Do Not Play with Fire

We report a case of exogenous lipoid pneumonia caused by inhalation of liquid paraffin in a fire eater young man. The patient was admitted to the Emergency Department because of acute retrosternal pain, dry cough and dyspnea. Chest radiograph showed multiple bilateral basal alveolar opacities associated to left pleural effusion; CT chest scan showed multiple bilateral areas of consolidation with cavity areas. BAL cytologic examination revealed abundant lipid-laden macrophages. Clinical symptoms resolved after corticosteroid treatment. Lipoid pneumonia is a rare and often underdiagnosed entity. The presence of lipid-laden macrophages in sputum or BAL fluid helps to confirm the diagnosis.


Introduction
Exogenous lipoid pneumonia is a rare disease that has traditionally been considered a chronic condition secondary to continued aspiration or inhalation of fatty substances.Sometimes an acute form may appear after a single aspiration of lipid material, being a characteristic accident of street artist or "fire-eaters" that may generate acute respiratory failure [1][2][3].
We report a case of pneumonia caused by inhalation of liquid paraffin in a fire eater young man.

Case Report
A 29-year-old male fire eater was admitted to the Emergency Department because of acute retrosternal pain, dry cough and dyspnea.Some hours before admission an accidental aspiration of liquid paraffin (Diavolina ® ) occurred during a flame-blowing show.
Analysis of blood gases showed a pO 2 of 72.1 mmHg, a pCO 2 of 30.6 mmHg, a pH value of 7.45 and a pO 2 / FiO 2 of 344.7 mmHg.
Chest radiograph showed multiple bilateral basal alveolar opacities associated to left pleural effusion (Figure 1).
Legionella and Pneumococcus urinary antigens were negative.
The patient was admitted in our ward and began antibiotic treatment with ceftriaxone and clarithromycin.
The patient was becoming progressively worse, with more cough and dyspnea on rest.
Inflammatory tests were high, hemocoltures were negative; HIV test was negative; serum Mycoplasma and Chlamydia tests were negative.
A CT chest scan showed multiple bilateral areas of consolidation with cavity areas (Figure 2).
Bronchoscopy and BAL fluid were performed.Results of all bacterial and fungal cultures remained negative.BAL cytologic examination revealed abundant lipidladen macrophages (Oil-Red coloration) (Figure 3).
Clinical symptoms resolved after appropriate corticosteroid treatment and the patient was discharged.At one month follow-up examination, laboratory data and chest radiograph were normal.

Discussion
Various practices can lead to exogenous lipoid pneumonia, e.g., the blowing of sesame oil through the nose in children in Southern India, the forcible feeding of ghee (clarified butter) in Saudi Arabia, the use of mineral oil to relieve small-bowel obstructions in Brazil and the use of gas-oil by fire-eaters [4].
Fire eaters during their show blow a combustible liquid to create a flame.Sometimes a part of this combusti-   ble can be inspired.
The diagnosis is frequently missed or delayed, and requires a high index of clinical suspicion [3].
Chest CT imaging typically shows bilateral alveolar consolidation and it is necessary to evaluate complications.
The presence of lipid-laden macrophages in sputum or BAL fluid helps to confirm the diagnosis [15].
The symptoms and pathologic changes often completely resolve with cessation of exposure; however, severe cases can progress to fibrosis and chronic respiratory failure [15].

Figure 1 .
Figure 1.Chest X-ray shows bilateral alveolar opacities with left pleural effusion.

Figure 2 .
Figure 2. CT chest scan shows multiple parenchymal opacit ies with cavity areas.