{"paper_id":"ad4e3e69-d077-4e0f-9591-8a6b257b9554","body_text":"11\nPathology Section\nLipoid Pneumonia and Peritoneal \nEndometriosis: Rare Incidental \nFindings on Autopsy\nNational Journal of Laboratory Medicine. 2022 Apr, Vol-11(2): PC01-PC03\nDOI: 10.7860/NJLM/2022/53058.2592 Case Report\nCASE REPORT\nA 12-year-old female, who was unwell for five to six days with the \ncomplaint of fever and was being treated at a private clinic. After her \ncondition worsened, she was brought to the tertiary care centre and \nwas managed conservatively, where she succumbed on the same \nday. Autopsy was performed, as it was a medico-legal hospital death.\nSubdural haemorrhage was noted and the brain parenchyma was \nunremarkable. Both lungs were congested and blood tinged froth \noozed out on cut section. Pericardial cavity and pericardium were \nunremarkable. Heart, coronary arteries, great vessels and valves \nwere unremarkable. All the coronary ostia were patent. Peritoneal \ncavity had about 300 cc of reddish brownish coloured fluid which \nwas sent for cytological examination. Liver weighed 1231 gm and \nwas grossly unremarkable. Spleen was enlarged and weighed \n174 gm and was congested. Pancrea was unremarkable. Stomach \nhad 5 cc of yellowish content. Small intestine contained fluids and \ngases. Large intestine contained faecal matter and gases. Mucosa \nof both small and large intestine was unremarkable. Pelvic cavity \nwas unremarkable. Urinary bladder and the rectum were empty. \nThe uterus was menstruating. Both sides adnexal organs were \nunremarkable.\nSmears were made from the peritoneal fluid that was sent for \ncytological examination and stained with Geimsa stain. The smears \nwere highly cellular with two population of cells. One type of cells \nwas reactive mesothelial cells. These were present in loosely \ncohesive sheets showing mild atypia with few having nuclear \ngrooves. The second type of cells was identified as endometrial \ncells. These cuboidal cells were present in small clusters along with \noccasional small sized spindle cells [Table/Fig-1]. The background \nwas haemorrhagic. On the basis of these findings and supportive \npostmortem findings of blood tinged haemorrhagic peritoneal fluid \nand menstruating uterus, a diagnosis of peritoneal endometriosis \nwas suggested.\nMultiple sections stained with Haematoxylin and Eosin (H&E) of brain, \nliver, kidney, spleen, heart and lungs were also examined. Sections \nfrom brain, heart, kidney, spleen and liver revealed no significant \npathology. Multiple sections from lungs showed markedly congested \nblood vessels. Numerous intra-alveolar macrophages containing \ndistinct intracytoplasmic vacuoles of varying sizes resembling lipid \nZini ChauraSia 1, renu GuPta 2, SwaPnil aGarwal 3\n \nKeywords: Alveolar macrophages, Lipid droplets, Peritoneal cytology\nABSTRACT\nLipoid pneumonia has been described in as early as 1925, by Laughlen GF , to be a rare variant of pneumonia caused by the \ninhalation of oil droplets. Around 50% of the patients with lipoid pneumonia are asymptomatic. Here, a case is presented where \nperitoneal fluid and tissue pieces from various organs of a 12-year-old female were received for examination after autopsy. There \nwas no history of any illness before death. Cytology of fluid revealed features suggestive of endometriosis. Microscopy of lung \nsections revealed numerous lipid droplets in the alveoli and the interstitium along with a mild inflammatory infiltrate suggestive of \nlipoid pneumonia. In view of incidental findings in present case report, the occupational history or history of inhalation of oil-based \nmedications becomes very important and should always be investigated. Also, in the absence of any symptoms peritoneal fluid \nneeds to be studied carefully for any pathology.