiographs [Figure 2], he was referred to our side.
|Figure 1: Chest radiograph posteroanterior view showing right-sided pneumothorax|
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|Figure 2: Chest radiograph posteroanterior view showing failure of lung to expand after intercostal drainage insertion|
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At admission, the patient was febrile, otherwise asymptomatic. Air column was moving, ICD was generating ~50 ml/day of thick purulent secretions, and bronchopleural fistula (BPF) was present. On evaluation, routine blood investigations were within normal limits, Mantoux showed no induration, he was unable to raise sputum, ICD pus smear for acid-fast bacilli was negative, Gram staining showed few pus cells and pus pyogenic culture did not show growth of any pathogen. Contrast-enhanced computed tomography (CT) of thorax revealed right-sided hydropneumothorax with underlying consolidated lung parenchyma, thickened pleura, and mediastinal lymphadenopathy [Figure 3] and [Figure 4]. There was no evidence of pneumatocele.
|Figure 3: Contrast-enhanced computed tomography thorax: Lung window showing right-sided hydropneumothorax with underlying consolidated lung and intercostal drainage in situ|
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|Figure 4: Contrast-enhanced computed tomography thorax: Mediastinal window showing right-sided pleural thickening and mediastinal lymphadenopathy|
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With neither the history nor investigations suggesting a diagnosis of TB or bacterial pneumonia, patient's history was reviewed. He gave a history of accidental diesel aspiration at his farm one and a half months back during transfer from a container to the generator. He had developed mild right-sided chest pain which was relieved on analgesics. One week later, he had developed a dry cough and low-grade fever. CXR had revealed right lower zone consolidation [Figure 5], for which he was prescribed antibiotics. In the following week, he developed severe right side chest pain and shortness of breath when pneumothorax was detected.
|Figure 5: Chest radiograph posteroanterior view showing right lower zone consolidation|
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At our center, the patient was put on intravenous antibiotics (considering super-added bacterial infection leading to pus formation), analgesics, and antitussives. ATT was stopped as there was no evidence of TB. The patient became asymptomatic; secretions became thin and <10 ml/day in amount and lung expanded to a certain extent. As BPF was present, he was discharged from our side with ICD in situ. Thoracoscopy was not performed since he had minimal drainage in the ICD per day with the expansion of the right lung. The patient visited us after 15 days as follow-up and is doing well. He is asymptomatic, BPF has closed, secretions are minimal in amount, lung has partially expanded, but there is significant pleural thickening and adhesions [Figure 6]. He has been advised chest physiotherapy and incentive spirometry and is due for his next follow-up visit in 15 days.
|Figure 6: Chest radiograph posteroanterior view showing right-sided partially expanded lung with adhesions and volume loss at the next follow-up visit after 15 days of discharge|
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| Discussion|| |
Chemical pneumonitis refers to the aspiration of an inoculum that is inherently toxic to the lungs. The various irritants which can lead to chemical pneumonitis are acid, animal fats, mineral oil, and volatile hydrocarbons such as diesel, petrol, and kerosene. Accidental exposure to these hydrocarbons has been associated with fire eaters, diesel fuel siphonage, aspiration of dry cleaning products and liquid polishes. These substances initiate an inflammatory reaction, which can involve whole of the respiratory tract, from the trachea to the alveoli.
Diesel aspiration is an uncommon cause of chemical pneumonitis. It can be either due to direct aspiration of fuel or secondary to aspiration of vomitus following ingestion. An important factor promoting aspiration after ingestion is the low viscosity of the hydrocarbon. It is more common in children aged <5 years, in whom accidental ingestion can occur from nontamper proof containers. Although diesel has systemic toxicity involving the central nervous system and cardiovascular system, the life-threatening complications mainly occur because of pulmonary toxicity, in the form of aspiration pneumonitis, lipoid pneumonia, lung abscess, pleural effusion and rarely, pneumothorax. A well-recognized complication of hydrocarbon pneumonitis is pneumatocele.
“Fire-eater's lung” is another variant of hydrocarbon pneumonitis. It typically involves adolescents or young adults who become exposed during fire-blowing performances using flammable chemicals such as kerosene and petrol.
As with any other aspiration disorder, the most common site of involvement in patients with diesel aspiration-induced pneumonitis too is the right middle lobe. On CT thorax, the characteristic findings are patchy air-space consolidation, centrilobular nodules, and ground glassing. Some patients may develop complications such as lung abscess, cyst, pleural effusion, and BPF.
A retrospective study was conducted of 32 cases of hydrocarbon aspiration pneumonitis following diesel siphonage in Vietnam to analyze the clinical features of such patients. This study found a male to female ratio of 16:1, predominantly a middle age disease, in automobile drivers and farmers. The treatment usually prescribed in these patients was antibiotics and steroids. They found that remission occurred in ~85% patients while ~10% patients developed complications.
No established guidelines exist for treatment of such cases. It is usually supportive in the form of oxygen support, steroids to accelerate recovery and avoidance of future exposure. Antibiotic use should be limited to patients with clinical evidence of infection. Chronic sequelae and residual effects of an irritant injury can be in the form of chronic rhinitis, airflow obstruction, and airway hyperresponsiveness.
In a TB endemic country such as India, young patients with a history of a cough, shortness of breath, and pneumothorax on CXR (as happened to be the case in this patient) are empirically given ATT, without any clinical features or investigations suggestive of the same. This underlines the importance of active history taking in each and every case so that relevant past exposure history is not overlooked and patients are not prescribed prolonged duration of ATT.
| Conclusion|| |
This case highlights the importance of history taking as patients usually conceal history of accidental ingestion or aspiration of fuel and other chemicals, especially if they do not have significant symptoms at that time. These patients can later present with nonresolving pneumonia, pleural effusion or pneumothorax and diagnosis can be missed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]