Epidemiology

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

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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
    • Meperidine (Demerol) (see Meperidine, [[Meperidine]])
    • Methlyphenidate (Ritalin) (see Methylphenidate, [[Methylphenidate]])
    • Methadone (see Methadone, [[Methadone]])
    • Hydromorphone (Dilaudid) (see Hydromorphone, [[Hydromorphone]])
    • Pentazocine (Talwin) (see Pentazocine, [[Pentazocine]])
    • Propoxyphene (see Propoxyphene, [[Propoxyphene]])
    • Amphetamine (see Amphetamine, [[Amphetamine]])
    • Tripelennamine (see Tripelennamine, [[Tripelennamine]])
  • 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

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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

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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]