Departemen Ilmu Radiologi RSAL Dr.

Mintohardjo
Fakultas Kedokteran Universitas Trisakti
2017

JOURNAL READING
ASPIRATION PNEUMONIA
Squalene Aspiration Pneumonia in Children: Radiographic and CT
Findings as The First Clue to Diagnosis
Pembimbing:

dr. Partogi, Sp.Rad

Fateha Putri Hakim (030.12.101)

Intan Rhama Safitry (030.13.099)
Muhamad Arfan Eriansyah (030.10.186)
 INTRODUCTION
Exogenous lipoid pneumonia an uncommon condition resulting from the
aspiration of mineral, vegetable or animal oils (squalene)

Reports have mainly been limited to adults.

Paediatric patients known to be particularly
at risk of exogenous lipoid pneumonia

ASPIRATION The diagnosis: after futile diagnostic efforts and

PNEUMONIA poor response to antimicrobials

Patients minimal nonspecific symptoms:

cough, fever and sputum

The radiological findings the first clue to

diagnosing squalene aspiration pneumonia.
 MATERIALS & METHODS
Retrospectively reviewied 8 children (4 boys and 4 girls) 3 months - 6 years
Diagnosed exogenous lipoid pneumonia caused
(radiological findings and medical records by the aspiration of squalene (from history of
) taking squalene and radiological findings)

Initial & follow-up chest radiographs were taken

(mean: 5.4 months)
CT using a Hi-speed or -9800 scanner, obtained
7 patients have mild symptoms: fever, cough,
during quiet breathing
& sputum
CT scans were assessed for the presence,
All patients were hospitalized and the
distribution, and extent of dense consolidation,
diagnostic workup No abnormalities
ground-glass opacity, or interstitial thickening
All patients didnt respond to
The distributions of the lesions on the CT scans
antimicrobial treatment improved
were categorized
progressively and slowly after halting exposure
Into: central/peripheral, posterior/anterior, and
to squalene.
upper/lower zone of the lung
 RESULTS

bilateral

While the
Chest radiographs showed
periphery of the
extensive, ill-defined, fluffy The distributions of
parahilar left lung was
and increase opacities in all the lesions were
relatively spared
patients.
in all patients

Predominantly in
the right lung
 Although most portions of the
In three of these six patients, the
lesions were not as dense as the
dense consolidation was situated
cardiac shadow, focal dense In the remaining three patient, the
at the right upper lobe, sharply
consolidation obliterating the right dense consolidation was
demarcated from bilateral,
cardiac border or diaphragm with air predominantly in the lower lobes
diffuse, parahilar fluffy density by
bronchograms was noted in six
the minor fissure.
patients.
The CT scans showed dense
consolidation surrounded by ground
glass opacity with geographic
lobular distribution in all seven
patients (Figs 2,3). Within the dense
consolidations, areas with relatively
low attenuation were identified in
one patient.
On CT, the lesions involved
multiple lobes of both lungs in all
seven patients and extended to
all pulmonary lobes in five
patients.
We did not find any difference in the
location of the pulmonary lesions
between infants and older children.
Fig 1. A 3-month-old girl
(patient 7). The chest
radiograph shows
parenchymal opacities in the
central zone of both lungs;
the peripheral zone is
relatively spared, especially
on the left side. Note dense
consolidation in the right
upper lobe demarcated by
the minor fissure (arrow)
Fig. 2 A 6-year-old boy (pa- tient
2). a Chest radiograph shows
parenchymal opacities in both
lungs. The peripheral zone is
relatively spared, especially on
the left side.
b. CT image (lung window setting)
shows ground-glass opacities sur-
rounding dense consolidation.
Note the predilection for
dependent areas.
c. CT image (mediastinal window
setting) at a more caudal level
shows areas of relatively low
attenuation (arrows) within the
dense con- solidations. d Follow-
up chest radiograph obtained 4
weeks after halting exposure to
squa- lene shows decreased, but
per- sisting lesions
Fig. 3 A 6-year-old girl
(patient 3).
a. Chest radiograph shows
parenchymal opacities in the
central zone of both lungs;
the peripheral zone is
relatively spared, especially
on the left- hand side.
b. High-resolution CT image
(lung window setting) shows
ground-glass opacities
surrounding dense consolida-
tions. Note the crazy-paving
pattern, geographical lobular
distribution, and the predilec
tion for dependent areas
 DISCUSSION

Previous studies : CT clearly demonstrated :

