A rare case of hydrothorax following hydrocarbon poisoning

INTRODUCTION

Hydrocarbons are the chief components in many types of fuels and products used every day. They can come in the form of a gas, liquid, solid, or polymer.¹ Exposure to these substances can cause significant health risks. Toxicity is dependent on multiple variables, including viscosity, surface tension, volatility, and additives.^2–4

CASE REPORT

A 4-year-old male child was brought to the pediatric intensive care unit (PICU) with a history of vomiting following accidental ingestion of paint thinner 6 hours before admission. Upon examination, his vital signs were stable. The respiratory system and examination of other systems were normal. Six hours after admission, the child developed tachypnea, hypoxia (SpO₂ 91% at room air), and diffuse crepitations on the right side of the chest. A chest X-ray showed diffuse infiltrates on the right side, possibly due to chemical pneumonitis [Figure 1]. He was started on intravenous (IV) amoxiclav, IV fluids and oxygen support with nasal prongs (4 l/minute) to maintain the SpO₂ around 95%. In the next 24 hours, the child became dyspneic with a high-grade fever and had decreased air entry noticed in the right infra-axillary and infra-mammary areas. A repeat chest X-ray [Figure 2] and bedside ultrasonography (USG) [Figure 3] showed moderate pleural effusion. In view of increasing respiratory distress, the child was kept on non-invasive positive pressure ventilation (NIPPV), a diagnostic pleural tap was done, and 30 ml of pleural fluid was aspirated. Pleural fluid analysis was suggestive of an exudative type of pleural effusion, with Gram staining and culture results negative for the presence of organisms. Six hours after the pleural tap, the child improved and was shifted to oxygen therapy with prongs. A chest X-ray 48 hours after the pleural tap was normal [Figure 4]. The child was discharged from the hospital on day 7, and the chest X-ray at the 1-week follow-up was normal.

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Figure 1:

Diffuse infiltrates on right side probably due to chemical pneumonitis.

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Figure 2:

Chest x-ray showing right side moderate pleural effusion.

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Figure 3:

Ultrasonography showing pleural effusion on right side of lung.

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Figure 4:

Chest x-ray showing resolution after plueral tap.

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DISCUSSION

Hydrocarbons are the chief components in many types of fuels and products used every day. Exposure to hydrocarbons in children can occur in different ways. Hydrocarbon poisoning is common among children, especially in summer months, as they are stored in household water bottles, and children commonly mistake them for water.

Hydrocarbon ingestion can lead to dangerous consequences such as aspiration pneumonitis. Significant pneumonitis occurs in less than 2% of cases,⁵ especially with ingestion of greater than 30 ml of hydrocarbon.¹ These chemicals penetrate deep into the lung and may also destroy surfactant, airway epithelium, alveolar septa, and pulmonary capillaries, presenting as necrotizing pneumonia with clinical manifestations of cough, shortness of breath, and hypoxia.⁶

Other systems, especially the liver, heart, and central nervous system (CNS), may suffer serious injury with exposure to hydrocarbons. Cardiac arrhythmias occur and are exacerbated by hypoxia, acid-base, and electrolyte imbalances.

MANAGEMENT

The mainstay treatment for hydrocarbon toxicity is supportive care, which includes O₂ support, IV fluids, and, rarely, extracorporeal membrane oxygenation (ECMO).⁷ Gastric emptying is usually contraindicated. Certain hydrocarbons have more inherent systemic toxicity, and if ingested in a volume of >30 ml, they may benefit from gastric emptying. For example, CHAMP refers to camphor, halogenated aromatic hydrocarbons, metals, and pesticides.

Clinical manifestations, including chest retractions, cough, and fever, may occur as early as 30 minutes or may be delayed by several hours. Radiological changes are usually seen in 2–8 hours, peaking in 48–72 hours; pneumatocele and pleural effusion may occur. Turpentine, gasoline, and naphthalene have more potential toxicity than heavy mineral and fuel oils.

If, after an observation period of 4–6 hours, there are no signs of pulmonary or systemic toxicity, including a clear chest radiograph, the patient may be discharged home with strict outpatient follow-up.

Investigations are required in symptomatic patients for early diagnosis to assess the extent of systems involved and early intervention for optimal outcomes. Initial orders should include a chest radiograph to aid in determining the extent of lung injury. Useful laboratory tests may include complete blood count, oxygen saturation, serum electrolytes, liver function tests, creatinine, glucose, and urinalysis. An electrocardiograph may also be useful for detecting cardiac arrhythmias, and pulse oximetry can be used to monitor hypoxia. Replace electrolytes as needed, as hypokalemia is common in hydrocarbon exposure.

If the patient is symptomatic on presentation, focus should be on possible respiratory or cardiac failure. If severe pulmonary toxicity is found or the patient has an altered mental status, intubation with a cuffed ET tube is needed, as patients may decompensate quickly. Antibiotics may be warranted only if a concomitant infection is suspected. The role of steroids in management is unclear.⁸

Pulmonary function abnormalities can persist for many years; hence, these children should be on long-term follow-up.

CONCLUSION

Accidental ingestion of hydrocarbons is most common in children during the summer months. The most common presenting complaint is mild respiratory illness, which needs only supportive treatment, but rarely presents with life-threatening complications. Early intervention can decrease morbidity and mortality.