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1 치료에대한반응이없는폐렴 이달의 X 선 대전선병원내과방도석, 정인성, 강기만, 박범철, 윤영걸, 김재수, 박열, 이성훈, 홍영철, 고경태, 박상민, 나동집 Unresolving Pneumonia Do Seok Bang, M.D., In Sung Jung, M.D., Ki Man Kang, M.D., Bum Chul Park, M.D., Young Gul Yoon, M.D., Jae Su Kim, M.D., Yol Park, M.D., Sung Hoon Lee, M.D., Young Chul Hong, M.D., Kyoung Tae Ko, M.D., Sang Min Park, M.D., and Dong Jib Na, M.D. Department of Internal Medicine, Sun Hospital, Dae Jeon, Korea A 47-year-old-man was admitted to the emergency department with dyspnea, right pleuritic pain, and high fevers for 3 days. He had a nonproductive cough that exacerbated the chest pain. A clinical examination revealed distressed and slightly tachypneic patient, with blood pressure of 110/90 mmhg, temperature of 39, pulse of 90 beats/min, respiratory rate of 24 breaths/min. A chest examination showed significantly diminished breath sounds in the right lung with dullness to percussion. Laboratory investigation demonstrated leukocytosis and a raised C-reactive protein. The results of arterial blood gas analysis revealed moderate hypoxemia. A radiograph and a CT scan of the chest showed extensive consolidation with multifocal low densities, and pleural effusion in the right lung. A diagnostic thoracentesis revealed straw-colored fluid, which was found to be a neutrophil-predominant exudate. At 7 days after admission, the clinical symptoms had not improved and the temperature was still 39 C despite the aggressive therapy of communityacquired pneumonia. After comprehensive history taking, we realized then that he accidentally aspirated kerosene while siphoning from fuel tank to put into the boiler 3 days ago. Bronchoscopy with bronchial washings could be successful in establishing the diagnosis of hydrocarbon pneumonitis by demonstration of a high lipid-laden macrophage index. Thereafter, the symptoms and radiographic opacities gradually improved, and he was discharged several days later. (Tuberc Respir Dis 2004; 57: ) Key words : Pneumonitis, Kerosene 증 환자 : 47세, 남자주소 : 기침과우측흉부통증및고열병력 : 47세남자가내원 3 일전부터갑자기악화된기침, 우측흉부통증, 호흡곤란및고열을주소로응급실을방문하였다. 10 여일동안감기증상이있던중 3 일전부터악화되어개인의원에서흉부사진촬영후폐렴의심되어전원되었다. 과거력 : 결핵, 당뇨병, 고혈압, 알레르기성질환등은없었고, 가족력상특이사항은없었다. Address for correspondence : Dong Jib Na, M.D. Department of Internal Medicine, SUN HOSPITAL 10-7 Mok-Dong, Jung-Gu, Dae-Jeon, Korea Phone : Fax : djna@sunhospital.com Received : Jul Accepted : Sep 례 이학적소견 : 내원당시급성병색으로혈압 110/ 90 mmhg, 맥박 90회 /min, 호흡수 24 회 /min, 체온 39 이며입술과혀가건조되어있었고우측폐에타진시둔탁하고호흡음이감소되었다. 그외심장, 복부, 사지및신경학적검사는정상이었다. 검사실소견 : 말초혈액검사상백혈구 18,500/ mm3 ( 호중구 91.8%, 림프구 3.6%, 단핵구 ; 4.1% ), 혈색소 14.3 g/dl, 혈소판 175,000/ mm3, 적혈구침강속도 29 mm /hr, 및 CRP mg/dl 이었다. 생화학검사상단백질 / 알부민 6.1/3.5 g/dl, AST/ALT 23/25 IU/L, LDH 511 IU/L, Bilirubin 2.3 mg/dl 이었다. 실온에서의동맥혈가스분석은 ph 7.442, PCO mmhg, PO mmhg, HCO mmol/l, 3 O 2 Sat 94.0% 이였다. 방사선소견 : 내원시촬영한단순흉부촬영상 (Fig. 1) 우하엽에침윤과흉막액의저류가관찰되었다. 내원 4일째시행한흉부전산화단층촬영상 (Fig. 2) 우 604

