Lung Pathology: Student/Resident Case Report Poster - Lung Pathology I |

An Uncommon Cause of Fever and Pulmonary Nodules FREE TO VIEW

Gretchen Brayman, MD; Enrique Calvo-Ayala, MD; Jimmy Green, MD
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Eastern Virginia Medical School, Norfolk, VA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):793A. doi:10.1016/j.chest.2016.08.889
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SESSION TITLE: Student/Resident Case Report Poster - Lung Pathology I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Centrilobular nodules are a radiographic finding in patients with respiratory symptoms. Arterioles and bronchioles of the secondary pulmonary lobule comprise the centrilobular structure and are only apparent on imaging when diseased. Hypersensitivity pneumonitis, pneumoconiosis and respiratory bronchiolitis are the most common causes.

CASE PRESENTATION: A 39 year old otherwise healthy female presented with severe chest pain and fever after intravenous drug use (IVDU). Initial computed tomography (CT) pulmonary angiography ruled out pulmonary embolism but showed scattered nodules, lymphadenopathy, right middle lobe pneumonia and parapneumonic effusion. Blood cultures grew methicillin resistant staphylococcus aureus (MRSA). In the setting of IVDU, it was presumed to be infective endocarditis with septic emboli causing the pneumonia and effusion. The fever persisted despite six weeks of appropriate antibiotics, successful drainage of the effusion and near resolution of the pneumonia on repeat chest CT. Workup for deep vein thrombosis and other infectious etiologies as the source of fever were unrevealing. Her chest pain worsened along with the new development of dyspnea and hypoxemia. A repeat chest CT showed worsening mediastinal, hilar and axillary lymphadenopathy as well as increased nodules now with centrilobular distribution (image 1). Bronchoalveolar lavage cultures grew MRSA. Transbronchial biopsies showed polarizable foreign body granulomas consistent with pulmonary talcosis presumably from IVDU (image 2). The patient admitted to injecting crushed oxycodone.

DISCUSSION: Pulmonary talcosis is a result of occupational inhalation of asbestos, silica or other talc-containing material as well as a result of IVDU. Talc is a filler used in medications. If crushed and injected intravenously, it can embolize and lead to granuloma formation in the pulmonary vasculature. CT findings include hyperdense centrilobular micronodules, ground glass opacities, conglomerate masses and panlobular emphysema. Biopsy shows granulomas containing birefringent material under polarized light. Clinically, this can manifest acutely or gradually with dyspnea, cough, fevers, night sweats and spontaneous pneumothorax. Chronic respiratory failure, emphysema, pulmonary hypertension and cor pulmonale can develop over time.

CONCLUSIONS: Pulmonary talcosis is a rare complication of IVDU and is commonly confused with other pulmonary pathology. In this case, MRSA septic emboli initially overshadowed the diagnosis. The appearance of centrilobular nodules on imaging raised suspicion for another ongoing process. Pulmonary talcosis should be considered in the differential of IVDU patients presenting with centrilobular nodules.

Reference #1: Richards JC, Lynch DA, Chung JH. Cystic and nodular lung disease. Clin Chest Med. 2015 Jun;36(2):299-312.

Reference #2: Marchiori E, Lourenco S, Gasparetto TD, et al. Pulmonary talcosis: imaging findings. Lung. 2010 Apr;188(2):165-71.

DISCLOSURE: The following authors have nothing to disclose: Gretchen Brayman, Enrique Calvo-Ayala, Jimmy Green

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