# Some sage advice: A case report of sage burning causing interstitial lung disease

## TL;DR

A woman developed lung disease from burning sage for spiritual purposes, highlighting the importance of detailed exposure histories in diagnosing respiratory conditions.

## Contribution

This case report describes a novel histological presentation of interstitial lung disease caused by burning sage, not previously documented.

## Key findings

- A 41-year-old never-smoker developed interstitial lung disease from repeated sage burning.
- Green pigmented macrophages were observed in bronchoscopic lavage, likely from chlorophyll exposure.
- Cessation of sage burning led to clinical improvement, confirming the exposure as the cause.

## Abstract

•A detailed employment history is vital in identifying less common exposures or to challenge the clinician’s preconceptions about what an occupation involves.•Smoke inhalation may come from other sources beyond first-hand tobacco smoke and may not be identified without targeted questioning.•The nature of the components of a fire such as the accelerant, fuel, perfumes and containment may help establish the significance of the exposure.•Here, significant repeated exposure to burning organic matter has led to interstitial lung disease, which is evidenced clinically, radiologically and pathologically in a way not previously described.

A detailed employment history is vital in identifying less common exposures or to challenge the clinician’s preconceptions about what an occupation involves.

Smoke inhalation may come from other sources beyond first-hand tobacco smoke and may not be identified without targeted questioning.

The nature of the components of a fire such as the accelerant, fuel, perfumes and containment may help establish the significance of the exposure.

Here, significant repeated exposure to burning organic matter has led to interstitial lung disease, which is evidenced clinically, radiologically and pathologically in a way not previously described.

Cigarette smoking remains the commonest cause of chronic obstructive pulmonary disease (COPD) and respiratory bronchiolitis-associated interstitial lung disease (RB-ILD). Biomass combustion remains a high risk for causing respiratory disease.

We present a case of a 41-year-old woman and never-smoker with worsening breathlessness. It was identified that she made fire pits burning sage and oils for spiritual work, but beyond this had no respiratory risk factors.

Radiological evidence of RB-ILD was identified and a bronchoscopic lavage demonstrated the presence of striking green pigmented macrophages, presumed to be chlorophyll uptake.

Cessation of burning sage exposure has resulted in a positive outcome. This case highlights the need for an extensive occupational or exposure history in respiratory medicine and describes histological features of interstitial lung disease not previously identified.