Tuberculosis and Respiratory Diseases Vol. 57. No. 6, Dec, 2004 a Figure 2.

effusion b Figure 1. Chest radiographic findings on admission showing right lung infiltrates (a) and free-flowing fluid (b). 측폐에광범위한경화및다발성의저음영소견과소량의흉막액이관찰되었다.

천자액의일반세균에대한그람염색및배양검사는음성이었다. 객담검사 : 일반세균그람염색및배양검사, 결핵균도말및배양검사모두음성소견보였다. 폐기능검사 : FEV 1 1.80L ( 예측치의 54%), FVC 2.03L ( 예측치의 46%), FEV 1 /FVC 88% 이었다.

2 Tuberculosis and Respiratory Diseases Vol. 57. No. 6, Dec, 2004 a Figure 2. Computed tomography of the chest at 4 days after admission, showing extensive consolidation in the right lung, with multifocal low-attenuation areas, and ipsilateral pleural effusion b Figure 1. Chest radiographic findings on admission showing right lung infiltrates (a) and free-flowing fluid (b). 측폐에광범위한경화및다발성의저음영소견과소량의흉막액이관찰되었다. 흉수천자 : 천자액은육안적으로화농성을보이진 않았으며백혈구 19,900/ mm3 ( 호중구 80%, 림프구 20%), ph 6.9, 단백질 g/dl, LDH 2,359 IU/l, Cholesterol 65 mg/dl, Glucose 147 mg/dl, ADA 25 IU/L 이었다. 천자액의일반세균에대한그람염색및배양검사는음성이었다. 객담검사 : 일반세균그람염색및배양검사, 결핵균도말및배양검사모두음성소견보였다. 폐기능검사 : FEV L ( 예측치의 54%), FVC 2.03L ( 예측치의 46%), FEV 1 /FVC 88% 이었다. 임상경과 : 내원시객담은별로없지만고열과심한기침이있고백혈구수가증가되어있으며흉부촬영상우측폐의침윤과흉수검사결과삼출액에합당한소견등으로부폐렴성삼출액을동반한지역사회폐렴을의심하고경험적항생제를투여하였다. 항생제교체투여후에도고열, 기침과흉부통증이지속되고혈액배양결과는음성이었으나백혈구수가감소되지않았다. 흉부방사선사진또한점차로악화되었고 4 일째시행한흉부전산화단층촬영상폐우엽특히, 우중엽에광범위한경화및다발성의저음영소견으로괴사성폐렴 (necrotizing pneumonia) 가의심되었다. 병력을재청취하여내원 3 일전집에서호스를사용하여난방용보일러에등유를주입하던중실수로한모금가량흡입한사실을비로소알게되었다. 입원 14 일째시행한기관지내시경상우중엽개구부주위의점막부종과 605

On twenty days after admission, chest radiography demonstrating improved right middle lobe infiltrates. 약간의백색분비물이외다른소견은관찰되지않았고채집한기관지상층세척액의육안적관찰시지방층은관찰되지않았다. 기관지세척액의 Oil red O 염색상 (Fig.