\n[Table/Fig-1]: Cluster of endometrial cells with few scattered stromal cells in a \nhaemorrhagic background (Geimsa stain, 200X).\n[Table/Fig-2]: Sections from lungs showing markedly congested blood vessels, \nnumerous intra-alveolar macrophages containing distinct intracytoplasmic vacuoles \nof varying sizes resembling lipid droplets (H&E, 100X).\ndroplets were also noticed [Table/Fig-2]. These lipid droplets were \nalso seen in the interstitium. Mild mononuclear inflammatory cell \n\n\nZini Chaurasia et al., Lipoid Pneumonia and Peritoneal Endometriosis on Autopsy www.njlm.net\nNational Journal of Laboratory Medicine. 2022 Apr, Vol-11(2): PC01-PC0322\nthe present case the patient did not have symptoms of pneumonia \nand thus, lipoid pneumonia was detected on autopsy. The \npathophysiology of lipoid pneumonia is not completely understood. \nGraef I has described in his article that oil droplets do not initiate a \ncough reflex because of bland nature of oil. When these oil droplets \nreach the lower airways, they inhibit the mucociliary clearance \nand are deposited in the alveoli and interstitium. Humans lack the \nenzymes to metabolise lipid hence these lipid droplets are engulfed \nby macrophages and stay there, slowly releasing lipid in interstitium \nupon disintegration. Following this a giant cell reaction is initiated \nand on long standing fibrosis of tissue occurs [18]. Fibrosis was \nprobably not seen in the present case as the patient was young \nand may be the duration of exposure to the inciting agent was not \nlong enough.\nAnother incidental finding in the present autopsy was that, the \nauthors reported was peritoneal endometriosis. Endometriosis is \ncommon entity with ovarian endometriosis (46%) being the most \ncommon followed closely by peritoneal endometriosis [19,20]. \nOther uncommon sites include extrapelvic locations like cervix, \nvagina, vulva, intestinal tract, urinary tract, abdominal wall, thoracic \ncage and lungs [21]. Markham SM et al., reported endometriosis \nin their study to be present in every tissue except spleen [22]. It \nprimarily affects women in the reproductive age group. The most \nfrequent symptoms include dysmennorrhoea, chronic pelvic pain \nand infertility. The patient being very young must have yet not \nexperienced any of the symptoms. The utility of peritoneal wash \ncytology for diagnosis of endometriosis has been reported widely \n[23,24]. In most cases, only haemosiderin-laden macrophages are \nidentified though the presence of endometrial cells is more specific \n[24-27]. The endometrial cells have been reported in around 25-\n52% of peritoneal wash samples examined [23,27]. Peritoneal \nfluid contains mesothelial cells that need to be differentiated \nfrom endometrial cells. The distinction of endometrial cells from \nmesothelial cells as given by Stowells SB et al., helps in identifying \nboth types and reach a conclusion [25]. Stowell SB et al., had \ntabulated the differences between mesothelial cells and endometrial \ncells which helped us to differentiate between the two population of \ncells that we saw on the smears from our case [25]. Confirmatory \ndiagnosis for endometriosis is generally made on laparoscopy, but \nsince the present case was an autopsy case, no records could \nbe traced.\nBoth the incidental findings on the autopsy were probably \nasymptomatic because the patient was very young to have \nmanifested the symptoms.