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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor={{Ochuko}}
|QuestionAuthor={{Ochuko}} (Edited by Yazan Daaboul)
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Pathology
|MainCategory=Pathology
Line 21: Line 21:
|MainCategory=Pathology
|MainCategory=Pathology
|SubCategory=Pulmonology
|SubCategory=Pulmonology
|Prompt=A 5-year-old boy with a history significant for chronic constipation is found to have a right upper lobe focal infiltrate on a chest radiograph obtained during evaluation for developmental delay and tonic-clonic seizures. The parents report daily ingestion of mineral oil laxatives to relieve his constipation, and explain that he had recently been complaining of occasional episodes of coughing and choking during intake of food. At presentation, he is completely asmyptomatic. His vital signs and physical examination are unremarkable. The pediatrician advises to stop the ingestion of mineral oil and to give oral antibiotics for 10 days. At follow-up examination, the patient continues to cough. Persistence of the infiltrate is noted on chest xray. Diagnostic bronchoscopy with bronchoalveolar lavage (BAL) is scheduled to identify the etiology of the patient's symptoms. What is the most likely BAL finding associated with this patient's condition?
|Prompt=A 5-year-old boy with a history significant for chronic constipation is found to have a focal infiltrate in the right upper lobe on a chest radiograph obtained during evaluation for developmental delay and tonic-clonic seizures. The parents report daily ingestion of mineral oil laxatives to relieve his constipation, and explain that he had recently also been complaining of occasional episodes of coughing and choking during intake of food. At presentation, he is completely asmyptomatic. His vital signs and physical examination are unremarkable. The pediatrician advises to stop the ingestion of mineral oil and to give oral antibiotics for 10 days. At follow-up examination, the patient continues to cough. Persistence of the infiltrate is noted on chest xray. Diagnostic bronchoscopy with bronchoalveolar lavage (BAL) is scheduled to identify the etiology of the patient's symptoms. What is the most likely BAL finding associated with this patient's condition?
|Explanation=Lipid-Laden Macrophages in Bronchial Lavage are clinically associated with tracheal aspiration in children with gastro-esophageal reflux (GER) or lobular consolidation distal to an obstructed bronchus. They are commonly seen whenever there is aspiration of mineral oil. The hypothesis is that the amount of lipids in alveolar macrophages, quantitated as the lipid-laden index (LLI), would correlate with lung inflammation in pediatric patients.
|Explanation=The patient in this vignette is most likely diagnosed with silent aspiration pneumonia. Silent aspiration is an important cause of chronic pneumonias in children, as demonstrated in this patient who has focal infiltrated in the right upper lobe. The patient has many risk factors for aspiration pneumonia, such as history of seizures, and history of frequent mineral oil laxative ingestion. Mineral oil is a viscous oil that depresses cough reflex and consequently facilitates the development of aspiration pneumonia due to deposition of oil in the alveoli. Chronic pulmonary inflammation eventually leads to exogenous lipoid pneumonia (ELP).
 
Generally, aspiration pneumonia is characterized by the presence of high lipid content within alveolar macrophages. Most cases of aspiration pneumonia result from the ascending of gastric content that include lipid components. When alveolar macrophages ingest gastric lipids, they are called lipid-laden macrophages in BAL.
 
