Paraffin Oil Pneumonitis During Pregnancy: A Case Report

Article Information

Moles Athanasios1, Fotopoulos Stavros1, Cheirakis Emmanouil1, Koronaios Vasilios1, Kalousis Evangelos3, Lintzeri Dimitra3, Lazarescu Daria2, Grigorakos Leonidas2,3*

1REA Maternity Hospital, Athens, Greece

2.Faculty of Nursing, National and Kapodistrian University of Athens, Greece

3Intensive Care, “KAT” Trauma Hospital of Athens, Kifissia, Athens, Greece

*Corresponding Author: Leonidas Grigorakos Assoc. Prof., 2 Nikis St, 14561, Kifissia, Athens, Greece

Received: 03 April 2018; Accepted: 09 April 2018; Published: 12 April 2018

Citation:

Moles Athanasios, Fotopoulos Stavros, Cheirakis Emmanouil, Koronaios Vasilios, Kalousis Evangelos, Lintzeri Dimitra, Lazarescu Daria, Grigorakos Leonidas. Paraffin Oil Pneumonitis During Pregnancy: A Case Report. Obstetrics and Gynecology Research 1 (2018): 032-037.

View / Download Pdf Share at Facebook

Abstract

Acute respiratory distress syndrome (ARDS) is a rare occurrence in pregnant patients and, when it occurs, it usually raises diagnostic dilemmas as it is attributed to many causes. We present the case of a 32-year-old G1P0 woman at 31 weeks of gestation who was hospitalized because of bleeding per vagina and symptoms of gastroesophageal reflux disease (GERD) with episodes of vomiting. Within 72 hours from her admission, she developed dyspnea, cough and hypoxemia and was transferred to our intensive care unit (ICU). She was diagnosed with paraffin oil pneumonitis, treated accordingly and discharged in good health. We highlight medical personnel should keep high suspicion for paraffin oil pneumonitis in pregnant patients with features of GERD who develop ARDS after treatment with liquid paraffin.

