Abstract
Exogenous lipoid pneumonia is caused by inhalation or aspiration of a fatty substance. It constitutes a rare entity, with atypical clinical findings, such as chronic cough or dyspnea, and is accompanied by the presence of diffuse interstitial infiltrates in chest CT scans. We present the case of an exogenous lipoid pneumonia in a psychotic patient with inflammatory bowel disease and mega-esophagus. A 45-year-old man was referred for consultation due to chronic cough and abnormal findings on multiple X-rays during the past 3 months, and on a previous CT scan. He suffered from schizophrenia and chronic inflammatory bowel disease under azathioprine. He daily received oily laxatives due to constipation. During the past months he received several antibiotic treatment regiments without any clinical or radiological benefit. The CT scan revealed the presence of consolidative opacities with air bronchogram involving both lungs in the middle and lower lobes, upper lobe emphysema and a severely dilated esophagus. The patient underwent fiberoptic bronchoscopy, without any abnormal endobronchial findings. The bronchoalveolar lavage (BAL) fluid was examined with bacterial, fungal and mycobacterium cultures that were negative and a cytological study for malignant cells which was also negative. Because of high clinical suspicion, BAL specimens were also examined for lipid staining. The presence of numerous foamy alveolar macrophages with lipid vacuoles stained with Oil Red (O) confirmed the presence of fat, thus enhancing the diagnosis of exogenous lipoid pneumonia. Lipoid pneumonia can mimic many other pulmonary diseases and, because of the insidious onset and the atypical findings, can be misdiagnosed. BAL examination is a diagnostic method that can detect the presence of foamy alveolar macrophages with lipid vacuoles stained with Oil Red (O) or Sudan III, findings indicative of lipoid pneumonia, thus avoiding more invasive diagnostic procedures.