\nCONCLUSION(S)\nThe rarity and non specific findings of Lipoid pneumonia makes it a \ncondition that can be misdiagnosed clinically. It leads to pulmonary \nfibrosis and hence, can be a cause of significant morbidity to patients, \nthereby making its early recognition and diagnosis important. \nThe clinicians need to be aware of this entity while assesing the \nradiological findings of delayed, persisting pneumonia and also \ntake note of important exposure history. Early diagnosis will lead to \ntargeted therapy and save the patient from unnecessary antiobiotic \nexposure, whereas peritoneal endometriosis is a much commoner \nentity. The peritoneal wash specimens in females with supporting \nhistory must be examined thoroughly. The attentive examination \nof specimen in the present case report led to diagnosis of lipoid \npneumonia, a rare entity and peritoneal endometriosis, a common \nentity that presents a good learning exercise during evaluating \nautopsy specimens.\nREFERENCES\n Moritz Ar. The medico-legal autopsy. Ann West Med Surg. 1950;4(9):469-72.[1]\n Laughlen GF. Studies on pneumonia following nasopharyngeal injections of oil. [2]\nAm J Pathol. 1925;1(4):407-14.\ninfiltrate in the interstitium was also seen. Occasional plasma cells \nwere also present. However, no fibrosis was found. Based on the \nhistopathological features, possibilty of lipoid pneumonitis was \nsuggested. Since, these were the findings of an autopsy case, no \nfurther investigation or confirmatory tests could be conducted for \nboth of the diagnosis.\nDISCUSSION\n‘Autopsy’ word is derived from ancient Greek word ‘autopsia’ \nwhich means to see for oneself [1]. Hence, the histopathological \nexamination of autopsy specimens contibute greatly to the \nvast knowledge of existing diseases and also to the pool of rare \nconditions. Histopathological examination always presents with \ninteresting and rare conditions for pathologists to study and learn. \nIt, thus, becomes a dynamic and continous source of learning and \nevolving. Lipoid pneumonia is one such rare variant of pneumonia. \nIt was first described by Laughlen GF in the twentieth century in one \nadult, one infant and two children. He reported lipoid pneumonia to \noccur after repeated inhalation of nasopharyngeal oil droplets [2].\nIn 1984, Becton DL et al., reported an interesting case of lipoid \npneumonia in a young girl due to use of lip gloss, earlier all case \nreports had been of older individual above the age of 50 years [3]. \nIn autopsy studies, Baron SE et al., have given its incidence to be \n1.0-2.5% [4]. Lipoid Pneumonia (LP), is described as an uncommon \ndisease caused by deposition of lipid in alveoli and interstitium [5]. It \nis classified as exogenous, endogenous and idiopathic based on the \nmode of lipid deposition. The exogenous type is the most common \nand the idiopathic variant is the rarest, which is also associated with \nsmokers [6].\nVarious case reports have suggested a varied age group, Becton \nDL et al., reporting in a 18-year-old girl to Rana D et al., reporting \nin 53-year-old male [3,7]. The authors report the present case in \na 12-year-old girl. Several authors have cited multiple causes for \ndeposition of lipid as: gas inhalation [8], oil based medications for \nrespiratory diseases [9], aspiration of milk [10], poppy seed oil [11], \negg yolk [12], use of spray paint [13], longstanding use of petroleum \njelly (vaseline, vicks) at bedtime [14], excessive use of lip balm (chap \nStick, a lipstick that contains petrolatums and lipids) and of flavoured \nlip gloss [3]. The clinical symptoms greatly vary according to the type \nof oil and duration of exposure. The