Keywords

Paraffin oil; Pneumonitis; Acute Respiratory Distress Syndrome; Pregnancy

Paraffin oil articles Paraffin oil Research articles Paraffin oil review articles Paraffin oil PubMed articles Paraffin oil PubMed Central articles Paraffin oil 2023 articles Paraffin oil 2024 articles Paraffin oil Scopus articles Paraffin oil impact factor journals Paraffin oil Scopus journals Paraffin oil PubMed journals Paraffin oil medical journals Paraffin oil free journals Paraffin oil best journals Paraffin oil top journals Paraffin oil free medical journals Paraffin oil famous journals Paraffin oil Google Scholar indexed journals Pneumonitis articles Pneumonitis Research articles Pneumonitis review articles Pneumonitis PubMed articles Pneumonitis PubMed Central articles Pneumonitis 2023 articles Pneumonitis 2024 articles Pneumonitis Scopus articles Pneumonitis impact factor journals Pneumonitis Scopus journals Pneumonitis PubMed journals Pneumonitis medical journals Pneumonitis free journals Pneumonitis best journals Pneumonitis top journals Pneumonitis free medical journals Pneumonitis famous journals Pneumonitis Google Scholar indexed journals Acute Respiratory Distress Syndrome articles Acute Respiratory Distress Syndrome Research articles Acute Respiratory Distress Syndrome review articles Acute Respiratory Distress Syndrome PubMed articles Acute Respiratory Distress Syndrome PubMed Central articles Acute Respiratory Distress Syndrome 2023 articles Acute Respiratory Distress Syndrome 2024 articles Acute Respiratory Distress Syndrome Scopus articles Acute Respiratory Distress Syndrome impact factor journals Acute Respiratory Distress Syndrome Scopus journals Acute Respiratory Distress Syndrome PubMed journals Acute Respiratory Distress Syndrome medical journals Acute Respiratory Distress Syndrome free journals Acute Respiratory Distress Syndrome best journals Acute Respiratory Distress Syndrome top journals Acute Respiratory Distress Syndrome free medical journals Acute Respiratory Distress Syndrome famous journals Acute Respiratory Distress Syndrome Google Scholar indexed journals Pregnancy articles Pregnancy Research articles Pregnancy review articles Pregnancy PubMed articles Pregnancy PubMed Central articles Pregnancy 2023 articles Pregnancy 2024 articles Pregnancy Scopus articles Pregnancy impact factor journals Pregnancy Scopus journals Pregnancy PubMed journals Pregnancy medical journals Pregnancy free journals Pregnancy best journals Pregnancy top journals Pregnancy free medical journals Pregnancy famous journals Pregnancy Google Scholar indexed journals Gastroesophageal Reflux Disease articles Gastroesophageal Reflux Disease Research articles Gastroesophageal Reflux Disease review articles Gastroesophageal Reflux Disease PubMed articles Gastroesophageal Reflux Disease PubMed Central articles Gastroesophageal Reflux Disease 2023 articles Gastroesophageal Reflux Disease 2024 articles Gastroesophageal Reflux Disease Scopus articles Gastroesophageal Reflux Disease impact factor journals Gastroesophageal Reflux Disease Scopus journals Gastroesophageal Reflux Disease PubMed journals Gastroesophageal Reflux Disease medical journals Gastroesophageal Reflux Disease free journals Gastroesophageal Reflux Disease best journals Gastroesophageal Reflux Disease top journals Gastroesophageal Reflux Disease free medical journals Gastroesophageal Reflux Disease famous journals Gastroesophageal Reflux Disease Google Scholar indexed journals C-Reactive Protein articles C-Reactive Protein Research articles C-Reactive Protein review articles C-Reactive Protein PubMed articles C-Reactive Protein PubMed Central articles C-Reactive Protein 2023 articles C-Reactive Protein 2024 articles C-Reactive Protein Scopus articles C-Reactive Protein impact factor journals C-Reactive Protein Scopus journals C-Reactive Protein PubMed journals C-Reactive Protein medical journals C-Reactive Protein free journals C-Reactive Protein best journals C-Reactive Protein top journals C-Reactive Protein free medical journals C-Reactive Protein famous journals C-Reactive Protein Google Scholar indexed journals White Blood Cell articles White Blood Cell Research articles White Blood Cell review articles White Blood Cell PubMed articles White Blood Cell PubMed Central articles White Blood Cell 2023 articles White Blood Cell 2024 articles White Blood Cell Scopus articles White Blood Cell impact factor journals White Blood Cell Scopus journals White Blood Cell PubMed journals White Blood Cell medical journals White Blood Cell free journals White Blood Cell best journals White Blood Cell top journals White Blood Cell free medical journals White Blood Cell famous journals White Blood Cell Google Scholar indexed journals High Flow Nasal Oxygen articles High Flow Nasal Oxygen Research articles High Flow Nasal Oxygen review articles High Flow Nasal Oxygen PubMed articles High Flow Nasal Oxygen PubMed Central articles High Flow Nasal Oxygen 2023 articles High Flow Nasal Oxygen 2024 articles High Flow Nasal Oxygen Scopus articles High Flow Nasal Oxygen impact factor journals High Flow Nasal Oxygen Scopus journals High Flow Nasal Oxygen PubMed journals High Flow Nasal Oxygen medical journals High Flow Nasal Oxygen free journals High Flow Nasal Oxygen best journals High Flow Nasal Oxygen top journals High Flow Nasal Oxygen free medical journals High Flow Nasal Oxygen famous journals High Flow Nasal Oxygen Google Scholar indexed journals Pregnant women articles Pregnant women Research articles Pregnant women review articles Pregnant women PubMed articles Pregnant women PubMed Central articles Pregnant women 2023 articles Pregnant women 2024 articles Pregnant women Scopus articles Pregnant women impact factor journals Pregnant women Scopus journals Pregnant women PubMed journals Pregnant women medical journals Pregnant women free journals Pregnant women best journals Pregnant women top journals Pregnant women free medical journals Pregnant women famous journals Pregnant women Google Scholar indexed journals Acute Lung Injury articles Acute Lung Injury Research articles Acute Lung Injury review articles Acute Lung Injury PubMed articles Acute Lung Injury PubMed Central articles Acute Lung Injury 2023 articles Acute Lung Injury 2024 articles Acute Lung Injury Scopus articles Acute Lung Injury impact factor journals Acute Lung Injury Scopus journals Acute Lung Injury PubMed journals Acute Lung Injury medical journals Acute Lung Injury free journals Acute Lung Injury best journals Acute Lung Injury top journals Acute Lung Injury free medical journals Acute Lung Injury famous journals Acute Lung Injury Google Scholar indexed journals