3 DS Bang, et al.: Hydrocarbon pneumonitis 치료만으로흉부통증과고열이점차소실되고백혈구수도감소하며흉부사진상 (Fig. 4) 침윤과흉막액이점차감소되어퇴원하였다. 고 찰 Figure 3. Bronchial washing specimen showing alveolar macrophages with numerous confluent red-staining cytoplasmic vacuoles filled with lipid (Oil red O stain, X 100) Figure 4. On twenty days after admission, chest radiography demonstrating improved right middle lobe infiltrates. 약간의백색분비물이외다른소견은관찰되지않았고채집한기관지상층세척액의육안적관찰시지방층은관찰되지않았다. 기관지세척액의 Oil red O 염색상 (Fig. 3) 조직구내에지방공포가관찰되었으며, 그람염색및배양검사, 결핵균도말및배양검사는모두음성이었다. 이후보전적인 외인성지방성폐렴은 1925년에처음기술된 1 후국내에도여러종류의동, 식물성지방물질에의한증례가있었으며최근에는탄화수소화합물 (hydrocarbon) 에의한경우도보고되었다 2-3. 탄화수소화합물중등유흡인에의한모 4 등의증례는기관지세척액의지방염색과정없이병력과임상적근거만으로진단한경우이다. 외국의경우는농촌지역에서영유아의중독사고로드물지않게발생하나 5 성인의경우휘발성이강하고냄새가있어극히드물고횃불을입에넣는묘기를하는사람이나 (Fire-eater's pneumonia) 환각상태에빠지기위해의도적으로휘발성물질을흡입한경우에발생된경우가있다 6-7. 일반적으로석유를정제하면프로판가스, 부탄가스, 가솔린, 나프타, 등유, 경유, 증유등의탄화수소화합물을얻게되며이와관련한폐합병증의경중은물질의점도와표면장력에의해좌우된다. 즉휘발성이강하고점도가낮을수록후두에의한효과적인반사가감소되어흡인이쉽게발생되고표면장력이낮을수록폐포부위에까지쉽게침투하여광범위한폐손상이올수있다. 등유는가정용연료로흔히사용되며경유및증유에비해휘발성이강하고점도가낮다. 등유나다른탄화수소화합물의흡인은 Fire-eater's pneumonia 로알려진다양한형태의화학성폐렴 (chemical pneumonitis) 를초래하는데임상양상을예측하기어렵고 fire-eating 에관한병력청취가확인되지않았을경우에는진단이매우힘들다 8. 일반적인증상으로심한흉부통증, 호흡곤란, 기침등이대부분에서나타나고그외에지속적인고열, 객혈및심한경우혼수, 간질등의의식상태의변화도초래될수있다. 흉부방사선소견은일측성혹은양측성의경화성침윤과경계가뚜렷한결절, 공기낭종 (pneumatocele), 606