symptoms are non specific and \npresent as chronic pneumonitis with chronic cough and progressive \ndysponea. Lipoid pneumonitis may be completely asymptomatic or \ncan present as mild disease [15]. Often the diagnosis is based on \nhistory of any exposure to oil products, but it is either missed or \ndifficult to establish [16]. Radiological findings in LP are too non \nspecific. The most frequent findings are ground-glass opacity or \nconsolidation of the lower lobes as seen in infective community-\nacquired pneumonia. Fibrosis and coalescence of oil droplets \ncan result in nodules and masses with irregular margins, closely \nmimicking lung cancer [16]. In such cases Bronchalveolar Lavage \n(BAL) and biopsy clinches the diagnosis. However, no such foci of \ncarcinoma were seen in the present case. The BAL reveals lipid \nladen macrophages, however presence of extracellular oily droplets \nis more specific for LP . Histopathological features suggestive of LP \nare presence of lipid-laden macrophages that fill and distend the \nalveoli and interstitium, accumulation of lipid material in interstitium, \ninflammatory infiltration as observed in the present case [17].\nFibrosis is another most significant finding seen in many cases [18]. \nHowever, neither fibrosis, nor any foci of carcinoma were observed \nin the present case. The diagnosis can be confirmed on frozen \nsections by using stains specific for lipids, where vacuoles are \nstained in orange with Sudan III, brownish-orange with Sudan IV, and \ndeep red with Oil Red O. Sudan black B stains cholesterol esters \nand triglycerides in dark blue, and some phospholipids in gray [18]. \nIn the present case, any special stain could not be attempted as all \nthe sections were formalin fixed and paraffine embedded. Also, in \n\nwww.njlm.net Zini Chaurasia et al., Lipoid Pneumonia and Peritoneal Endometriosis on Autopsy\nNational Journal of Laboratory Medicine. 2022 Apr, Vol-11(2): PC01-PC03 33\n Becton DL, Lowe JE, Falletta JM. Lipoid pneumonia in an adolescent girl [3]\nsecondary to use of lip gloss. J Pediatr. 1984;105(3):421-23.\n Baron SE, Haramati LB, Rivera VT. Radiological and clinical findings in acute and [4]\nchronic exogenous lipoid pneumonia. J Thorac Imaging. 2003;18(4):217-24.\n Hadda V, Khilnani GC, Bhalla AS, Mathur S. Lipoid pneumonia presenting [5]\nas non resolving community acquired pneumonia: A case report. Cases J. \n2009;16(2):9332.\n Madan K, Walia R, Kumar J, Jain D, Guleria R, Venkatnarayan K. Diesel siphoner’s [6]\nlung: Exogenous lipoid pneumonia following hydrocarbon aspiration. Lung India. \n2014;31(1):63-66.\n Rana D, Kaushik N, Sadhu S, Kalra R, Sen R. Idiopathic Lipoid Pneumonia: An [7]\nincidental finding in autopsy specimen. Autops Case Rep. 2020;10(1):e2020143. \nDoi: 10.4322/acr.2020.143. PMID: 32039070; PMCID: PMC7004259.\n Yampara Guarachi GI, Barbosa Moreira V, Santos Ferreira A, Sias SM, Rodrigues [8]\nCC, Teixeira GH. Lipoid pneumonia in a gas station attendant. Case Rep \nPulmonol. 2014;2014:358761. Doi: 10.1155/2014/358761. Epub 2014 Oct 8. \nPMID: 25374742; PMCID: PMC4206916.\n Pinkerton H. Oils and fats e Their entrance into and fats in the lungs of infants and [9]\nchildren: A clinical and pathologic report. AJDC. 1928;33:259-85.\n Bromer RS, Wolman IJ. Lipoid pneumonia in infants and children. Radiology. [10]\n1939;32(1):01-07.\n Gondouin A, Manzoni PH, Ranfaing E, Brun J, Cadranel J, Sadoun D, et al. [11]\nExogenous lipid pneumonia: A retrospective multicentre study of 44 cases in \nFrance. Eur Respir J. 1996;9:1463-69.\n Bandla HP , Davis SH, Hopkins NE. Lipoid pneumonia: A silent complication of [12]\nmineral oil aspiration. Pediatrics. 