Pulmonary-Cutaneous Talcosis.

SESSION TITLE: ILD Student/Resident Case Report PostersSESSION TYPE: Medical Student/Resident Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Pulmonary Talcosis (PT) is a rare disease mostly due to inhalation of talc. Intravascular PT is a variant that might be seen in IVDU who inject crushed tablets. We report a case of PT in IVDU mimicking pneumonia with unique cutaneous foreign body giant cell reaction similar to the lung lesion.CASE PRESENTATION: A 63 yo AA male with a PMH of HTN, chronic HCV & h/o IVDU presented with persistent dry cough, worsening dyspnea & night sweats for more than 2 months. He denied fever, chills, smoking or sick contacts. A month earlier he had similar symptoms when CXR showed RLL infiltrates & treated as pneumonia. On current admission, he was in mild respiratory distress & complains of pain in right wrist. Temp 36.8,BP 143/97,HR 96,RR 22 and SaO2 92 % on 4L. He had right basilar crepitations posteriorly & skin over right wrist was red, tender and warm with restricted ROM. The rest of exam was normal. CBC & CMP were normal. Legionella & Strep urine AGs, mycoplasma serology, blood & respiratory cultures were negative. HIV serology was negative. CXR showed persistent RLL infiltrates and he was treated for HCA pneumonia and cellulitis. Incision & drainage of the right wrist was dry. Surgical debridement with pathology followed. CT chest showed RLL mass with spiculated edges & no lymphadenopathy. A bronchoscopy was negative for intrabronchial lesions and pathology from both lung (Fig.2) & skin (Fig.1) lesions showed foreign body giant cell reaction to polarizable foreign material. BAL was negative for malignant cells, AFB, fungi or bacteria. The patient later admitted to injecting crushed opioid tablets.DISCUSSION: Pulmonary disease due to Talc was thought to be mostly related to occupational exposure,1 after first described in 1986 in miners with cough and dyspnea. PT due to exposure to cosmetic powder talc was reported.2 Intravenous PT was described among IVDU who inject crushed tablets. Following IVDU, talc deposits in the pulmonary vasculature inciting angiothrombosis, foreign body granulomas & pulmonary fibrosis. Extrapulmonary talcosis in the myocardium, liver, kidneys and spleen was rarely reported.3 Skin Involvement was not reported. Diagnosis of PT needs thorough history taking & high suspicion index. Histopathology is the gold standard. Prognosis is poor & response to steroids is variable. Lung transplant is the only viable option for end stage lung disease.CONCLUSIONS: Although PT is rare; cough, dyspnea & pulmonary infiltrates with poor response to conventional therapies should prompt clinicians to consider PT in IVDUs.Reference #1: 1 Woywodt A, Schneider W, Goebel U and Luft FC.Hypercalcemia due to talc granulomatosis.Chest. 2000;117(4):1195-1196Reference #2: 2 Shakoor A, Rahatullah A, Shah AA and Zubairi AB. Pulmonary talcosis 10 years after brief teenage exposure to cosmetic talcum powder. BMJ case reports. 2011;2011:10.1136/bcr.08.2011.4597Reference #3: 3 Tomashefski JF,Jr and Hirsch CS. The pulmonary vascular lesions of intravenous drug abuse.Human pathology.1980;11(2):133-145DISCLOSURE: The following authors have nothing to disclose: Michael Ghobrial, Hany FaragNo Product/Research Disclosure Information.