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 "Clinical assessment of substance use disorders" 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].
Subscribers log in hereLiterature review current through: Nov 2017. | This topic last updated: Apr 01, 2016.References
- Chute DJ, Rawley J, Cox J, et al. Angiocentric systemic granulomatosis. Am J Forensic Med Pathol 2010; 31:146.
- Pintado V, Valencia ME, Lavilla P, et al. [Angiothrombotic pulmonary granulomatosis in intravenous drug addicts]. Rev Clin Esp 1991; 188:362.
- Low SE, Nicol A. Talc induced pulmonary granulomatosis. J Clin Pathol 2006; 59:223.
- Farber HW, Falls R, Glauser FL. Transient pulmonary hypertension from the intravenous injection of crushed, suspended pentazocine tablets. Chest 1981; 80:178.
- Farber HW, Fairman RP, Millan JE, et al. Pulmonary response to foreign body microemboli in dogs: release of neutrophil chemoattractant activity by vascular endothelial cells. Am J Respir Cell Mol Biol 1989; 1:27.
- Genereux GP, Emson HE. Talc granulomatosis and angiothrombotic pulmonary hypertension in drug addicts. J Can Assoc Radiol 1974; 25:87.
- Ferrer J, Montes JF, Villarino MA, et al. Influence of particle size on extrapleural talc dissemination after talc slurry pleurodesis. Chest 2002; 122:1018.
- Paré JP, Cote G, Fraser RS. Long-term follow-up of drug abusers with intravenous talcosis. Am Rev Respir Dis 1989; 139:233.
- Schmidt RA, Glenny RW, Godwin JD, et al. Panlobular emphysema in young intravenous Ritalin abusers. Am Rev Respir Dis 1991; 143:649.
- Groth DH, Mackay GR, Crable JV, Cochran TH. Intravenous injection of talc in a narcotics addict. Arch Pathol 1972; 94:171.
- Vevaina JR, Civantos F, Viamonte M Jr, Avery WG. Emphysema associated with talcum granulomatosis in a drug addict. South Med J 1974; 67:113.
- Stern EJ, Frank MS, Schmutz JF, et al. Panlobular pulmonary emphysema caused by i.v. injection of methylphenidate (Ritalin): findings on chest radiographs and CT scans. AJR Am J Roentgenol 1994; 162:555.
- Kringsholm B, Christoffersen P. The nature and the occurrence of birefringent material in different organs in fatal drug addiction. Forensic Sci Int 1987; 34:53.
- Johnson DC, Petru A, Azimi PH. Foreign body pulmonary granulomas in an abuser of nasally inhaled drugs. Pediatrics 1991; 88:159.
- Oubeid M, Bickel JT, Ingram EA, Scott GC. Pulmonary talc granulomatosis in a cocaine sniffer. Chest 1990; 98:237.
- Lamb D, Roberts G. Starch and talc emboli in drug addicts' lungs. J Clin Pathol 1972; 25:876.
- Bendeck SE, Leung AN, Berry GJ, et al. Cellulose granulomatosis presenting as centrilobular nodules: CT and histologic findings. AJR Am J Roentgenol 2001; 177:1151.
- Diaz-Ruiz MJ, Gallardo X, Castañer E, et al. Cellulose granulomatosis of the lungs. Eur Radiol 1999; 9:1203.
- Nguyen VT, Chan ES, Chou SH, et al. Pulmonary effects of i.v. injection of crushed oral tablets: "excipient lung disease". AJR Am J Roentgenol 2014; 203:W506.
- Ganesan S, Felo J, Saldana M, et al. Embolized crospovidone (poly[N-vinyl-2-pyrrolidone]) in the lungs of intravenous drug users. Mod Pathol 2003; 16:286.
- Johnston B, Smith P, Health D. Experimental cotton-fibre pulmonary embolism in the rat. Thorax 1981; 36:910.
- Kulaylat MN, Barakat N, Stephan RN, Gutierrez I. Embolization of illicit needle fragments. J Emerg Med 1993; 11:403.
- Marchiori E, Zanetti G, Mano CM, et al. Talc-induced pulmonary granulomatosis or septic pulmonary embolism? A diagnostic challenge. Ann Thorac Surg 2010; 90:362.
- Houck RJ, Bailey GL, Daroca PJ Jr, et al. Pentazocine abuse. Report of a case with pulmonary arterial cellulose granulomas and pulmonary hypertension. Chest 1980; 77:227.
- Rhodes RE, Chiles C, Vick WW. Talc granulomatosis presenting as spontaneous pneumothorax. South Med J 1991; 84:929.
- Lundquest DE, Young WK, Edland JF. Maternal death associated with intravenous methylphenidate (Ritalin) and pentazocine (Talwin) abuse. J Forensic Sci 1987; 32:798.