Lipid-Laden Macrophages are clinically associated with tracheal aspiration in children with gastro-esophageal reflux (GER) or lobular consolidation distal to an obstructed bronchus.  
|AnswerA=Creola Bodies
|AnswerA=Creola Bodies
|AnswerAExp=Creola bodies (CrBs) are clusters of columnar ciliated hyperplastic cells often observed in sputum of patients with bronchial asthma. They are suggestive of bronchial injury.
|AnswerAExp=Creola bodies (CrBs) are clusters of columnar ciliated hyperplastic cells often observed in sputum of patients with bronchial asthma. They are suggestive of bronchial injury.
|AnswerB=Reserve cell hyperplasia
|AnswerB=Reserve cell hyperplasia
|AnswerBExp=These are tight clusters of uniform small cells with hyperchromatic nuclei, they are the earliest changes seen in squamous metaplasia and are commonly found in cigarette and marijuana smokers.
|AnswerBExp=Reserve cell hyperplasia are small uniform cells observed in bronchial wash. It is frequently included in the cytopathological differential diagnosis of small cell undifferentiated carcinoma. They are not typically observed in patients with aspiration pneumonia.
|AnswerC=Hemosiderin-Laden Macrophages
|AnswerC=Hemosiderin-laden macrophages
|AnswerCExp=The presence of hemosiderin-laden alveolar macrophages in bronchoalveolar lavage fluid is a useful tool for diagnosing diffuse lung bleeding. However, many diffuse interstitial pulmonary diseases also reveal evidence of these cells in aspirates.
|AnswerCExp=Hemosiderin-laden macrophages in BAL may be helpful in the diagnosis of diffuse pulmonary hemorrhage syndromes and diffuse interstitial pulmonary diseases (DIPD).
|AnswerD=Lipid-Laden Macrophages
|AnswerD=Lipid-laden macrophages
|AnswerDExp=They are commonly seen whenever there is aspiration of mineral oil. Lipid-Laden Macrophages in bronchial lavage are clinically associated with tracheal aspiration in children with gastro-esophageal reflux (GER) or lobular consolidation distal to an obstructed bronchus.
|AnswerDExp=Lipid-laden macrophages, defined as an increased lipid content in alveolar macrophages, may be seen in BAL in patients with recurrent pulmonary aspiration in cases of gastroesophageal reflux.
|AnswerE=Ferruginous Bodies
|AnswerE=Ferruginous Bodies
|AnswerEExp=Ferruginous Bodies (also called Asbestos bodies) are clear central fibers within a golden brown iron-protein complex. They are indicative of occupational asbestos exposure.
|AnswerEExp=Ferruginous bodies are one type of asbestos bodies that are characterized by clear central fibers surrounded by a golden brown iron-protein complex. They are associated with occupational asbestos exposure.
|References=Bandla HP, Davis SH, Hopkins NE. Lipoid pneumonia: a silent complication of mineral oil aspiration. ''Pediatrics''. 1999;103(2):E19
 
Naryshkin S, Young NA. Respiratory cytology: A review of non-neoplastic mimics of malignancy. ''Diagn Cytopathol''. 1992;9(1):89-97
 
Perez-Arellano JL, Losa Garcia JE, Garcia Macias MC, et al. Hemosiderin-laden macrophages in bronchoalveolar lavage fluid. ''Acta Cytol''. 1992;36(1):26-30.
 
|RightAnswer=D
|RightAnswer=D
|WBRKeyword=lipoid, pneumonia, aspiration, exogenous, bronchoalveolar, lavage, BAL, pediatrics, developmental, delay, seizure, macrophage, macrophages, lipid, laden, lipid-laden, alveolar
|Approved=Yes
|Approved=Yes
}}
}}

