Foreign body granulomatosis
- Katherine P Hendra, MD
Katherine P Hendra, MD
- Assistant Clinical Professor of Medicine
- Tufts University School of Medicine
- Harrison W Farber, MD
Harrison W Farber, MD
- Professor of Medicine
- Boston University School of Medicine
Pulmonary foreign body granulomatosis is caused by intravenous injection of pulverized pharmaceutical tablets or, rarely, by nasal inhalation of drugs cut with insoluble binding agents. Several terms have been used to describe this condition, including self-induced pulmonary granulomatosis, pulmonary angiothrombotic granulomatosis, pulmonary mainline granulomatosis, and angiocentric (or angiothrombotic) systemic granulomatosis [1,2].
Tablets intended for oral use typically contain insoluble binding agents, such as talc (hydrated magnesium silicate), microcrystalline cellulose, crospovidone, potato starch, and cornstarch . Medications abused in this manner (either alone or in combination) include methylphenidate (Ritalin), oral opiates (methadone, pentazocine, and meperidine), and antihistamines.
Pulmonary foreign body granulomatosis will be reviewed here. The recognition and management of drug abusers and pulmonary disease in injection drug users are discussed separately. (See "Substance use disorder: Principles for recognition and assessment in general medical care" and "Overview of pulmonary disease in injection drug users".)
The pathophysiology of lung disease caused by injection of pulverized tablets varies based on the agent injected and the route of exposure. The most information comes from studies of talc granulomatosis.
Talc — Talc (hydrous magnesium silicate) is used in tablets (eg, methadone, pentazocine, methylphenidate, amphetamine) as a filler and lubricant. Experimental injection of crushed pentazocine tablets or an equivalent amount of talc in dogs revealed similar changes in pulmonary artery pressures and lymph flow with the two agents . Talc embolization causes an initial arteritis, which is associated with the rapid influx of neutrophils around the intravascular foreign body. This influx may in part be mediated by endothelial cell production of a neutrophil chemoattractant factor . Increased levels of immunoglobulins and products of lymphocyte activation (eg, tumor necrosis factor, interleukins) are also present. Areas of thrombosis in the pulmonary arteries have been described in autopsy series of patients who died following acute injection [2,3,6].
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- Microcrystalline cellulose
- Cotton-wool fibers
- Cornstarch and soluble sugars
- Needle fragments
- CLINICAL FEATURES
- Clinical presentation
- Physical examination
- DIFFERENTIAL DIAGNOSIS
- DIAGNOSTIC EVALUATION
- Laboratory testing
- Pulmonary function tests
- Right heart catheterization
- Bronchoalveolar lavage
- Lung biopsy
- Asymptomatic radiographic changes
- Acute onset
- Chronic progressive disease
- Pulmonary hypertension
- LUNG TRANSPLANTATION
- SUMMARY AND RECOMMENDATIONS