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Bronchiolitis Obliterans Organizing Pneumonia Following a Jalapeño Grease FireLung Injury Following Jalapeño Grease Fire FREE TO VIEW

Brian T. Garibaldi, MD; Natalie E. West, MD; Peter B. Illei, MD; Peter B. Terry, MD
Author and Funding Information

From the Division of Pulmonary and Critical Care (Drs Garibaldi, West, and Terry), and Department of Pathology (Dr Illei), Johns Hopkins University School of Medicine, Baltimore, MD.

CORRESPONDENCE TO: Brian T. Garibaldi, MD, Johns Hopkins University School of Medicine, Division of Pulmonary and Critical Care, 1830 E Monument St, 5th Floor, Baltimore, MD 21205; e-mail: bgariba1@jhmi.edu


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(2):e31-e33. doi:10.1378/chest.14-1338
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Bronchiolitis obliterans organizing pneumonia (BOOP) is an inflammatory lung disease characterized by granulation tissue in the respiratory bronchioles, alveolar ducts and alveoli. BOOP can be caused by a number of etiologies including infection, toxic inhalation, medications, radiation, and collagen vascular disease, or it can be idiopathic. We report here a case of BOOP following inhalational exposure to a jalapeño grease fire. Capsaicin and other jalapeño-derived compounds are known causes of epithelial damage and airway inflammation but to our knowledge have never been implicated in the development of BOOP. This case adds to the growing list of exposures associated with BOOP and highlights the importance of taking a thorough exposure history in patients with lung injury of unknown etiology.

Figures in this Article

Bronchiolitis obliterans organizing pneumonia (BOOP) is an inflammatory lung disease characterized by granulation tissue in the respiratory bronchioles, alveolar ducts, and alveoli.1 BOOP can be caused by a number of insults, including infection, inhalation, drug therapy, radiation, and collagen vascular disease, or it can be idiopathic.2 Idiopathic cases are termed cryptogenic organizing pneumonia.3 We report here a case of BOOP caused by an unusual inhalational exposure.

A 20-year-old previously healthy man was transferred to our hospital for evaluation of multiple lung masses. He was in his usual state of health until 4 weeks prior to admission when he developed acute left-sided pleuritic chest pain that awoke him from sleep. He denied fever or recent upper respiratory symptoms. The pain was relieved by over-the-counter nonsteroidal antiinflammatory drugs. About 10 days after the onset of the pleuritic pain, the patient developed a nonproductive cough accompanied by mild dyspnea on exertion. His primary care physician prescribed azithromycin for possible community-acquired pneumonia and ordered a chest radiograph, which showed bilateral nodular opacities (Fig 1A). A chest CT scan revealed multiple, ill-defined, mass-like consolidations, the largest measuring 4.8 × 3.2 cm (Fig 1B).

Figure Jump LinkFigure 1 –  A, Chest radiograph with diffuse bilateral nodular opacities. B, Chest CT scan with bilateral nodules and mass-like consolidations with a small left-sided pleural effusion.Grahic Jump Location

The patient’s past medical history was remarkable for attention deficit hyperactivity disorder, for which he took methylphenidate. He attended a local community college and lived at home with his parents. He was a nonsmoker and denied any recent environmental exposures. He did not have any pets. He did not use alcohol or illicit drugs. He denied inhaling or injecting methylphenidate.

His temperature was 36.1°C, BP was 135/60 mm Hg, heart rate was 88 beats/min, respiratory rate was 18 breaths/min, and oxygen saturation was 98% on ambient air. His examination was notable for decreased breath sounds at the lung bases bilaterally, with scant inspiratory crackles at the left base. He did not have audible wheezes, rhonchi, or squeaks. Initial laboratory findings, including results of a complete blood count and comprehensive metabolic panel, were normal. Blood, urine, and sputum cultures were negative. Tests for HIV antibody, cryptococcal antigen, urine histoplasma antigen, cocciodiodes antibody, and blastomycosis antibody were negative. Serologic testing for rheumatologic disease was negative, including antinuclear antibody, rheumatoid factor, antineutrophil cytoplasmic antibody, and myositis antibodies. Bronchoscopy findings with BAL did not indicate infection. Transbronchial biopsy specimens revealed intraalveolar accumulation of histiocytes with focal organizing lung injury. Specimens from a surgical lung biopsy, performed to rule out malignancy, revealed multiple foci of organizing pneumonia with associated small nonnecrotizing granulomata (Fig 2A), as well as an organizing pleuritis (Fig 2B). The biopsy specimen observations and clinical picture were most consistent with BOOP.