4 Tuberculosis and Respiratory Diseases Vol. 57. No. 6, Dec, 2004 기관지흉막루 (bronchopleural fistula) 및자발성기흉이관찰될수있으며특히흉부전산화단층촬영은합병증의발생에따른치료방향의결정에도움이된다 9. 전산화단층촬영시지방조직에합당한혹은비특이적저감쇠 (low attenuation) 의변화가부분적으로관찰될수있으며 10, 본증례에서도전산화단층촬영시폐렴의괴사성병변이라고생각되었던저감쇠소견이관찰되었다. 객담이나기관지세척액의지방염색으로지방공포를함유한대식세포가발견되면진단에도움이된다. 본증례의경우지역사회폐렴에대한경험적광범위항생제치료에도불구하고임상호전이없었고, 병력재청취하는과정중에비로소등유흡입사실을확인하고임상적으로지방성폐렴을의심할수있었다. 이후객담에서는확인할수없었지만기관지내시경검사후세척액에서지방공포를확인하였다. 기관지세척액에대한전자현미경검사로다수의지방봉입체 (lipoid inclusion) 를함유한대식세포를발견한경우도있다 11. 진단이불확실한경우는폐조직검사를할수도있다. 치료는보존적개념으로저산소증의경우는산소를투여하고심한경우는기계환기를할수도있지만대부분의경우예후는양호해서완전회복되는것으로알려져있다. 또한등유를비롯한석유계화합물의흡인경우위세척은효과없으며오히려폐흡인을악화시킬수있다. 스테로이드는간질성폐경화 (interstitial lung consolidation) 가발생된예에서효과를보고하였지만 12 보편화된치료는아니며 13 증상이심한경우에한해서증례에따라사용할수있다. 합병증으로폐기관지루같은구조적인손상이초래되었을경우에는수술적치료가필요하며, 2 차적인세균감염의증거가있을때는항생제를사용하지만일반적인항생제사용은효과가없다 13. 본증례는처음지역사회폐렴으로생각하고항생제를사용했지만지방성폐렴으로확인된후에는추가적인치료없이대증적요법만으로경과관찰중호전된경우로 2 차적세균감염의가능성은낮은것으로판단된다. 요 외인성지방성폐렴은흔한질환은아니지만동물성, 식물성및광물성지방물질이원인이될수있으며발견된예보다훨씬빈도가많을것으로판단된다. 따라서자세한병력청취로원인물질에대한노출을우선확인하여지방성폐렴을의심하는것이선행되어야한다. 약 참고문헌 1. Laughlen GF: Studies on pneumonia following nasopharyngeal injection of oil. Am J Pathol 1925; 1: Chang Youl Lee, Sung Woo Choi, Young Kim, Byung Chun Chung, Hyung Joong Kim, Chul Min Ahn, et al. A case of Chemical Pneumonitis Induced by Ingestion of Hydrocarbon. Tuberc Respir Dis 2000;49(5): Do Hyoung Kim, Min Young Lee, In Gyun Oh, Byoung Yerb Kim, Goung Sup Lee, Chang Seon Lee, et al. A case of chemical pneumonitis induced by hydrocarbon ingestion. Korean J Med 2001;61 (1): Eun Kyung Mo, Seung Joon Lee, Jee-Woong Son, Dong Gyu Kim, Myung Goo Lee, In Gyu Hyun, et al. Four case of kerosene pneumonitis. Korean J Med 2000;59: Reed RP, Conradie FM. The epidemiology and clinical features of paraffin (kerosene) poisoning in rural African children. Ann Trop Paediatr 1997;17: Birolleau S, Belleguic C, Lena H, Chemery L, Delaval P. Fire-eater's lung: report of six cases. Rev Pneumol Clin 1999;55: Sheridan RL. Burns with inhalation injury and petrol aspiration in adolescents seeking euphoria through hydrocarbon inhalation. Burns 1996;22: Bulava A, Kolek V, Lukl J. Fire-eater's pneumonia --a difficult differential diagnosis. Cas Lek Cesk 2001;140(8): Franquet T, Gomez-Santos D, Gimenez A, Torrubia S, Monill JM. Fire eater's pneumonia: radiographic and CT findings. J Comput Assist Tomogr 2000;24 (3): Lee KS, Muller NL, Hale V, Newell JD Jr, Lynch DA, Im JG. Lipoid pneumonia: CT findings. J Comput Assist Tomogr 1995;19(1):

5 DS Bang, et al.: Hydrocarbon pneumonitis 11. Burkhardt O, Merker HJ, Shakibaei M, Lode H. Electron microscopic findings in BAL of a fire-eater after petroleum aspiration. Chest 2003;124(1): Kamijo Y, Soma K, Asari Y, Ohwada T. Pulse steroid therapy in adult respiratory distress syndrome follow- ing petroleum naphtha ingestion. J Toxicol Clin Toxicol 2000;38(1): Steele RW, Conklin RH, Mark HM. Corticosteroids and antibiotics for the treatment of fulminant hydrocarbon aspiration. JAMA 1972;219:

Trd022.hwp

Trd022.hwp 김신태, 이선녕, 이석정, 정필문, 박홍준, 신명상, 김종환, 이부길, 김상하, 리원연, 신계철, 용석중 Shin-Tae Kim, M.D., Shun Nyung Lee, M.D., Seok Jeong Lee, M.D., Pil Moon Jung, M.D., Hong Jun Park, M.D., Myung Sang Shin, M.D., Chong Whan Kim,