Ann Thorac Surg 2003;76:1740-1741
© 2003 The Society of Thoracic Surgeons
Case report
Chronic pain due to talc pleurodesis for spontaneous pneumothorax
Richard Milton, FRCSa*,
Alex R. J. Cale, FRCSa
a East Yorkshire Heart Center, Castlehill Hospital, Hull, United Kingdom
Accepted for publication April 3, 2003.
* Address reprint requests to Dr Milton, East Yorkshire Heart Center, Castlehill Hospital, Castle Road, Cottingham, Hull HU16 5JQ, United Kingdom
e-mail: richardmilton{at}doctors.org.uk
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Abstract
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Spontaneous pneumothorax is a common condition that usually affects young adults. Talc insufflation, either as a poudrage or by using slurry, is recognized as an effective treatment. We report a case of talc that resulted in chronic debilitating pain and necessitated further surgery.
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Introduction
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Talc is a highly effective pleurodesis agent used in the treatment of both pneumothorax and pleural effusion [1]. However, problems due to talc can occur, including acute pain, fever, and more seriously, adult respiratory distress syndrome [2].
We present a case of previous talc pleurodesis that resulted in chronic pain and necessitated further surgery.
A 27-year-old British man had a right-sided spontaneous pneumothorax develop while on holiday in Holland. This was managed by closed intercostal drainage. However, when the drain was removed his lung collapsed, and he underwent video-assisted thoracoscopic talc poudrage. Subsequently the patient was discharged with a fully expanded lung.
Four weeks later at home in Britain, he suffered a spontaneous pneumothorax of the left lung, which was managed by video-assisted thoracoscopic pleurectomy and apical bullectomy. The patient was discharged after 5 days with a fully expanded left lung.
At follow-up, the patient complained of right-sided chest pain (talc poudrage), predominantly toward the apex, but he had no pain on the left side (pleurectomy). Despite review by pain management specialists and treatment with multiple analgesics and antidepressants, the pain persisted for more than 1 year, which caused significant disruption and changes in his lifestyle. A computed tomographic scan of the patient’s chest revealed calcified pleural thickening, particularly at the right apex, which was associated with the talc pleurodesis (Fig 1).
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Fig 1. Computed tomographic scan of the chest demonstrating calcified pleural thickening towards the right apex (arrow).
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Two years after the talc poudrage he underwent a right thoracotomy. There was extensive thickening of the parietal pleura, up to 2 cm thick, similar to that seen in an empyema. However, surprisingly there were few adhesions between the lung and the pleura. Within this thickened pleura were nodules ranging from a few millimeters to a centimeter in diameter, which was associated with evidence of active inflammation. One of the larger nodules was burrowing into the second interspace posteriorly and impinging on the intercostal bundle near the neck of the second rib, which itself was partially eroded. An extensive pleurectomy was performed removing all abnormal tissue. Histologic examination showed that there was extensive infiltration of the pleura by Langerhans giant cells forming part of a foreign body reaction to a crystalline material (Fig 2).
The patient made an uneventful postoperative recovery and was discharged 7 days after surgery. He was pain-free and no longer taking analgesics 3 months after surgery.
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Fig 2. Section through pleurectomy specimen, stained with hematoxylin & eosin under partly polarized light. The pleura is infiltrated extensively by Langerhans giant cells forming part of a foreign body–type reaction to a crystalline material (hematoxylin & eosin, x20).
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Comment
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Talc is effective as a pleurodesis agent when it is administered by poudrage or by using slurry [3]. The talc appears to work by causing a low-grade mononuclear cell inflammatory reaction resulting in fibrinous pleural adhesions [4]. Although associated with a low morbidity, patients may show signs of tachycardia and low-grade fever after talc administration. Other more serious com-plications associated with the use of talc include adult respiratory distress syndrome, infection, and pneumonitis [2]. Although talc pleurodesis has not been associated with the development of intrathoracic malignancy [5], other crystalline substances have been associated with it, such as asbestos. However, talc has been implicated in the development of ovarian carcinoma [6]. In our institution, talc is used exclusively in the treatment of malignant pleural effusions and persistent pneumothorax in patients unfit for general anesthetics.
Chronic pain after talc administration in this case resulted in significant morbidity and impacted hugely on this patient’s quality of life. Given the low mortality and morbidity associated with video-assisted thoracoscopic pleurectomy and abrasion, or both, the authors would recommend this as the treatment of choice in the management of spontaneous pneumothorax in young patients.
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References
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- de Campos J.R., Vargas F.S., de Campos W., et al. Thoracoscopy talc poudrage: a 15-year experience. Chest 2001;119:801-806.[Medline]
- Brant A., Eaton T. Serious complications with talc slurry pleurodesis. Respirology 2001;6:181-185.[Medline]
- Kennedy L., Sahn S.A. Talc pleurodesis for the treatment of pneumothorax and pleural effusion. Chest 1994;106:1215-1222.[Medline]
- Kennedy L., Harley R.A., Sahn S.A., Strange C. Talc slurry pleurodesis. Pleural fluid and histologic analysis. Chest 1995;107:1707-1712.[Medline]
- Anonymous. A survey of the long-term effects of talc and kaolin pleurodesis. Research Committee of the British Thoracic Association and the Medical Research Council Pneumoconiosis Unit. Br J Dis Chest 1979;73:285–8
- Chang S., Risch H.A. Perineal talc exposure and risk of ovarian carcinoma. Cancer 1997;79:2396-2401.[Medline]
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Abstract
Introduction