Figure Jump LinkFigure 2 –  A, Low-power view demonstrating organizing pneumonia with multiple fibrinous plugs (hematoxylin and eosin, magnification × 100). B, High-power view highlighting an area of granulation tissue in the alveolar space (hematoxylin and eosin, magnification × 400). C, High-power view showing poorly formed granulomatous inflammation with multinucleated giant cells (hematoxylin and eosin, magnification × 400). D, High-power view demonstrating fibrinous pleuritis (hematoxylin and eosin, magnification × 400).Grahic Jump Location

Upon further questioning, the patient’s father recalled an incident 2 weeks prior to the onset of the patient’s symptoms in which a grease fire occurred while the patient was frying jalapeño peppers. The resulting smoke caused cough, rhinorrhea, and eye irritation that forced both the patient and his father to leave the house. The acute symptoms improved within 30 min of the exposure. The father was in a different room of the house at the time of the fire and had significantly less smoke exposure. He did not develop any subsequent pulmonary symptoms.

The patient was initiated on a 6-month course of tapering prednisone. His symptoms and radiographic abnormalities resolved with no recurrence after 2 years of follow-up.

There is evidence in animals and humans that jalapeño-derived capsaicinoids cause lung inflammation and small-airway fibrosis. Inhalational exposure to capsaicinoids in animals leads to a dose-dependent increase in airway inflammation and epithelial cell damage.4,5 In humans, nebulized capsaicin leads to a dose-dependent increase in cough.6 Fatal exposure to pepper spray used by law enforcement agencies has been associated with acute follicular bronchiolitis on autopsy.7 Bronchiolitis obliterans has also been reported in popcorn-factory workers exposed to powdered jalapeño flavoring in the absence of significant diacetyl exposure.8

BOOP has been attributed to inhalational insults.2,9 To our knowledge, BOOP has not been reported following jalapeño exposure. Inhalational smoke injury from house fires is a known cause of BOOP, making it difficult to definitively conclude that the jalapeños were the sole cause of lung injury in this case.10 However, the predominance of jalapeños in the grease fire, as well as the ability of capsaicin and other jalapeño-derived compounds to cause inflammation and epithelial damage, strongly implicate jalapeños as the cause of this patient’s lung injury.

In conclusion, we report here a case of BOOP following exposure to a jalapeño grease fire. This case adds to the growing list of BOOP etiologies and highlights the importance of taking a thorough exposure history in patients with undiagnosed lung injury.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions:CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

BOOP

bronchiolitis obliterans organizing pneumonia

Epler GR, Colby TV, McLoud TC, Carrington CB, Gaensler EA. Bronchiolitis obliterans organizing pneumonia. N Engl J Med. 1985;312(3):152-158. [CrossRef] [PubMed]
 
Epler GR. Bronchiolitis obliterans organizing pneumonia, 25 years: a variety of causes, but what are the treatment options? Expert Rev Respir Med. 2011;5(3):353-361. [CrossRef] [PubMed]
 
Cottin V, Cordier JF. Cryptogenic organizing pneumonia. Semin Respir Crit Care Med. 2012;33(5):462-475. [CrossRef] [PubMed]
 
Reilly CA, Taylor JL, Lanza DL, Carr BA, Crouch DJ, Yost GS. Capsaicinoids cause inflammation and epithelial cell death through activation of vanilloid receptors. Toxicol Sci. 2003;73(1):170-181. [CrossRef] [PubMed]
 
Kudlacz EM, Knippenberg RW. In vitro and in vivo effects of tachykinins on immune cell function in guinea pig airways. J Neuroimmunol. 1994;50(2):119-125. [CrossRef] [PubMed]
 
