SummaryTraditional herbal therapy is often underestimated as a possible cause of drug-induced lung diseases. We report the case of a 51 years old man who developed acute respiratory failure after abuse and misuse of a traditional Thai herbal inhaler. The composition of the herbal therapy was only partially known. However, we supposed that the menthol balm may have been responsible of the pulmonary lipoid inclusions and trans-anethole may have caused diffuse alveolar lung damage.
KEY WORDS: diffuse parenchymal lung disease, herbal therapy, drug-induced lung disease, ARDS.A 51 years old man was admitted to the Cardiology Unit because of sudden chest pain, palpitations and shortness of breath. He was a worker in a manufacturing company without any particular dust or metal exposition. Moreover, he was an occasional drummer and a mild smoker, without a relevant past history. Until those sudden symptoms, he didn't have previously exercise limitation. At hospital cardiologists promptly diagnosed the rupture of a tendon cord of the mitral valve with severe mitral failure, and planned cardiosurgery. During this first hospitalization, the patient had some episodes of paroxysmal supra-ventricular tachycardia (max. 135 bpm), then solved by adenosine infusion. The patient developed a small "hospital-acquired pneumonia" at the right lower lobe, so an antibiotic therapy (levofloxacin 500mg os b.i.d.) was added at hospital discharge. After seven days from discharge, the patient was another time admitted to the hospital because of progressive dyspnea and hemoptysis. He had cyanosis, tachypnea, tachycardia, mild fever, but no apparent signs of heart failure. Radiology imaging (chest X-ray and thorax CT scan) showed bilateral shadows consistent with diffuse pneumonia (Figure 1). Other main findings at the second admission were: hypoxemia and hypocapnia (PaO2 50mmHg, PaCO2 33mmHg), elevated reactive C-protein (163 mg/L)), increased blood eosinophils (9.8%), normal D-dimer and BNP, negative autoimmunity. A bronchoscopy was then performed to obtain bronchoalveolar lavage (BAL) and lung transbronchial cryobpsies. The BAL resulted not diagnostically significant, nor an infectious agent was identified. The cryobpsy showed a picture typical of an inhalation pneumonia with lipid intracellular droplets in some alveolar macrophage, but without be really diagnostic for lipoid pneumonia (Figure 2). The pathologists observed also patchy organizing pneumonia and diffuse lung injury. So, the physicians questioned the patient again to realize which substances may have been inhaled quite recently, according to the quite rapid worsening of symptoms and development of bilateral pneumonia. After an accurate interrogation to the patient, we acknowledged that after the first episode of acute shortness of breath due to the rupture of mitralic tendon cord, the patient inhaled repeatedly a "natural" product given by a friend who was just come back from Thailand ( Figure 3). The product was a small cylinder containing a lipid balm basis underlying a vegeta...