INTRODUCTION: Pleurodesis is the symphysis between the visceral and parietal pleural surfaces. Compared with other agents for chemical pleurodesis, talc may be the most effective with the least recurrence of effusion(1). The safety of intrapleural application of talc has been debated with known cases of respiratory failure and acute respiratory distress syndrome(1). We present a unique case of a patient who developed a stable pleural mass following this treatment, eventually causing symptoms 17 years after talc pleurodesis. A PET/CT revealed intense hypermetabolic uptake suggesting malignancy. A core biopsy demonstrated an intense inflammatory reaction with macrophage ingestion of a polarizable foreign body, talc.
CASE PRESENTATION: A 37 year old female with a history of extensive tobacco abuse presented to our clinic as a referral for evaluation of a left pleural mass. The patient had a distant history of recurrent left pneumothoraces requiring chest thoracostomy tubes with concurrent large upper lobe bullae. She underwent a left upper lobe bullectomy and talc pleuriodesis 17 years prior to her presentation. She was followed with serial CT scans of the chest because of calcified left pleural nodularity. Her chief complaints at her intital visit to our clinic were left chest pain for the prior several years and dyspnea on exertion. Because of a questionable change in the morphology of the pleural mass, a PET/CT was ordered. The imaging demonstrated intense hypermetabolic uptake with a maximum SUV of 13.8 in mulptiple soft tissue densities along the left pleura including the major fissure, concerning for malignancy. The radiographic appearance suggested localized fibrous mesothelioma. A CT guided core biopsy of the left pleural lesion was performed and demonstrated fibrosis and an extensive foreign body reaction. There was diffuse polarizable material with intense macrophage ingestion. There was no evidence of malignancy.
DISCUSSIONS: Talc pleurodesis is a widely utilized and successful prodecure in the management of recurrent pneumothoraces or recurrent and refractory pleural effusions. The most common adverse events occurring after talc pleurodesis are fever, dyspnea, pain, and gastrointestinal symptoms. Less common side effects include arrhythmia, empyema, talc dissemination and respiratory failure secondary to ARDS. Talc is a sclerosing agent which induces an intense, but intentional inflammatory response resulting in rapid adhesion of the parietal and visceral pleura. In the literature, only scarce information is available on the inflammatory mechanism. It is theorized that sclerosing agents such as talc induce an influx of polymorphonuclear neutrophils followed by an accumulation of mononuclear cells. Several chemokines have been implicated including interleukin-8 (IL-8) and monocyte chemotactic protein (MCP-1)(2). Our patient has a cellular response suggesting acute inflammation, to a foreign body which has resided in her pleural space for almost two decades.
CONCLUSION: In summary, we present a unique case of a 37 year-old patient with chronic chest pain, a hypermetabolic calcified pleural mass which is proven to be an intense inflammatory reaction to talc pleurodesis 17 years prior. Ongoing symptomatic acute inflammation to very remote pleural talc administration has not previously been desribed in the literature.
DISCLOSURE: Anwar Haque, No Financial Disclosure Information; No Product/Research Disclosure Information