Revision as of 15:19, 30 July 2014
Author [[PageAuthor::Ogheneochuko Ajari, MB.BS, MS [1] (Edited by Yazan Daaboul)]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Pathology
Sub Category SubCategory::Pulmonology
Prompt [[Prompt::A 5-year-old boy with a history significant for chronic constipation is found to have a focal infiltrate in the right upper lobe on a chest radiograph obtained during evaluation for developmental delay and tonic-clonic seizures. The parents report daily ingestion of mineral oil laxatives to relieve his constipation, and explain that he had recently also been complaining of occasional episodes of coughing and choking during intake of food. At presentation, he is completely asmyptomatic. His vital signs and physical examination are unremarkable. The pediatrician advises to stop the ingestion of mineral oil and to give oral antibiotics for 10 days. At follow-up examination, the patient continues to cough. Persistence of the infiltrate is noted on chest xray. Diagnostic bronchoscopy with bronchoalveolar lavage (BAL) is scheduled to identify the etiology of the patient's symptoms. What is the most likely BAL finding associated with this patient's condition?]]
Answer A AnswerA::Creola Bodies
Answer A Explanation AnswerAExp::Creola bodies (CrBs) are clusters of columnar ciliated hyperplastic cells often observed in sputum of patients with bronchial asthma. They are suggestive of bronchial injury.
Answer B AnswerB::Reserve cell hyperplasia
Answer B Explanation [[AnswerBExp::Reserve cell hyperplasia are small uniform cells observed in bronchial wash. It is frequently included in the cytopathological differential diagnosis of small cell undifferentiated carcinoma. They are not typically observed in patients with aspiration pneumonia.]]
Answer C AnswerC::Hemosiderin-laden macrophages
Answer C Explanation AnswerCExp::Hemosiderin-laden macrophages in BAL may be helpful in the diagnosis of diffuse pulmonary hemorrhage syndromes and diffuse interstitial pulmonary diseases (DIPD).
Answer D AnswerD::Lipid-laden macrophages
Answer D Explanation AnswerDExp::Lipid-laden macrophages, defined as an increased lipid content in alveolar macrophages, may be seen in BAL in patients with recurrent pulmonary aspiration in cases of gastroesophageal reflux.
Answer E AnswerE::Ferruginous Bodies
Answer E Explanation AnswerEExp::Ferruginous bodies are one type of asbestos bodies that are characterized by clear central fibers surrounded by a golden brown iron-protein complex. They are associated with occupational asbestos exposure.
Right Answer RightAnswer::D
Explanation [[Explanation::The patient in this vignette is most likely diagnosed with silent aspiration pneumonia. Silent aspiration is an important cause of chronic pneumonias in children, as demonstrated in this patient who has focal infiltrated in the right upper lobe. The patient has many risk factors for aspiration pneumonia, such as history of seizures, and history of frequent mineral oil laxative ingestion. Mineral oil is a viscous oil that depresses cough reflex and consequently facilitates the development of aspiration pneumonia due to deposition of oil in the alveoli. Chronic pulmonary inflammation eventually leads to exogenous lipoid pneumonia (ELP).

Generally, aspiration pneumonia is characterized by the presence of high lipid content within alveolar macrophages. Most cases of aspiration pneumonia result from the ascending of gastric content that include lipid components. When alveolar macrophages ingest gastric lipids, they are called lipid-laden macrophages in BAL.

Lipid-Laden Macrophages are clinically associated with tracheal aspiration in children with gastro-esophageal reflux (GER) or lobular consolidation distal to an obstructed bronchus.
Educational Objective:
References: Bandla HP, Davis SH, Hopkins NE. Lipoid pneumonia: a silent complication of mineral oil aspiration. Pediatrics. 1999;103(2):E19

Naryshkin S, Young NA. Respiratory cytology: A review of non-neoplastic mimics of malignancy. Diagn Cytopathol. 1992;9(1):89-97

Perez-Arellano JL, Losa Garcia JE, Garcia Macias MC, et al. Hemosiderin-laden macrophages in bronchoalveolar lavage fluid. Acta Cytol. 1992;36(1):26-30.]]

Approved Approved::Yes
Keyword WBRKeyword::lipoid, WBRKeyword::pneumonia, WBRKeyword::aspiration, WBRKeyword::exogenous, WBRKeyword::bronchoalveolar, WBRKeyword::lavage, WBRKeyword::BAL, WBRKeyword::pediatrics, WBRKeyword::developmental, WBRKeyword::delay, WBRKeyword::seizure, WBRKeyword::macrophage, WBRKeyword::macrophages, WBRKeyword::lipid, WBRKeyword::laden, WBRKeyword::lipid-laden, WBRKeyword::alveolar
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