- Marchiori E, Lourenço S, Gasparetto TD, et al. Pulmonary talcosis: imaging findings. Lung 2010; 188:165.
- Martidis A, Yung CW, Ciulla TA. Talc embolism: a static retinopathy. Am J Ophthalmol 1997; 124:841.
- El-Jabali F, Cohen S. Images in clinical medicine. Talc retinopathy. N Engl J Med 2006; 354:e11.
- Fraser-Bell S, Capon M. Talc retinopathy. Clin Exp Ophthalmol 2002; 30:432.
- Nadim F, Walid H, Adib J. The differential diagnosis of crystals in the retina. Int Ophthalmol 2001; 24:113.
- Del Giudice P. Cutaneous complications of intravenous drug abuse. Br J Dermatol 2004; 150:1.
- O'Connor RN, Brunham RC, Bowden DH. Pulmonary talc granulomatosis mimicking Pneumocystis carinii pneumonia. CMAJ 1988; 138:53.
- Marinelli WA, Davies SF. Granulomatous diseases of the lung that mimic respiratory infections. Semin Respir Infect 1988; 3:181.
- Radow SK, Nachamkin I, Morrow C, et al. Foreign body granulomatosis. Clinical and immunologic findings. Am Rev Respir Dis 1983; 127:575.
- Farber HW, Fairman RP, Glauser FL. Talc granulomatosis: laboratory findings similar to sarcoidosis. Am Rev Respir Dis 1982; 125:258.
- Flora GS, Sharma AM, Sharma OP. Talc granulomatosis: two unusual presentations. Sarcoidosis 1991; 8:136.
- Woywodt A, Schneider W, Goebel U, Luft FC. Hypercalcemia due to talc granulomatosis. Chest 2000; 117:1195.
- Nan DN, Fernández-Ayala M, Iglesias L, et al. Talc granulomatosis. A differential diagnosis of interstitial lung disease in HIV patients. Chest 2000; 118:258.
- Ben-Haim SA, Ben-Ami H, Edoute Y, et al. Talcosis presenting as pulmonary infiltrates in an HIV-positive heroin addict. Chest 1988; 94:656.
- Itkonen J, Schnoll S, Daghestani A, Glassroth J. Accelerated development of pulmonary complications due to illicit intravenous use of pentazocine and tripelennamine. Am J Med 1984; 76:617.
- Ward S, Heyneman LE, Reittner P, et al. Talcosis associated with IV abuse of oral medications: CT findings. AJR Am J Roentgenol 2000; 174:789.
- Padley SP, Adler BD, Staples CA, et al. Pulmonary talcosis: CT findings in three cases. Radiology 1993; 186:125.
- Ong TH, Takano A. Severe endobronchitis and airway stricture caused by inhalation of cosmetic talc. Chest 2012; 142:511.
- Redondo AA, Ettensohn DB, Khan M, Kessimian N. Bronchoalveolar lavage in talc induced lung disease. Thorax 1988; 43:1019.
- Kringsholm B, Christoffersen P. Lung and heart pathology in fatal drug addiction. A consecutive autopsy study. Forensic Sci Int 1987; 34:39.
- Abraham JL, Brambilla C. Particle size for differentiation between inhalation and injection pulmonary talcosis. Environ Res 1980; 21:94.
- Paré JA, Fraser RG, Hogg JC, et al. Pulmonary 'mainline' granulomatosis: talcosis of intravenous methadone abuse. Medicine (Baltimore) 1979; 58:229.
- Smith RH, Graf MS, Silverman JF. Successful management of drug-induced talc granulomatosis with corticosteroids. Chest 1978; 73:552.
- Chau CH, Yew WW, Lee J. Inhaled budesonide in the treatment of talc-induced pulmonary granulomatosis. Respiration 2003; 70:439.
- Hashimoto M, Kobayashi K, Yamagata N, et al. Suppression of pulmonary granulomatous inflammation by immunomodulating agents. Agents Actions 1992; 37:99.
- Farber H, Glauser FL. The effect of oral hydralazine on the pulmonary hemodynamics of patients with pulmonary foreign body granulomatosis. Chest 1982; 82:708.
- Cook RC, Fradet G, English JC, et al. Recurrence of intravenous talc granulomatosis following single lung transplantation. Can Respir J 1998; 5:511.
- Shlomi D, Shitrit D, Bendayan D, et al. Successful lung transplantation for talcosis secondary to intravenous abuse of oral drug. Int J Chron Obstruct Pulmon Dis 2008; 3:327.
- Weinkauf JG, Puttagunta L, Nador R, et al. Long-term outcome of lung transplantation in previous intravenous drug users with talc lung granulomatosis. Transplant Proc 2013; 45:2375.
- 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