A Case of Fire-eater's Pneumonia in an Active-Duty Soldier

Matthew Aboudara, MD; Joon Yun, MD

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In This Article

Discussion

The current case highlights the clinical presentation and course of patients in whom fire-eater's pneumonia develops. Aspiration of volatile hydrocarbons or "fire-eater's pneumonia" is a dramatic hydrocarbon pneumonitis occasionally seen in children and fire-eating performers. The petroleum derivative kerdane, a low viscosity and surface tension substance composed of toluene, xylene, ethylbenzene, propylbenzene, and methylbenzene, is frequently used by fire-eating performers and has been implicated in the majority of such cases.[2] The use of paraffin, or octane, has also been observed.[3] Serious toxicity from hydrocarbon compounds with high viscosity and surface tension such as mineral oil and petrolatum is less likely[1]; however, these compounds have been implicated in exogenous lipoid pneumonia, a chronic lower respiratory tract illness with histologic findings similar to those of fire-eater's pneumonia.[4] Aviation jet fuel and other commercial hydrocarbons such as kerosene, turpentine, and gasoline are composed of a mixture of several varieties of hydrocarbons, most of which are members of the paraffin, naphthene, or aromatic classes. The different types of jet fuels are determined by the varying proportions of compounds from these 3 classes.[5] JP-8 jet fuel, a kerosene-based compound, possesses relatively low viscosity and has the ability to rapidly diffuse throughout the bronchial tree and disrupt the surfactant barrier, causing an inflamed, hyperemic, nonpurulent reaction similar to that observed in our patient. Microscopic features that are similar to lipoid pneumonia include lipid-filled macrophages as the predominant cell type with a paucity of microorganisms.[6]

Despite fever and serum markers of infection, fire-eater's pneumonia is generally a pseudo-infectious lung disease with an intense inflammatory cytokine release. Antibiotics are rarely needed in the treatment of these patients as was found in our patient. The use of corticosteroids remains controversial. Some studies suggest that steroids may improve outcomes in severely affected individuals, yet these data are only based on a limited number of patients.[2,7] The use of gastric decontamination to prevent subsequent pulmonary injury from hydrocarbon ingestion is controversial. It may have potential benefit in large (> 30 cc), intentional ingestion of compounds with systemic toxicity.[1]

While long-term prognosis is uncertain, one study[2] documented normal radiographic features and pulmonary function tests 6 months after the initial injury. As is typical of fire-eater's pneumonia and was demonstrated in our patient, conservative supportive care is frequently a successful strategy of treatment.

The opinions or assertions contained herein are those of the authors and should not be construed as reflecting the views of the Department of the Army or the Department of Defense.

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