1. In chest radiographs have described diffuse
bilateral, parahilar infiltration found in our
a) the predilection for the
patients. dependent and central
2. The right predominant parahilar fluffy portions of the lungs
infiltration with occasional more extensive b) the geographical lobular
involvement of the right upper lobe was distribution of the lesions
characteristic in our patients. c) the crazy-paving pattern.
3. Resulting from the aspiration of various lipid
substances other than squalene, although in
These CT findings have been
Spickard and Hirschmann studies have described in adult cases
suggested that the diffuse bilateral infiltrates caused by aspiration of
are uncommon in exogenous lipoid squalene or other lipid
pneumonia. substances
 Several investigators have classified these variable radiological findings as sequential
changes following aspiration, with or without pathological correlation. Lee et al.
have recently analysed high- resolution CT findings of adult patients with squalene
aspiration pneumonia and categorized them into three subgroups:

(a) diffuse ground-glass opacity pattern with a recent history of taking a large amount of
squalene,
(b) dense consolidation pattern with a history of taking squalene for months, and
(c) interstitial thickening pattern with a history of taking squalene for years.
 LIMITATION

The limitations of this study include the fact that there was no histopathological
proof of squalene aspiration pneumonia in most of our patients.

The second limitation is that it is not certain that all paediatric patients having
squalene aspiration pneumonia will show the radiological findings observed in
this study, since cases with atypical or minimal radiographic appearance might
fail to be diagnosed and included.
 CONCLUSION

Radiographs of children with squalene aspiration

pneumonia show predominantly right-sided,
parahilar fluffy infiltrations with little interval
change; CT shows multilobular consolidations
surrounded by ground-glass opacities with a crazy-
paving pattern in a geographical lobular
distribution, predominantly in dependent areas.
 REFERENCE
1. de Oliveira GA, Del Caro SR, Bender Lamago CM, et al (1985) Radiographic plain film and CT findings in lipoid
pneumonia in infants following aspira- tion of mineral oil used in the treatment of partial small bowel obstruction by
Ascaris Lumbricoides. Pediatr Radiol 15:157160
2. Lee KS, Mu ller NL, Hale V, et al (1995) Lipoid pneumonia: CT findings. J Comput Assist Tomogr 19:4851
3. Annobil SH, Ogunbiyi AO, Benjamin B (1993) Chest radiographic findings in childhood lipoid pneumonia following
aspiration of animal fat. Eur J Radiol 16:217220
4. Hugosson CO, Riff EJ, Moore CC, et al (1991) Lipoid pneumonia in infants: a radiographical-pathological study. Pe- diatr
Radiol 21:193197
5. Balakrishman S (1973) Lipoid pneu- monia in infants and children in south India. BMJ 4:329331
6. Lee JS, Im JG, Song KS, et al (1999) Exogenous lipoid pneumonia: high-res- olution CT findings. Eur Radiol 9:287291
7. Asnis DS, Saltzman HP, Melchert A (1993) Shark oil pneumonia. An overlooked entity. Chest 103:976977
8. Lee JY, Lee KS, Kim TS, et al (1999) Squalene-induced extrinsic lipoid pneu- monia: serial radiological findings in nine
patients. J Comput Assist Tomogr 23:730735
9. Spickard A 3rd, Hirschmann JV (1994) Exogenous lipoid pneumonia. Arch In- tern Med 154:686692
10. Volk BW, Nathason L, Losner S, et al (1951) Incidence of lipoid pneumonia in survey of 389 chronically ill patients. Am J
Med 10:316324
 REFERENCE
11. Genereux GP (1970) Lipids in the lungs: radiologic-pathologic correlation. J Can Assoc Radiol 21:215
12. Wright BA, Jeffrey PH (1990) Lipoid pneumonia. Semin Respir Infect 5:314321
13. Franquet T, Gimenez A, Bordes R, et al (1998) The crazy-paving pattern in exogenous lipoid pneumonia: CT-pathologic
correlation. AJR 170:315317
14. Laurent F, Philippe JC, Vergier B, et al (1999) Exogenous lipoid pneumonia: HRCT, MR, and pathologic findings. Eur
Radiol 9:11901196
15. Kennedy JD, Costello P, Balikian JP, et al (1981) Exogeneous lipoid pneu- monia. AJR 136:11451149
16. Joshi RR, Cholankeril JV (1985) Com- puted tomography in lipoid pneumonia. J Comput Assist Tomogr 6:211213
17. Seo JB, Im JG, Kim WS, et al (1999) Shark liver oil-induced lipoid pneumo- nia in pigs: correlation of high-resolu- tion
CT and histopathologic findings. Radiology 212:8896
18. Van den Plas O, Trigaux JP, Van Beers B, et al (1990) Gravity-dependent infil- trates in a patient with lipoid pneumo- nia.
Chest 98:12531254
19. Hampton SO, Bickham CE, Winship T (1955) Lipoid pneumonia. AJR 73:938949
20. Pierson JW (1932) Some unusual pneumonias associated with the aspira- tion of fats and oils in the lungs. AJR 27:572
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