Severe fire-eater’s lung: full recovery is possible with time


The devastating toxic pneumonitis caused by aspiration of  ‘fire eating’ fuel can be overcome with time, and complete lung regeneration may be achieved with early antibiotic treatment to prevent superinfection, respiratory specialists in Italy report.

A multidisciplinary team of clinicians has detailed a case of severe fire eater’s lung (FEL) in a young man who developed potentially fatal complications, but who subsequently made a complete recovery, showing that a young lung has the ability to regenerate despite extensive damage.

Outlining the case in a paper published in Thorax, the Italian authors describe the presentation of a 19-year-old male to an emergency room following accidental aspiration of pyrofluid, which contains high-boiling aliphatic/paraffin aromatic free hydrocarbons.

Initial symptoms were feeling sick, shortness of breath and a mild drug cough, followed by vomiting, burning chest pain and dyspnoea. At this point, oxygen saturation (SpO2) on ambient air was 92%, and examination revealed tachypnoea, tachycardia, normal temperature and the presence of breath sounds without additional pathological sounds. There were no oral lesions, and lab tests showed a neutrophilic leukocytosis without increased C reactive protein (CRP) levels.

Arterial blood gases on room air revealed PaO2 8.9 kPa, PaCO2 5.5 kPa, pH 7.30, HCO3- 20 mmol/L, Lac 3.8 mmol/L, and PaO2/inspired oxygen fraction (FiO2) 42.4 kPa. A chest X-ray showed mild accentuation of the broncho-vascular structure with a consolidation in the left basal area, and high-resolution chest CT (HRCT) revealed bilateral parenchymal consolidation and a complete occlusion of the lower lobar bronchus bilaterally, and fluid-dense effusion was seen in the right basal area. Blood cultures and sputum tests were negative, but treatment with the broad-spectrum antibiotic therapy piperacillin/tazobactam was initiated alongside systemic steroids, analgesics and oxygen therapy.

On day 2, there was a worsening of arterial blood gases and so cycles of high flow nasal cannula and non-invasive ventilation (NIV) were given, with bronchodilators, teicoplanin and fluconazole added to the treatment regimen, resulting in clinical stability over the achieved following days.

The patient was transferred to a pulmonology ward on the eight day, with chest pain and dyspnoea, and SpO2 of 97% while receiving FiO2 0.6. On examination there was a reduction of breath sounds and diffuse crackles were also heard.

On day 10 the patient developed a fever and continued to experience dry cough and dyspnoea. At this stage, blood tests showed neutrophilic leukocytosis and elevated CRP, while nasal swabs were positive for methicillin-resistant Staph aureus, blood cultures were positive for Staph haemolyticus and a sputum sample tested positive for Aspergillus galactomannan. This prompted prescription of a targeted therapy with linezolid and broad spectrum antibiotic treatment with piperacillin/tazobactam and isavuconazole, the authors said.

HRCT showed reduced parenchymal consolidation of the right lower lobe, but persistent left lower lobe consolidation with multiple cavitation. “Similar findings were observed in the middle lobe and in the lingula, together with small pseudonodular thickenings in the subpleural area and fibrotic striae at the bases,” noted Speciality Respiratory Fellow Dr Maria Luisa Nicolardi.

While arterial blood gases, dyspnoea and chest pain progressively improved over the next few says, with the patient also showing normal cell count and a reduction in CRP level, dry cough persisted and diffuse crackles were unchanged. However, there was a sudden deterioration in clinical status on day 23, the patient having developed a temperature of 39.5°C with productive cough containing dark and bloody sputum.

Subsequent tests were positive for Enterobacter cloacae, Stenotrophomonas maltophilia, Serratia marcescens and Aspergillus spp. Blood cultures were negative, but lab tests revealed leucopenia and a mild increase in CRP level, the authors said. This spurred a switch to antibiotic therapy with meropenem, ciprofloxacin and vancomycin, while isavuconazole was continued. A chest CT revealed “moderate reduction of the consolidations of the middle lobe and left lower lobe, with persistence of the lipoid content and partial reduction of pneumatoceles”, and bilateral pneumothorax was also observed.

On day 25, the patient experienced severe acute chest pain, worsened by breathing and cough, with desaturation (SpO2 92%, on FiO2 0.28), tachypnoea and tachycardia. There was a reduction of breath sounds in the right hemithorax, and chest X-ray showed an extensive, right side pneumothorax. After insertion of a chest drain, the pneumothorax was completely resolved after one week.

Recovery

At one month, the patient’s clinical condition began to gradually improve, with a decrease in productive cough and dyspnoea and resolution of chest pain one month after admission. Inflammatory markers and microbiological tests were negative, and a new HRCT showed further reduction of the two consolidations of the middle lobe and left lower lobe. At this stage, antibiotics and oxygen therapy were stopped, and the patient was discharged after 40 days.

The patient was no longer exhibiting symptoms three months after he aspired Pyrofluid, his oxygen saturation level was 100% on room air, and breath sounds were normal. Also, an HRCT showed: “an almost complete resolution of middle lobe and left lower lobe consolidations and no pneumatoceles; new onset of fibrocicatricial striae of connection with the pleura and some small traction bronchiectasis; absence of pneumothorax, pleural and pericardial effusion and lymphadenopathy” and spirometry readings were within the normal range, the authors said.

In the absence of consensus guidelines outlining optimal treatment of fire eater’s lung, especially for more severe cases, the clinicians who treated this case suggest considering early antibiotic therapy, particularly as FEL’s clinical, laboratory and radiologic profile can overlap with that of bacterial pneumonia. Also, as has previously been reported, systemic corticosteroids can be used in severe cases to limit the inflammatory response and fibrosis, and while surgical resection is usually unwarranted, it can be useful for managing FEL’s complications, they noted.

Crucially, the authors emphasised that the severe form of fire eater’s lung can have a good prognosis if superinfection can be prevented, and that the condition usually has a “favourable resolution” with patients recovering fully anywhere between a few weeks and 3 months.

“Finally, our observation demonstrates that in severe FEL a long-term follow-up is necessary, because several complications may occur particularly within the first month of the disease. Also, we strongly encourage a conservative attitude, as the lung can show a complete regeneration even if the initial damage is extensive,” they concluded.

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