Polytetrafluoroethylene fume–induced pulmonary edema: a case report and review of the literature

A previously healthy 35-year-old Japanese man was admitted to our hospital with dyspnea and dry cough. He had fallen asleep while leaving a PTFE-coated pan on the stove, which caught fire. He awoke 10 hours later with severe dyspnea and noticed that the room was filled with white smoke. The PTFE coating of the pan was completely burned off, although the fire had not spread outside the pan. Upon admission, his vital signs were as follows: body temperature, 37.1°C; heart rate, 100 beats/min; blood pressure, 131/97mmHg; respiratory rate, 30 breaths/min; and percutaneous oxygen saturation, 98% (on oxygen 10L/min via a non-rebreather mask). The patient was alert and denied using any medications, including illicit drugs. Auscultation revealed bilateral coarse crackles. His white blood cell count was 22,100/μl with 91.2% neutrophils, and his arterial oxygen pressure was 233.5mmHg while he was on 10L/min oxygen. A chest X-ray showed bilateral infiltration (Figure 1A). Chest computed tomography (CT) revealed massive, bilateral, patchy consolidations with ground-glass opacities and sparing of the peripheral areas (Figure 1B). These lesions were distributed in a dorsally dominant manner (Figure 1B). The patient’s echocardiogram and electrocardiogram were normal, so a diagnosis of PTFE fume–induced, non-cardiogenic pulmonary edema with systemic inflammatory response syndrome (SIRS) was made. The patient was admitted and treated with non-invasive positive pressure ventilation (NPPV) and intravenous sivelestat (Elaspol®; Ono Pharmaceutical, Osaka, Japan). NPPV was initiated in a setting of positive end-expiratory pressure of 8cmH₂O and intravenous sivelestat at a dosage of 4.8 mg/kg/day, which dramatically alleviated his symptoms and improved his oxygenation on the day of admission. His respiratory status rapidly improved, and a second chest CT scan on day 9 revealed complete resolution of the infiltrates (Figure 1B). The patient was discharged to home without any sequelae on hospital day 11.

On 30 September 2014, we searched for all reported cases of PTFE fume–induced pulmonary edema on the PubMed, Embase, Web of Science, OvidSP and several Japanese databases (Ichushi Web, J-STAGE, Medical Online and CiNii), without language restriction and using the following keywords: “polymer fume fever,” “Teflon®,” “polytetrafluoroethylene,” “pulmonary/lung edema” and “acute lung injury/acute respiratory distress syndrome (ARDS).” Three of the authors (RH, YO and RI) performed independent screenings. Cross-referencing was performed, and all the relevant case reports and studies were included. We excluded the following: (1) cases without evidence of pulmonary edema, (2) cases without an association with PTFE fumes and (3) academy meeting abstracts. The search produced 121 articles, of which 17 were potential candidates [1-16]. Next, clinical features including patient characteristics, the situation under which exposure occurred, symptoms, treatment and outcome were reviewed by three intensivists (RH, YO, and RI). One report was excluded because of insufficient information [3], leaving 16 reports and 17 relevant cases [1,2,4-16] for inclusion in this review. The temperature of the overheated PTFE was estimated based on information in the relevant reports (molding settings [4,5,11], cigarettes [17] and an overheated pan [18]). SIRS was defined according to the criteria originally proposed by the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference [19]. All CT images of PTFE fume–induced pulmonary edema were interpreted independently by two chest radiologists (KK and TT). The distribution of the disease and the dominant lesion were also noted. Thirteen reports without CT findings were excluded [1,4-14], resulting in four reports [2,3,15,16] and eight cases ultimately being eligible for inclusion in this review.

The clinical characteristics of PTFE fume–induced pulmonary edema described in this review, including our patient, are summarized in Table 1. The patient demographics of the cases in the literature review consisted of 16 men and 2 women, aged 21 to 59 years. Many patients were smokers (12 of 18), and most did not have any comorbidities (15 of 18). Among all of the reports included here, seven cases involved exposure to PTFE-containing materials in factories or laboratories, 6 cases were of patients who had smoked PTFE-contaminated cigarettes and 5 reports described exposure to fumes from overheating PTFE-coated kitchenware in the home. Common symptoms were dyspnea (17 of 18), cough (12 of 18) and flu-like symptoms such as fever (9 of 18) and chills (6 of 18). SIRS was frequently present (10 of 18). All patients had evidence of exposure to fumes developed from overheated (391 to 875°C) PTFE. One patient was exposed to PTFE fumes for 9 hours and died 5 hours after admission despite intensive treatment that included intubation [11]. Neither NPPV nor neutrophil elastase inhibitor was used in previously reported cases. Transbronchial lung biopsy was performed in one case, which revealed marked neutrophil migration into the alveoli with edema in the alveolar septa [12]. Table 2 shows the chest CT characteristics of PTFE fume–induced pulmonary edema, including our patient. Four patients underwent chest CT on the day of admission: two on day 2 and two on day 4. Common findings were ground-glass opacities (eight of eight), peripheral area sparing (six of eight) and patchy consolidation (four of eight). With the exception of a single patient, these lesions were distributed bilaterally (seven of eight) and predominantly on the back in most cases (five of eight).

Written informed consent was obtained from the patient for publication of this case report and the accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.