23-year-old female, who was having history suggestive of chronic rhino bronchial allergy for the past five years, attended pulmonology outpatient with the complaint of cough, dyspnea and fever since more than four weeks. Vital signs were within normal range with SpO2 of 96%; her physical examination revealed bibasal lung crackles. Her past medical history revealed treatment with inhaled corticosteroids and fluticasone nasal spray on an irregular basis during exacerbations. She complains of recurrent headaches and underwent septoplasty with submucosal diathermy three years ago. Her routine blood work was within normal range with no peripheral eosinophilia and no sputum eosinophilia; her total serum IgE level was 731 ng/ml; her spirometry revealed mild restrictive ventilatory defect. Serum 25 hydroxy vitamin D3 was 9.12 ng/ml; chest radiograph showing bilateral infiltrates prompted for a computed tomography scan of chest (HRCT- Chest). The latter revealed multiple small well defined and ill-defined centrilobular nodules in both lungs, significantly in the left inferior lingula and in the basal segments of left lower lobe. The lesions show areas of tree-in-bud appearance and areas of confluence. Few small scattered centrilobular nodules were seen in the right lung in all the lobes (Fig. 1, Fig. 2).
Clinicoradiological opinion was either atypical pneumonia or to rule out tuberculosis. She underwent fiberoptic bronchoscopy for bronchial wash and transbronchial lung biopsy; bronchial washings sent for smear for acid fast bacilli and fungal elements were negative, with gram stain showing occasional polymorphs; geneXpert MTB/RIF was not detected; 20 ml of bronchial washings which was hemorrhagic revealed an occasional alveolar macrophage with many neutrophils with a background of blood elements. Trans bronchial lung biopsy (TBLB) revealed histological features suggestive of Lipoid Pneumonia (Fig. 3).
Meticulous history, retrospectively, revealed patient habituated to applying a petrolatum ointment to the nose, externally, daily at night since more than a year. She was treated with oral prednisolone, tapered over a period of six months, apart from her regular inhaled corticosteroid and Fluticasone nasal spray. Her follow up HRCT-Chest at the end of one year showed partial resolution of the previous lesions, and patient is clinically stable without any relevant symptoms. (Fig. 4).
HRCT section at the level of the lower lobes reveals mild cylindrical bronchiectasis in the left lower lobe, faint tiny centrilobular nodules in the left lower lobe, right lower lobe and fibrotic lesions in the left lingula.