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Ann Thorac Surg 2009;87:1941-1943. doi:10.1016/j.athoracsur.2008.11.005
© 2009 The Society of Thoracic Surgeons
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Case Reports

An Unusual Presentation of Spontaneous Pneumothorax Secondary to Talc-Induced Pulmonary Granulomatosis

Manuel Caceres, MDa, Rebecca Braud, BSb, Harvey Edward Garrett, Jr, MDc,d,*

a Department of Cardiothoracic Surgery, Appalachian Regional Healthcare, Hazard, Kentucky
b Department of Cardiothoracic Surgery, Louisiana State University School of Medicine, New Orleans, Louisiana
c Department of Cardiothoracic Surgery, Baptist Memorial Hospital, Memphis, Tennessee
d Department of Cardiothoracic Surgery, The University of Tennessee HSC, Memphis, Tennessee

Accepted for publication November 3, 2008.

* Address correspondence to Dr Garrett, Jr., 6029 Walnut Grove Rd, Suite 401, Memphis, TN 38120 (Email: egarrettmd{at}cvsclinic.com).


   Abstract
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 Abstract
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Talc-induced pulmonary granulomatosis is an unusual condition resulting from the intravenous administration of medications intended for oral use. A patient with this condition who presented with a spontaneous tension pneumothorax is reported. Although the radiographic findings of a diffuse reticulonodular pattern are typical, this patient was found to have diffuse, small cavitary pulmonary nodules. Surgeons should be aware of this rare condition and should have a low threshold for performing a thoracoscopic lung biopsy.


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Talc-induced pulmonary granulomatosis (TIPG) as a result of the intravenous administration of powdered medications intended for oral use has been reported in the literature. Talc is a common excipient used in a variety of oral medications. The description of this condition is limited to isolated case reports and small case series primarily involving drug-addicted individuals. Different patterns of pulmonary reticulonodular disease have been described. An unusual case of TIPG presenting as diffuse cavitary pulmonary nodules, complicated by spontaneous tension pneumothorax is presented.

A 41-year-old man presented to the emergency room with complaints of productive cough, shortness of breath, fever, and chills. Past medical history was significant for hepatitis C, chronic pain, and tibial osteomyelitis after multiple orthopedic procedures as a result of trauma to the lumbar spine and lower extremities. The patient admitted to chronic use of oral narcotics and benzodiazepines. Physical examination revealed a low-grade fever and coarse breath sounds bilaterally with decreased breath sounds in the left base. There was no palpable lymphadenopathy. The remainder of the physical examination was otherwise unremarkable.

A chest roentgenogram revealed patchy, bibasilar pneumonic infiltrates. A computed tomographic (CT) chest scan revealed bilateral pulmonary infiltrates and multiple small cavitary pulmonary nodules approximately 1 cm in diameter, many of them abutting the pleural surface (Fig 1).


Figure 1
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  		Fig 1. Spontaneous pneumothorax secondary to talc-induced pulmonary granulomatosis.

 
The patient was admitted to the hospital and treated with intravenous antibiotics for presumed community acquired pneumonia. Four days later, sudden shortness of breath developed in the patient, who was found to have a tension pneumothorax. The lung was re-expanded after placement of a thoracostomy tube. The patient recovered, the thoracostomy tube was removed, and he was discharged home after a 14-day hospitalization. Subsequently, for the next 2 weeks the patient continued to complain of shortness of breath. A second CT scan of the chest 4 weeks after initial presentation revealed a loculated pleural effusion at the left base and persistent cavitary pulmonary lesions (Fig 2). Additional tests were performed searching for mycobacterial and fungal infections or Wegener's granulomatosis, considering the unusual cavitary lesions found in the CT scan of the chest. Fungal serology, tuberculin skin test, acid-fast stains of the sputum, anti-neutrophillic antibodies, and human immunodeficiency virus status were reported as negative.


Figure 2
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  		Fig 2. Loculated pleural effusion after re-expansion of a pneumothorax developed as a result of talc-induced pulmonary granulomatosis.

 
The patient was finally taken to the operating room where he underwent thoracoscopic drainage of the loculated left pleural effusion along with an additional wedge biopsy of the upper lobe. Bacterial, mycobacterial, and fungal cultures of the pleural fluid were negative.

Pathologic examination of the lung revealed multiple noncaseating granulomas suggestive of sarcoidosis; however, further analysis revealed the lung parenchyma to contain birefringent particles. These elements were present in the lumen and walls of the pulmonary capillaries, as well as the perivascular connective tissue and alveolar septa. The appearance and refractive properties of these particles were consistent with talc.

The patient then admitted to intravenous use of self-administered, crushed oral methadone. He fully recovered fully and his symptoms resolved. A subsequent CT scan of the chest at 2 months postoperatively revealed residual pleural scarring and re-expansion of the left lung.


