An Unusual Case of Dyspnea Solved by Multidisciplinary Approach

Abstract

INTRODUCTION: Challenging cases are gratifying when they are solved by pooling of inputs by experts in multiple disciplines. We present one such case of a young woman who was breathless for two years. CASE PRESENTATION: A 40 year old Caucasian female presented to our pulmonary clinic for evaluation of shortness of breath on exertion which she had had for two years. She had been extensively worked up elsewhere previously and given a diagnosis of cryptogenic organizing pneumonia after an open lung biopsy. She had been on steroid for a year, followed by Azathioprine currently, but had had no resolution of symptoms. The patient denied fevers, weight loss, night sweats, joint pains or skin rashes. She was a homemaker and had no pets. She denied exposure to birds, dusts or molds. Her past medical history was significant for hypothyroidism, depression and esophageal reflux. Family history was noncontributory. She denied tobacco or alcohol or recreational drug use. Examination was unremarkable except for scattered bibasilar crackles. Routine blood counts and complete metabolic profile were unremarkable. Connective tissue disease panel was negative for all markers. Pulmonary Function Testing revealed a severe restrictive defect. High Resolution CT of the chest followed by VATS lung biopsy were repeated, representative cuts of which are shown in Figures 1 and 2. As features were concerning for aspiration, the patient was interviewed again. She admitted to applying liberal quantities of Vicks VapoRub(TM) cream to her nostrils at bed-time for several years to date. A diagnosis of Chronic Exogenous Lipoid Pneumonia was made. The patient was advised to stop using the cream the way she did. Azathioprine was stopped and steroid was tapered. DISCUSSION: Chronic Exogenous Lipoid Pneumonia (LP) is an uncommon condition occuring due to recurrent inhalation exposure to oil present in food, oil based medications or laxatives. Clinical symptoms are nonspecific. HRCT may show presence of consolidations with areas of fat attenuation. The opacities are typically peribronchovascular with predominant lower lobe involvement. The condition is characterized by presence of lipid-laden macrophages that fill and distend the alveoli and interstitium, where there may be accumulation of lipid material, inflammatory cellular infiltration and variable amount of fibrosis. Open lung biopsy is usually needed only when transbronchial biopsy is unrevealing. There is no clear therapeutic option. The key measure is identifying and discontinuing exposure to the offending agent. CONCLUSIONS: Diagnosis of chronic exogenous LP is difficult as the history is often missed. A high index of suspicion and meticulous history-taking are rewarding. .