Article Details

Abbreviations

GERD = Gastroesophageal Reflux Disease
ARDS = Acute Respiratory Distress Syndrome
DVT = Deep Venous Thrombosis
TEE = Transthoracic Echocardiography
WBC = White Blood Cell
CRP = C-Reactive Protein
HFNO = High Flow Nasal Oxygen
G1P0 = Pregnant for the first time and has not yet delivered
ALI = Acute Lung Injury

1. Introduction

Acute respiratory distress syndrome (ARDS) rarely occurs in the pregnant patients with an estimated incidence of 16-70:100.000 cases [1]. Pregnancy-related ARDS is attributed to many causes and many times poses a diagnostic dilemma. Acute respiratory failure during pregnancy or the peripartum period may be caused by conventional respiratory insult or a pregnancy-specific disorder. The usual differential diagnosis includes pulmonary edema (tocolytics, cardiogenic, preeclampsia-eclampsia), pneumonia, asthma exacerbation, aspiration, pulmonary embolism, amniotic fluid embolism, air embolism, transfusion reactions, pyelonephritis, chorioamnionitis [2].

Routine use of stimulant laxatives is not recommended in pregnancy as there is a risk of lipoid pneumonia occurrence caused by the aspiration of liquid paraffin and mineral/castor oil [3]. The most commonly affected patients are those at the extremes of age who have risk factors for aspiration. The result is either an inflammatory response with regional edema and intralveolar hemorrhage (presenting acutely with cough, fever, and dyspnea) or a ‘paraffinoma’ with aspirated oils encapsulated in the fibrous tissue (presenting with a mass seen on imaging in an asymptomatic patient) [3].

In this case report, we highlight the difficulty of differentiated diagnosis of acute respiratory failure in pregnancy and the role of paraffin oil administration as a cause of pneumonitis.

2. Case Presentation

A 32-year-old G1P0 woman at 31 gestational weeks was hospitalized because of bleeding per vagina and frequent uterine contractions. The patient had 1-2 episodes of vomiting/day for the last 3 days. She also reported frequent heartburn.

Vital signs were normal and the physical examination was unremarkable. She did not report abdominal pain, dyspnea, cough, headache, visual disturbances or chest pain.

Her past medical history was significant for gastroesophageal reflux disease (GERD). Upon admission she did not have ruptured membranes. She was treated with oral nifedipine 20 mg tid, oral progesterone 100 mg tid, oral roxithromycin 300 mg once daily, paraffin oil 20 ml bid, and with betamethasone sodium phosphate intramuscularly.
Laboratory tests upon admission showed a white blood cell (WBC) count of 12,170/?l and a differential showing 78% neutrophils. C-reactive protein (CRP) was 0.6 mg/dl (normal limits 0.0-0.8 mg/dl).