Collier JG, Fuller RW. Capsaicin inhalation in man and the effects of sodium cromoglycate. Br J Pharmacol. 1984;81(1):113-117. [CrossRef] [PubMed]
 
Steffee CH, Lantz PE, Flannagan LM, Thompson RL, Jason DR. Oleoresin capsicum (pepper) spray and “in-custody deaths.” Am J Forensic Med Pathol. 1995;16(3):185-192. [CrossRef] [PubMed]
 
Kullman G, Sahakian N. NIOSH Health Hazard Evaluation Report. Yatsko’s popcorn, Sand Coulee, Montana. Cincinnati, OH: Department of Health and Human Services; 2007. HETA 2006-0195-3044.
 
Ohshimo S, Bonella F, Guzman J, Costabel U. Hypersensitivity pneumonitis. Immunol Allergy Clin North Am. 2012;32(4):537-556. [CrossRef] [PubMed]
 
Srivastava S, Haddad R, Kleinman G, Manthous CA. Erythema nodosum after smoke inhalation-induced bronchiolitis obliterans organizing pneumonia. Crit Care Med. 1999;27(6):1214-1216. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 –  A, Chest radiograph with diffuse bilateral nodular opacities. B, Chest CT scan with bilateral nodules and mass-like consolidations with a small left-sided pleural effusion.Grahic Jump Location
Figure Jump LinkFigure 2 –  A, Low-power view demonstrating organizing pneumonia with multiple fibrinous plugs (hematoxylin and eosin, magnification × 100). B, High-power view highlighting an area of granulation tissue in the alveolar space (hematoxylin and eosin, magnification × 400). C, High-power view showing poorly formed granulomatous inflammation with multinucleated giant cells (hematoxylin and eosin, magnification × 400). D, High-power view demonstrating fibrinous pleuritis (hematoxylin and eosin, magnification × 400).Grahic Jump Location

Tables

References

Epler GR, Colby TV, McLoud TC, Carrington CB, Gaensler EA. Bronchiolitis obliterans organizing pneumonia. N Engl J Med. 1985;312(3):152-158. [CrossRef] [PubMed]
 
Epler GR. Bronchiolitis obliterans organizing pneumonia, 25 years: a variety of causes, but what are the treatment options? Expert Rev Respir Med. 2011;5(3):353-361. [CrossRef] [PubMed]
 
Cottin V, Cordier JF. Cryptogenic organizing pneumonia. Semin Respir Crit Care Med. 2012;33(5):462-475. [CrossRef] [PubMed]
 
Reilly CA, Taylor JL, Lanza DL, Carr BA, Crouch DJ, Yost GS. Capsaicinoids cause inflammation and epithelial cell death through activation of vanilloid receptors. Toxicol Sci. 2003;73(1):170-181. [CrossRef] [PubMed]
 
Kudlacz EM, Knippenberg RW. In vitro and in vivo effects of tachykinins on immune cell function in guinea pig airways. J Neuroimmunol. 1994;50(2):119-125. [CrossRef] [PubMed]
 
Collier JG, Fuller RW. Capsaicin inhalation in man and the effects of sodium cromoglycate. Br J Pharmacol. 1984;81(1):113-117. [CrossRef] [PubMed]
 
Steffee CH, Lantz PE, Flannagan LM, Thompson RL, Jason DR. Oleoresin capsicum (pepper) spray and “in-custody deaths.” Am J Forensic Med Pathol. 1995;16(3):185-192. [CrossRef] [PubMed]
 
Kullman G, Sahakian N. NIOSH Health Hazard Evaluation Report. Yatsko’s popcorn, Sand Coulee, Montana. Cincinnati, OH: Department of Health and Human Services; 2007. HETA 2006-0195-3044.
 
Ohshimo S, Bonella F, Guzman J, Costabel U. Hypersensitivity pneumonitis. Immunol Allergy Clin North Am. 2012;32(4):537-556. [CrossRef] [PubMed]
 
Srivastava S, Haddad R, Kleinman G, Manthous CA. Erythema nodosum after smoke inhalation-induced bronchiolitis obliterans organizing pneumonia. Crit Care Med. 1999;27(6):1214-1216. [CrossRef] [PubMed]
 
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