   Comment
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Methadone was introduced in 1964 as an oral maintenance agent for the treatment of heroin addicts [1]. Subsequently, its effectiveness was found to be considerably greater when administered parenterally. Tablets were illicitly crushed and dissolved in water prior to intravenous use. This practice was subsequently expanded to include other oral medications, including pentazocine hydrochloride, methylphenidate, and amphetamine sulfate, among others.

Talc-induced pulmonary granulomatosis, as a result of intravenous talc injection, has been described in the literature, in case reports, and in small case series. There have been four categories of TIPG described: (1) talcosilicosis, (2) talcoasbestosis, (3) inhalation of pure talc, and (4) intravenous administration of talc-containing oral medications. Except for the last category, TIPG has generally been through an inhalational route [2].

Talc is used by the pharmaceutical industry as an excipient in oral medications. Once the tablets are crushed and intravenously injected, the talc particles lodge in the pulmonary capillary bed and incite the formation of perivascular granulomas. Some patients may develop small vessel thrombosis resulting in pulmonary hypertension. Talc particles can also migrate into the interstitium and create a diffuse fibrotic reaction [3]. Repeated intravenous exposure to talc particles seems directly related to the likelihood of migration into the pulmonary interstitium which results in a restrictive pattern consistent with pulmonary fibrosis [4].

The largest radiologic review of pulmonary talcosis was reported by Ward and colleagues [5] who described CT roentgenographic findings in 12 patients, most of whom were methadone-addicted individuals. The predominant findings consisted of a diffuse fine nodular pattern, a combination of nodules and conglomerate masses, and panacinar and centrilobular emphysema. Pare and colleagues [6] described the clinical course of 6 patients with TIPG over 10 years. Again, roentgenographic findings included diffuse pinpoint micronodularity, presence of apical conglomerate masses, and emphysema. On long-term follow-up, progressive pulmonary fibrosis developed in some of these patients, and 3 of them ultimately expired from respiratory insufficiency.

There is no prior report of the presence of multiple cavitary lesions as a result of TIPG. Rhodes and colleagues [7] authored the only report found in the literature of TIPG presenting as spontaneous pneumothorax. In this report, the chest roentgenogram revealed a loculated pneumothorax associated with a reticulo-nodular background. Pare and colleagues [6] described the cases of 2 patients who developed a pneumothorax near the end of their terminal course.

This is an unusual case of talc-induced pulmonary granulomatosis presenting with unique radiographic findings, consisting of multiple subpleural pulmonary cavitary lesions associated with pneumothorax. The diagnosis of TIPG requires a high level of suspicion and is likely to be missed without a lung biopsy. These patients may be immunosuppressed, and the presentation can be confused with a variety of opportunistic infections. Intravenous administration of oral medications is a growing problem, and TIPG has to be considered in the setting of any pulmonary abnormalities in this patient population.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Dole VP, Nyswander ME. Rehabilitation of heroin addicts after blockade with methadone NY State J Med 1966;55:2011-2017.
  2. Hollinger MA. Pulmonary toxicity of inhaled and intravenous talc Toxicol Lett 1990;52:121-127.[Medline]
  3. Low SE, Nicol A. Talc induced pulmonary granulomatosis J Clin Pathol 2006;59:223.[Free Full Text]
  4. Oubeid M, Bickel JT, Ingram EA, Scott GC. Pulmonary talc granulomatosis in a cocaine sniffer Chest 1990;98:237-239.[Abstract/Free Full Text]
  5. Ward S, Heyneman LE, Reittner P, Kazerooni EA, Godwin JD, Muller. Talcosis associated with IV abuse of oral medications: CT findings Am J Roentgenol 2000;174:789-793.[Abstract/Free Full Text]
  6. Pare JP, Cote G, Fraser RS. Longterm follow-up of drug abusers with intravenous talcosis Am Rev Respir Dis 1989;139:233-241.[Medline]
  7. Rhodes RE, Chiles C, Vick WM. Talc granulomatosis presenting as spontaneous pneumothorax South Med J 1991;84:929-930.[Medline]



This article has been cited by other articles:


Home page
 Ann. Thorac. Surg.Home page
E. Marchiori, G. Zanetti, C. M. Mano, B. Hochhegger, and K. L. Irion
Talc-Induced Pulmonary Granulomatosis or Septic Pulmonary Embolism? A Diagnostic Challenge
Ann. Thorac. Surg., July 1, 2010; 90(1): 362 - 363.
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Home page
 Ann. Thorac. Surg.Home page
M. Caceres and H. Garrett Jr
Reply
Ann. Thorac. Surg., July 1, 2010; 90(1): 363 - 363.
[Full Text] [PDF]

This Article
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