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Author [[PageAuthor::Ogheneochuko Ajari, MB.BS, MS [1] (Reviewed by Yazan Daaboul)]]
Exam Type USMLE Step 1
Main Category Pathology
Sub Category Pulmonology
Prompt A 5-year-old boy with a past medical history significant for tonic clonic seizures is found to have a focal infiltrate in the right upper lobe on a routine chest radiograph. The parents report a history of chronic constipation from which he has received daily oral doses of mineral oil laxative. They also describe occasional episodes of coughing and choking during food intake in the past 2 weeks. His physical examination is mostly unremarkable, except for coarse crackles in the right upper lung field. The pediatrician advises the parents to discontinue mineral oil administration and prescribes clindamycin for 10 days. Six weeks later, persistence of the right upper lobe infiltrate is noted on imaging. Diagnostic bronchoscopy with bronchoalveolar lavage (BAL) is scheduled to identify the etiology of the patient's findings. What is the most likely BAL finding associated with this patient's condition?
Answer A Creola bodies
Answer A Explanation 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 Reserve cell hyperplasia
Answer B Explanation Reserve cell hyperplasia is characterized by small uniform cells observed in BAL. It is frequently included in the cytopathological differential diagnosis of small cell undifferentiated carcinoma. It are not typically observed in patients with aspiration pneumonia.
Answer C Hemosiderin-laden macrophages
Answer C Explanation Hemosiderin-laden macrophages in BAL may be helpful in the diagnosis of diffuse pulmonary hemorrhage syndromes and diffuse interstitial pulmonary diseases (DIPD). They are also known as "heart failure cells since they may be observed in patients with congestive heart failure.
Answer D Lipid-laden macrophages
Answer D Explanation Lipid-laden macrophages, defined as an increased lipid content in alveolar macrophages, may be seen in BAL of patients with recurrent pulmonary aspiration.
Answer E Ferruginous bodies
Answer E Explanation 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 D
Explanation The patient in this vignette is most likely diagnosed with silent aspiration pneumonia. Silent aspiration is an important cause of chronic pneumonia in children, as demonstrated in this patient who has focal infiltrates in the right upper lobe. 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. 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. Lipid-laden macrophages are clinically associated with tracheal aspiration in children with gastro-esophageal reflux (GER) and seizures.

Educational Objective: Lipid-laden macrophages are commonly observed in the bronchoalveolar lavage (BAL) of patients with aspiration pneumonia. Oral ingestion of mineral oil, a laxative with viscous oil content, may suppress cough reflex and facilitate aspiration pneumonia.
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 Yes
Keyword lipoid, pneumonia, aspiration, exogenous, bronchoalveolar, lavage, BAL, pediatrics, developmental, delay, seizure, macrophage, macrophages, lipid, laden, lipid-laden, alveolar
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