Lung on fire. A very severe case of fire-eater's lung

A 19-year-old male smoker presented in the emergency room after accidental aspiration of an unquantifiable amount of Pyrofluid, a liquid mixture of high-boiling aliphatic/paraffin aromatic free hydrocarbons, during a fire-eating performance. A few minutes after the aspiration he started to feel sick, with shortness of breath and mild dry cough. On admission to our hospital, he had an episode of emesis and presented burning retrosternal chest pain and dyspnoea. Physical examination revealed oxygen saturation (SpO2) on ambient air of 92%, tachypnoea, tachycardia, normal temperature. Chest auscultation showed the presence of breath sounds without additional pathological sounds. The rest of the systemic examination was normal. Oropharyngoscopy was negative for oral lesions. Laboratory exams showed a neutrophilic leukocytosis (white cell count (WCC) 15.56×109/L, neutrophil 10.91×109/L), without increased C reactive protein (CRP) levels. Arterial blood gases on room air revealed PaO2 8.9 kPa, PaCO2 5.5 kPa, pH 7.30, (HCO3 -) 20 mmol/L, (Lac) 3.8 mmol/L, and PaO2/inspired oxygen fraction (FiO2) 42.4 kPa. Chest X-ray demonstrated mild accentuation of the broncho-vascular structure with a consolidation in the left basal area (figure 1A). High-resolution chest CT (HRCT) showed bilateral parenchymal consolidation involving most of the inferior lobes and a complete occlusion of the lower lobar bronchus bilaterally; moreover, fluid-dense effusion was present in the right basal area (figure 1B). Although blood cultures and microbiological tests on sputum were negative, a broad-spectrum antibiotic therapy was initiated with piperacillin/tazobactam. The patient was also treated with systemic steroids, analgesics and oxygen therapy via a Venturi mask at FiO2 of 0.4.