Exogenous lipoid pneumonia is a rare entity. It was first characterized in 1925, when Laughlen published a case of lipoid pneumonia caused by a nasopharyngeal injection of oil.1 As this phenomenon is rare, we would like to report a new case of lipoid pneumonia, presenting in this case in a “fire-eater” who accidently inhaled paraffin during a circus act performed in the street.

A 19-year-old man, presented with dry cough, dyspnea, general malaise, and right rib pain after an episode of choking on paraffin during a fire-eating act. He smoked 2 cigarettes/day (accumulated smoking history of 3 pack-years) and worked as an amateur circus street performer. Physical examination revealed temperature 38.5°C, and disperse wheezing on exhalation on auscultation. Clinical laboratory test results included 27100 leukocytes/μl (91% neutrophils) and CRP 298mg/l. Chest X-ray showed bilateral alveolar infiltrates and computed tomography (CT) revealed 3 cavities, the largest being 35mm in diameter, in the middle lobe, and 1 in the left lower lobe, with partial fluid occupation and remains of low-density material (−3 to −50HU) of lipid origin. Fiberoptic bronchoscopy was normal, and bronchoalveolar lavage fluid revealed 59% neutrophils, 17% lymphocytes, and 24% histiocytes; cultures for bacteria, mycoses and mycobacteria were negative. Sputum cytology showed numerous macrophages with clear, foamy cytoplasm, consistent with aspiration of foreign matter (Fig. 1). Antibiotic treatment was started (amoxicillin-clavulanate acid for 2 weeks) and corticosteroids (methylprednisolone 60mg/day/i.v. for 1 week, followed by prednisone, tapered over a 10-day period). The patient showed clinical and radiological improvement. In the follow-up in the outpatient clinic, he was asymptomatic and chest X-ray and lung function tests were normal (FVC 4370ml, 84% predicted; FEV1 4100ml, 93%; FEV1%/FVC 94; DLCOsb 82%; DLCO/VA 100%).

Fig. 1.

(Top right) hematoxylin–eosin (HE), 400×. (Top left) hematoxylin–eosin (HE) with monoclonal antibody CD163, 400×. (Below) hematoxylin–eosin (HE) with para-aminosalicylic acid (PAS), 400×.

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Our patient presented with an acute form of lipoid pneumonia. This is of interest due to the unusual nature of its origin: accidental aspiration of paraffin in a street performer during a circus act in the street. Clinical presentation, unlike chronic forms, develops with sudden onset of dyspnea, fever, coughing fits, chest pressure, and, in some cases, hemoptysis. To our knowledge, the first case of lipoid pneumonia in a fire eater dates from 19842 and some isolated cases have been reported since then.3,4

Areas of homogeneous condensation with a diffuse or localized air bronchogram can been seen on chest X-ray. The extension of parenchymal damage can be documented with CT, and in our case, cavities occupied with low density material, consistent with lipid origin,4 were seen with this technique. These cavities were pneumatoceles, which can take more than 2 months to resolve.3

The diagnosis is based on a finding of macrophages containing lipid vacuoles, as observed in the sputum samples of our patient.5

In conclusion, this was a case of lipoid pneumonia due to aspiration of paraffin in an amateur fire-eater. It is a very rare disease, but incidence rates may rise in the near future.