On the third day of hospitalization, the patient developed cough and shortness of breath. On physical examination she was dyspneic. Vital signs revealed hypoxia 80% on room air, tachypnea with a respiratory rate of 34, a temperature of 36.70 C, a heart rate of 125 beats per minute (bpm), and blood pressure of 110/60 mm Hg. Her physical exam revealed fine crackles at both lung bases. Heart sounds were normal without murmurs and clicks. The patient was in distress and diaphoretic. There was no facial or hand edema nor tenderness and swelling of the lower extremity. At that time, a chest X-ray showed bilateral infiltrates without bronchograms located in both lower lobes (Figure 1). The electrocardiogram was normal.

fortune-biomass-feedstock

Figure 1: Chest x-ray demonstrating bilateral infiltrates without bronchograms located in both lower lobes

The patient was admitted to the ICU. Broad-spectrum antibiotics, intravenous corticosteroids, and high flow nasal oxygen (HFNO) were administered. Arterial blood gas sampling after initiation of HFNO (air 40l/min, FiO2: 0.35) showed a pH 7.50, PaCO2 28 mmHg, and PaO2 73 mmHg (PaO2/FiO2=208). The patient was treated with intravenous furosemide without an improvement of her symptoms.

Once arrived in the ICU she was submitted to laboratory tests, which were repeated until release (Table 1).

Laboratory parameters

Day 1

Day 2

Day 5

WBC

19,790/?l

14,440/ l

10,000/?l

CRP (mg/dl)

0.01

13.73

2.8

Platelet count

198,000/ml

213,000/ml

235,000/ml

Table 1: Laboratory parameters during ICU stay

Liver and renal function tests, including prothrombin time, troponin I, and serum albumin level, were within normal limits. There was no proteinuria. A venous duplex Doppler sonography excluded deep venous thrombosis (DVT) while the transthoracic echocardiography (TEE) was normal.

The second day in the ICU the patient was still dyspneic, she had a dry cough, was on HFNO, had a temperature of 37.90C, no uterine contractions, normal diuresis, and fine crackles at both lung bases. Her abdomen was soft with normal bowel sounds.

Blood and urine cultures were negative. PCR for influenza was negative. The fetal heart rate was within 130 - 140 bpm rate. Amniocentesis performed that day did not reveal any organisms on Gram stain and culture was negative.
The patient was disconnected from the HFNO on the fourth day when she felt much better. She was afebrile, receiving oxygen with nasal canula on 1lt/min(pH 7.44, PaCO2 32 mmHg, and PaO2 92 mmHg), still had fine crackles at both lung bases but with improvement.

After five days in the ICU the patient was transferred to the ward. She was hospitalized two more days and then she was discharged home. At the time she was discharged she did not have any dyspnea or cough and the lungs were clear to auscultation.

3. Discussion

Respiratory distress in pregnancy is an acute emergency and necessitates rapid assessment and therapy. Approximately 50% of the cases of pulmonary edema in pregnancy were attributed to tocolytic therapy or cardiac disease. The remaining cases were ascribed to either preeclampsia or iatrogenic volume overload [5]. Our patient received tocolytic therapy with oral nifedipine. Previous studies reveal acute pulmonary failure during tocolysis mainly with beta agonists and intravenous nicardipine [6].

Our patient did not respond to therapy with furosemide and the lung injury persisted for five days. She did not have known cardiac disease and the TEE was normal. There was no elevation in blood pressure and no proteinuria. At the time of acute lung injury (ALI) she was not receiving intravenous fluids, so volume overload was ruled out. She did not have symptoms of infection prior to the development of acute respiratory failure. She was afebrile and the CRP at the time of ALI was normal making the diagnosis of pneumonia unlikely [7].

Intra-amniotic infection was unlikely because the results of amniocentesis were normal and so was the fetal heart rate, while there was no history of asthma and no wheezes. Pulmonary embolism was taken into consideration but a venous duplex Doppler sonography excluded DVT since there was no right ventricle strain, there was no pleuritic pain or hemoptysis [8].

More so, amniotic fluid embolism was unlikely because of lack of cardiovascular collapse, seizers or disseminated intravascular coagulation, risk factors such as labor, multiparity, amniotomy, uterine manipulations, trauma [9]. Air embolism was also excluded because there were no intravenous manipulations [10,11].

