Cholesterol pneumonia

Introduction: We present a thirty year old female who presents shortly following cadaveric renal transplantation with respiratory failure, subsequently diagnosed with exogenous lipid pneumonia and pulmonary alveolar proteinosis reaction.

Case Presentation: A thirty year old female presented 12 days post cadaveric renal transplant, with 12 hours of dyspnea, cough, clear sputum, fevers (38.2 [degrees] C), chills, myalgias, arthralgias, lethargy, non-bloody vomitus, diarrhea and headache. The patient's noncompliance led to inadequate CMV prophylaxis, despite her being at high risk for this (+ donor/ -recipient). Medications on admission were cyclosporin, prednisone, mycophenalate, acyclovir, trimethoprim-sulfamethoxazole (PCP prophylaxis), iron, phosphate, and erythropoietin. She smoked cigarettes ([is less than] 1/2 ppd) and marijuana since age fourteen. She denied further use since her transplant.

Examination revealed pulse 110, respiratory rate 12, blood pressure 135/90 and temperature 38.2 [degrees] C. Oxygen saturation was 95% on room air (88-90% earlier in day). Bibasilar bronchovesicular breath sounds and a few crackles were present. Chest radiograph showed bilateral lower zone inhomogeneous opacification corresponding to both alveolar and interstitial disease. White blood count was 25.8 x [10.sup.9]/L, hemoglobin 66 g/L, and platelets 249 x [10.sup.9]/L. Electrolytes and renal function were normal. She was given ganciclovir 125 mg bid IV, erythromycin 1 g qid and vancomycin 1 g bid. Cyclosporin dose was reduced. Bronchoscopy with BAL the following day showed gram positive cocci on stain, but final cultures were negative. Studies for PCP, CMV, Legionella, Fungi and AFB were negative, so antibacterial therapy was continued. A renal allograft biopsy diagnosed mild rejection, and the patient was given solumedrol for 3 days.

The patient deteriorated clinically and on chest radiograph, [PO.sub.2] 44 mm Hg on room air (arterial blood gas). Open lung biopsy was performed, and showed areas of pulmonary alveolar proteinosis (PAP) reaction with acute inflammation superimposed on a background of longstanding exogenous lipid pneumonia (ELP). Shell vials for CMV from the biopsy were negative. She stabilized and was discharged shortly thereafter, however her pulmonary condition deteriorated requiring readmission within a few days. A BAL was done and showed cream colored return, consistent with pulmonary alveolar proteinosis. Another BAL was done 3 weeks later because of persistent symptoms and isolated CMV. She was treated with intravenous ganciclovir with rapid improvement in her pulmonary status within 48 hours, and she was sent home on daily intravenous ganciclovir for a total of ten weeks. The patient remains well five months following discharge, with mild persistent interstitial disease on chest radiograph. On questioning the patient's marijuana use further, she smoked a preparation known as "weed oil" ([is greater than] 10 years). It utilized hydroponically, grown marijuana leaves combined with isopropyl alcohol and heated to distill and collect the vapor. The resulting mixture was burned for a short period to eliminate the alcohol, and then mixed with either vaseline jelly, vitamin E or a similar fat based substance and placed in a closed container, which was externally heated and the vapors inhaled.

Discussion: We conclude that this patient's exogenous lipid pneumonia was related to the smoking of marijuana in the form of "weed oil." An association of lipid pneumonia and PAP has been proposed in the literature.[1,2] Two recent reports describe the development[3] and recurrence[4] of PAP following lung transplantation. The accompanying dysfunction of alveolar macrophages seen with PAP along with ELP predisposed her to infections. To our knowledge, this is the first description of pulmonary alveolar proteinosis or exogeuous lipid pneumonia following renal transplantation. Our case confirms the good prognosis that is possible with early recognition and treatment.

References

[1] Fisher M, Roggli V, Morten D, et al. Coexisting endogenous lipoid pneumonia, prominent cholesterol granulomas, and pulmonary alveolar proteinosis in a pediatric population: a clinical, radiographic and pathologic correlation with proposed common pathophysiology. Pediatr Pathol 1992; 12:36.5-383

[2] McDonald JW, Roggli VL, Bradford WD. Coexisting endogenous and exogenous lipoid pneumonia and pulmonary alveolar proteinosis in a patient with neurodevelopmental disease. Pediatr Pathol 1994; 14:505-511

[3] Yousem SA. Alveolar lipoproteinosis in lung allograft recipients. Hum Pathol 1997; 28(12):1383-1386

[4] Parker LA, Novotny DB. Recurrent Alveolar proteinosis following double lung transplantation. Chest 1997; 111(5):1457-1458

Dilini Vethanayagam, MD,(*) S. Pugsley, MD,(*) E. J. Dunnl PhD,(**) D. Russell, MD,(*) M. Kay, MD,(**) C. Allen, BM(*)--Departments of Medicine(*) and Laboratory Medicine,(**) St. Joseph's Hospital, McMaster University, Hamilton, Ontario, Canada

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