1999;103(2):E19.\n Libuse HM, Rohatgi PK. Diffuse cholesterol granulomatous pneumonitis in a [13]\npatient exposed to spray paints. Chest. 2000;118(4):p. 303S.\n Brown AC, Slocum PC, Putthoff SL, Wallace WE, Foresman BH. [14]\nExogenous lipoid pneumonia due to nasal application of petroleum jelly. \nChest.1994;106;1311-12.\n Betancourt SL, Martinez-Jimenez S, Rossi SE, Truong MT, Carrillo J, Erasmus [15]\nJJ. Lipoid pneumonia: Spectrum of clinical and radiologic manifestations. AJR \nAm J Roentgenol. 2010;194:103-09.\n Franquet T, Gime ´nez A, Bordes R, Rodriguez-Arias JM, Castella J. The crazy-[16]\npaving pattern in exogenous lipoid pneumonia: CT-pathologic correlation. AJR. \n1998;170:315-17.\n Rossi SE, Erasmus JJ, Volpacchio M, Franquet T, Castiglioni T, MacAdams HP . [17]\n“Crazy-paving” pattern at thin-section CT of the lungs: Radiologic-pathologic \noverview. Radiographics. 2003;23:1509-19.\n Graef I. Pulmonary changes due to aspirations of lipids and mineral oil. Am J [18]\nPathol. 1935;11:862-63.\n Arava S, Iyer VK, Mathur SR. Cytological diagnosis of peritoneal endometriosis. [19]\nJ Cytol. 2010;27(2):77-78.\n Saavalainen L, Tikka T, But A, Gissler M, Haukka J, Tiitinen A, et al. Trends [20]\nin the incidence rate, type and treatment of surgically verified endometriosis- \nA nationwide cohort study. Acta Obstet Gynecol Scand. 2018;97(1):59-67.\n Murphy AA. Clinical aspects of endometriosis. Ann N Y Acad Sci. 2002;955:1-[21]\n10; discussion 34-6, 396-406.\n Markham SM, Carpenter SE, Rock JA. Extrapelvic endometriosis. In Obstetrics [22]\nand Gynecology Clinics of North America. 1989;193-219.\n Potuono JA, Herran C, Echanojauregui AD, Riego AG. Peritoneal flushing and [23]\nbiopsy in laparoscopically diagnosed endometriosis. Fertil Steril. 1982;38:538-41.\n Zuna RE, Mitchell ML. Cytologic findings in peritoneal washings associated with [24]\nbenign gynecologic disease. Acta Cytol. 1988;32:139-47.\n Stowell SB, Wiley CM, Perez-reyes N, Powers CN. Cytologic diagnosis of [25]\nperitoneal fluids. Applicability to the laparoscopic diagnosis of endometriosis. \nActa Cytol. 1997;41:817-22.\n Gaulier A, Jouret-mourin A, Marsan C. Peritoneal Endometriosis: Report of a case [26]\nwith cytologic, cytochemical and histopathologic study. Acta Cytol. 1983;27:446-49.\n Selvaggi SM. Diagnostic pitfalls of peritoneal washing cytology and the role of cell [27]\nblocks in their diagnosis. Diagn Cytopathol. 2003;28:335-41.\nPartiCularS OF COntriButOrS:\n1. Senior Resident, Department of Pathology, Dr. Baba Saheb Ambedkar Medical College and Hospital, Delhi, India.\n2. Head, Department of Pathology, Dr. Baba Saheb Ambedkar Medical College and Hospital, Delhi, India.\n3. Medical Officer, Department of Pathology, Dr. Baba Saheb Ambedkar Medical College and Hospital, Delhi, India.\nPlaGiariSM CheCKinG MethODS:  [Jain H et al.]\n•  Plagiarism X-checker: Dec 20, 2021\n•  Manual Googling: Jan 29, 2022\n•  iThenticate Software: Feb 11, 2022 (17%)\netyMOlOGy:  Author OriginnaMe, aDDreSS, e-Mail iD OF the COrreSPOnDinG authOr:\nDr. Zini Chaurasia,\nSenior Resident, Department of Pathology, Dr. Baba Saheb Ambedkar Hospital, \nRohini, Delhi, India.\nE-mail: 1989.zini@gmail.com\nDate of Submission: Oct 28, 2021\nDate of Peer Review: Dec 26, 2021 \nDate of Acceptance: Jan 29, 2022\nDate of Publishing: apr 01, 2022\nauthOr DeClaratiOn:\n•  Financial or Other Competing Interests:  None\n•  Was informed consent obtained from the subjects involved in the study?  Yes\n•  For any images presented appropriate consent has been obtained from the subjects.  NA","source_license":"CC0","license_restricted":false}