Aspiration of gastric contents is most common during labor or soon after delivery. This is probably because the effects of sedation, analgesia, increased intraabdominal pressure, and recumbency are added to pre-existing factors that predispose pregnant women to aspiration. Aspiration may induce chemical pneumonitis, airway obstruction, or acute bronchospasm. Features of chemical pneumonitis include an abrupt onset of symptoms and signs, a cough productive of material that resembles gastric contents, diffuse crackles, and chest X-ray infiltrates that are multifocal and predominate in the dependent portions of the lung. In addition, fever is moderate [12].  Lipoid pneumonia is caused by the aspiration of mineral oil when used for constipation and the result is either an inflammatory response with regional edema and intralveolar hemorrhage or a ‘paraffinoma’ with aspirated oils encapsulated by fibrous tissue. In our case, we considered more possible that the patient’s acute respiratory failure was due to pneumonitis from paraffin oil as she was always alert, the aspiration was indolent and the cough was dry, without gastric contents.

To conclude, we highlight that medical personnel should keep high suspicion for paraffin oil pneumonitis in pregnant patients with features of GERD who develop ARDS after treatment with liquid paraffin. Thus, routine use of stimulant laxatives should be avoided during pregnancy.

4. Competing interests

The authors declare that there is no conflict of interest regarding the publication of this paper.

References

  1. Rush B, Martinka P, Kilb B, McDermid R, et al. Acute Respiratory Distress Syndrome in Pregnant Women. Obstet Gynecol 129 (2017): 530?535.
  2. Catanzarite V, Willms D, Wong D, Landers C, Cousins L, Schrimmer D. Acute respiratory distress syndrome in pregnancy and the puerperium: causes, courses, and outcomes. Obstet Gynecol 97 (2001): 760-764.
  3. Powrie R, Greene M, Camann E (eds). De Swiet’s Medical Disorders in Obstetric Practice, 5th edition. 2010, Wiley-Blackwell Publications.
  4. Betancourt SL, Martinez-Jimerez S, Rossi SE, Truong MT, Carrilo J, Erasmus JJ. Lipoid pneumonia: Spectrum of clinical and radiologic manifestations. AJR Am J Roentgenol 194 (2010): 103.
  5. Lapinsky SE. Acute respiratory failure in pregnancy. Obstet Med 8 (2015): 126?132.
  6. Kutuk MS, Ozgun MT, Uludag S, Dolanbay M, Yildirim A. Acute pulmonary failure due to pulmonary edema during tocolytic therapy with nifedipine. Arch Gynecol Obstet 288 (2013): 953-954.
  7. Graves CR. Pneumonia in pregnancy. Clin Obstet Gynecol 53 (2010): 329-336.
  8. Bennett A, Chunilal S. Diagnosis and Management of deep Vein Thrombosis and Pulmonary Embolism in Pregnancy. Semin Thromb Hemost 42 (2016): 760.
  9. Grigorakos L, Markou N, Lazarescu D, Tzortzopoulou K, Gkouni M, Papaioannou E, Bikou M, Moles A. Effective Management of Patients with Amniotic Fluid Embolism in the Intensive Care Unit: Two Case Reports. Int Arch of Med 10 (2017): 527.
  10. Bandi VD, Munnur U, Matthay MA. Acute Lung Injury and acute respiratory distress syndrome in pregnancy. Crit Care Clin 20 (2004): 577.
  11. Grigorakos L Evaluating mechanical ventilation in patients with Acute Respiratory Distress Syndrome. Arch Pulmonol Respir Care 4 (2018): 001-005.
  12. Son YG, Shin J, Ryu HG. Pneumonitis and pneumonia after aspiration. J Dent Anesth Pain Med 17 (2017): 1-12.

© 2016-2024, Copyrights Fortune Journals. All Rights Reserved