Foreign Body Granulomatosis

Epidemiology

  • Prevalence: talc granulomatosis occurs in 15-80% of addicts (by autopsy studies): depending on type of addiction (ie: drug used)

Etiology and Physiology

IV Injection of Talc (Magnesium Silicate) (see Talc, [[Talc]])

  • Etiology: intravenous injection of talc, which is commonly used as a filler for drugs of abuse
    • Orally-Formulated Drugs of Abuse: talc or starch fillers are commonly used in the intravenous injection of orally-formulated drugs
    • Crack Cocaine (see Cocaine, [[Cocaine]]): talc is also commonly used to “cut” injectable crack cocaine
    • Heroin (see Heroin, [[Heroin]]): interestingly, foreign body granulomatosis occurs less commonly with heroin abuse, as heroin is typically mixed in soluble fillers (such as quinine, lactose, or maltose)
  • Physiologic Consequences of Injected Talc
    • Pulmonary Fibrosis and Advanced Emphysema: due to injected talc usually is taken up by interstitium in lungs
    • Pulmonary Vascular Inflammation and Secondary Thrombosis: due to embolized talc

IV Injection of Other Particulate Matter

  • Etiology: talc or starch fillers are commonly used in the intravenous injection of orally-formulated drugs (like meperidine, methlyphenidate, methadone, dilaudid, talwin, propoxyphene, amphetamines, and tripelennamine)
  • Physiologic Consequences of Injected Particulate Matter
    • Pulmonary Hypertension: due to occlusion of pulmonary vasculature by injected foreign material (especially cotton fibers)
    • Granulomatous Arteritis: due to talc
    • Pulmonary Fibrosis and Lung Destruction: due to particles migration through the wall of vessel

Clinical Manifestations

Pulmonary Manifestations

Progressive Massive Fibrosis-Like Conglomerate Lung Masses (see Lung Nodule or Mass, [[Lung Nodule or Mass]])

  • Clinical: xxx

Granulomatous Interstitial Lung Disease/Fibrosis (see Interstitial Lung Disease-Etiology, [[Interstitial Lung Disease-Etiology]])

  • Diagnosis
    • CXR/Chest CT Patterns
      • 1-3 mm micronodular infiltrates, mimicking picture seen in pulmonary alveolar microlithiasis
      • Upper lobe reticular infiltrates
      • Normal: 50% of cases
    • Pulmonary Function Tests (PFT’s): decreased DLCO (early indicator)
    • Bronchoscopy: lymphocytosis, intracellular and free talc
    • Lung Biopsy: granulomas, multinucleated giant cells, mononuclear inflammatory cells, lymphocytes, fibrosis, strongly birefringent crystals using polarzied light (talc) within granulomas
  • Clinical
    • Dyspnea (see Dyspnea, [[Dyspnea]])
  • Treatment
    • Corticosteroids (see Corticosteroids, [[Corticosteroids]]): unclear if they are effective

Hilar Lymphadenopathy (see Mediastinal Mass, [[Mediastinal Mass]])

  • Clinical: xxx

Advanced Emphysema-Like Picture (see Obstructive Lung Disease, [[Obstructive Lung Disease]])

  • Epidemiology
  • Diagnosis
    • CXR/Chest CT
      • Hyperinflation with basilar bullae

Granulomatous Pulmonary Arterial Occlusion with Pulmonary Hypertension (see Pulmonary Hypertension, [[Pulmonary Hypertension]])

  • Diagnosis
    • CXR/Chest CT
  • Clinical
    • Syncope
    • Right-Sided Congestive Heart Failure (CHF)
    • Sudden Death

Ocular Manifestations

  • Talc Retinopathy (occurs in >50% of cases): talc emboli near macula within small vessels

References

  • Am J Roentgenol 2000; Pare, ARRD 1989
  • Chest 2000; 118 (1): 258-260
  • Intravascular Talcosis due to Intravenous Drug Use Is an Underrecognized Cause of Pulmonary Hypertension. Pulm Med. 2012; 2012: 617531. doi: 10.1155/2012/617531 [MEDLINE]