PNEUMOTHORAX, SUBCUTANEOUS EMPHYSEMA AND PNEUMATOCELE IN A CHILD WITH ACCIDENTAL KEROSENE INGESTION
Rajniti Prasad, Sunil Muthusami, Nisha Pandey, O P Mishra
Department of Pediatrics, Institute of Medical Sciences, BHU, Varanasi, India
Address for Correspondence
Dr. Rajniti Prasad, Lecturer, Dept. of Pediatrics, Institute of Medical Sciences, BHU, Varanasi-221005.
Email
rajnitip@yahoo.co.in
Keywords
kerosene oil, pneumothorax, sub-cutaneous emphysema and pneumatocele
Accidental kerosene oil ingestion is a problem in the developing world. Low socio-economic status and frequent use of kerosene oil, a cheap fuel, for cooking in rural areas and urban slums are the major cause. Most poisonings occur in the under five age group.(1,2) Kerosene oil ingestion results primarily in respiratory symptoms.(3) Ingestion of even 1 ml kerosene oil is significantly related to pulmonary complications.(2,4) Low viscosity enhances penetration into more distal airways, and low surface tension facilitates spread over a large area of lung tissue. We report a child who came to our hospital with pneumatoceles, subcutaneous emphysema and pneumothorax after accidental ingestion of kerosene oil.

A 2 years old girl was brought by her parents with respiratory distress that started five days ago, when she had inadvertently swallowed an unknown amount of kerosene oil. Immediately after ingestion, the child had violent cough and choking. Within half an hour, she started breathing rapidly and became severely dyspneic over the last 6 hours. Examination revealed an extremely dyspneic febrile child with a respiratory rate of 70/min associated with prominent intercostal recession and exaggerated use of the accessory muscles of breathing. Other general physical examination was normal. Chest examination showed extensive subcutaneous emphysema involving the entire left hemithorax and extending up to the neck and submandibular region. Respiratory movements were restricted on the left side. There was a tympanic note on percussion of the left hemithorax and complete absence of breath sounds. Chest radiograph showed left sided pneumothorax with bilateral basal and perihilar pneumonitis, pneumatocele in the right lung. Needle thoracostomy was immediately performed and air was drained. An intercostal tube was then inserted and antimicrobials (cefotaxime, cloxacillin and gentamicin) given for 14 days. The child's dyspnea and tachypnea improved over the next 7 days and she was discharged on day 14.

In general kerosene has a bad taste. Therefore large volumes are rarely ingested. However it is reported that children rarely consume more than 30 ml.(5) Signs and symptoms of respiratory involvement usually begin within 30 minutes after aspiration and may progress during the first 24 to 48 hours and then subside in the following one to two weeks.(6) In children, respiratory symptoms may be prolonged.(7) Harris et al (8) reported a 72% incidence of pneumonia in kerosene poisoning whereas formation of pneumatoceles is believed to be a rare event.(2,6) Pneumatoceles usually appear late with a range of 2-21 days.(8) Pneumatocele formation does not depend on the amount of aspirated hydrocarbon. It is secondary to bronchiolar inflammation with partial obstruction of the lumen in the areas of the infiltrations.(8,9) The mechanism of production of pneumothorax is due to the over distension and rupture of alveoli. Alternatively they may be produced by coalescing of areas of necrosis that eventually penetrate a bronchial wall.(9) Pneumatoceles secondary to kerosene/hydrocarbon ingestion regress spontaneously within a few months

Anas et al (5) established guidelines for the management of patients with hydrocarbon ingestion. Gastric lavage and induction of emesis are contraindicated. An asymptomatic child with an initially normal chest x-ray need not be hospitalized if asymptomatic for six to eight hours. Repeating chest x-rays is unnecessary in such a case. Asymptomatic children with initially abnormal chest x-ray should be kept under observation for 6-8 hours. Symptomatic children with abnormal roentgenograms should be admitted and patients with normal roentgenograms should be observed for at least six hours; if symptoms persist or worsen they should be admitted. Supportive therapy in the form of oxygen, continuous positive airway pressure and mechanical ventilation are instituted if necessary. Bronchospasm is preferably treated by ß2 selective agonists. Prophylactic antibiotics are not routinely prescribed.(1)
Funding
None
Conflict of Interest
None
References :
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  2. Gupta P, Singh RP, Murali MV, Bhargava SK, Sharma P. Kerosene oil poisoning-a childhood menace. Indian Pediatr. 1992; 29:979-984.
  3. Truemper E, Reyes de la Rocha SR, Atkinson SD . Clinical characteristics, pathophysiology, and management of hydrocarbon ingestion: case report and review of the literature. Pediatr Emerg Care1987; 3: 187-193.
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  6. Thalhammer GH, Eber E, Zach MS. Pneumonitis and pneumatoceles following accidental hydrocarbon aspiration in children. Wien Klin Wochenschr 2005;117: 150-153.
  7. Griffin JW, Daeschner CV, Collins VP, Eaton WL. Hydrocarbon pneumonitis following furniture polish ingestion: a report of fifteen cases. J Pediatr 1954 45: 13-26.
  8. Bergeson PS, Hales SW, Lustgarten MD, Lipow HW. Pneumatoceles following hydrocarbon ingestion. Am J Dis Child 1975; 129: 49-54.
  9. Eade NR, Taussig LM, Marks MI .Hydrocarbon pneumonitis. Pediatrics 1974 ; 54: 351-357.
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Last Updated : Saturday, September 01, 2007 Vol 5 Issue 4 Art #16
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Prasad R, Muthusami S, Pandey N, Mishra P O. PNEUMOTHORAX, SUBCUTANEOUS EMPHYSEMA AND PNEUMATOCELE IN A CHILD WITH ACCIDENTAL KEROSENE INGESTION. Pediatric Oncall [serial online] 2007[cited 2007 January 1];5. Art #16. Available From : http://www.pediatriconcall.com/Journal/Article/FullText.aspx?artid=93&type=J&tid=&imgid=&reportid=307&tbltype=
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