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OBJECTIVE: Transarterial chemoembolization is a widely used therapy for the treatment of hepatocellular carcinoma. A rare adverse event is acute respiratory distress syndrome from pulmonary embolization of Lipiodol, an iodinated oil commonly used during the procedure. The objective of this report is to describe an atypical case of acute respiratory distress syndrome from Lipiodol embolization in a patient who underwent transarterial chemoembolization for hepatocellular carcinoma 9 days prior to presentation, despite having received relatively small amounts of Lipiodol (5.5 mL). Although this diagnosis has classically been based on radiological findings, we established a diagnosis after lipid-laden macrophages were detected in bronchial alveolar lavage fluid. DESIGN: Case report. SETTING: ICU of a major metropolitan academic medical center. PATIENTS: Single case. INTERVENTIONS: Diagnostic interventions included noncontrast CT scan of the chest and cytologic examination of bronchial alveolar lavage fluid with oil red O staining. Therapeutic interventions included mechanical ventilation and methylprednisolone infusions. MEASUREMENTS AND MAIN RESULTS: Noncontrast CT demonstrated nonspecific diffuse ground glass opacification, most prominent within the upper lobes. Mechanical ventilation was begun for hypoxemic respiratory failure. Cytologic examination of bronchial alveolar lavage fluid revealed a high proportion of lipid-laden macrophages, findings consistent with Lipiodol embolism. Despite infusions of methylprednisolone, the patient expired on hospital day 8. CONCLUSIONS: Acute respiratory distress syndrome from Lipiodol embolization following transarterial chemoembolization can occur even with small Lipiodol volumes. Cytologic examination of bronchial alveolar lavage fluid with oil red O staining is a useful diagnostic modality, especially when imaging studies are equivocal.

Rationale Cases of granulomatous reaction to pneumocystis have been reported in immuno-compromised patients, most commonly in HIV infected patients but also rarely in patients with hematologic disease. Because of the low incidence of G-PCP, there are only case reports and case series describing different presentations. It has been suggested that because of low organism burden and distribution of disease, bronchoscopy with lavage and biopsy has a low yield in non-HIV patients in diagnosing granulomatous pneumocystis pneumonia (G-PCP). We reviewed our cumulative experience in G-PCP, to characterize the disease and diagnostic approach among patients with different underlying diseases. Method We reviewed the medical records of patients whose pathology results were G-PCP in our tertiary urban hospitals between 1993 and 2012 including demographics, underlying disease, radiographic findings and diagnostic approach. Result We identified 38 G-PCP patients; 27 medical records were available for review. Sixteen patients were HIV-infected. The 11 non-HIV patients had lymphoma or rheumatoid arthritis. Nine of the 11 non-HIV patients had non-diagnostic bronchoscopies and required either CT guided core or open lung biopsy. By contrast, 13 of the 16 HIV patients had diagnostic bronchoscopies(p value=0.002). Among the 11 non-HIV patients, 4 had diffuse large B cell lymphoma that had been treated with multiple cycles of chemotherapy and were subsequently found to have solitary or multiple lung masses. Disease recurrence was suspected based on CT-PET scan findings. However, all pathology specimens showed non-necrotizing granulomatous inflammation with pneumocystis. None showed malignancy or acid fast bacilli. Of note, none of these patients had respiratory symptoms and pneumocystis pneumonia was not considered in the differential diagnosis prior to biopsy. All responded well to anti-pneumocystis therapy. Conclusion The presentation of granulomatous pneumocystis pneumonia in patients without HIV is often atypical. Specifically, the diagnosis should be considered in patients with treated large B cell lymphoma who present with a lung mass on chest imaging. Non-bronchoscopic biopsy is usually required for diagnosis