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Pulmonary Talcosis 10 Years After Brief Teenage Exposure to Cosmetic Talcum Powder

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Pulmonary Talcosis 10 Years After Brief Teenage Exposure to Cosmetic Talcum Powder View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by eCommons@AKU eCommons@AKU Department of Medicine Department of Medicine September 2011 Pulmonary talcosis 10 years after brief teenage exposure to cosmetic talcum powder. Amarah Shakoor Aga Khan University Arsalan Rahatullah Aga Khan University Adil Aijaz Shah Aga Khan University Ali Bin Sarwar Zubairi Aga Khan University, [email protected] Follow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_med_med Part of the Pulmonology Commons Recommended Citation Shakoor, A., Rahatullah, A., Shah, A. A., Zubairi, A. (2011). Pulmonary talcosis 10 years after brief teenage exposure to cosmetic talcum powder.. BMJ case reports, 1-5. Available at: http://ecommons.aku.edu/pakistan_fhs_mc_med_med/303 Rare disease Pulmonary talcosis 10 years after brief teenage exposure to cosmetic talcum powder Amarah Shakoor, Arsalan Rahatullah, Adil Aijaz Shah, Ali Bin Sarwar Zubairi Department of Medicine, Aga Khan University, Karachi, Sindh, Pakistan Correspondence to Dr Ali Bin Sarwar Zubairi, [email protected] Summary Pulmonary talcosis is a rare but debilitating variant of pneumoconiosis often presenting with isolated non-specifi c symptoms of progressive exertional dyspnoea or cough. Occupational exposure to talc dust and intravenous drug abuse are well-recognised aetiological factors with only a few cases related to cosmetic talc exposure being reported to date. The authors report a case of a young woman in whom a mere 4 month ritual of inhaling cosmetic talcum powder led to full-blown pulmonary talcosis being diagnosed 10 years later. The importance of a taking a pertinent history relating to environmental exposures in all patients presenting with respiratory symptoms is re-established here. BACKGROUND weight loss or night sweats. She had been evaluated, a year Pure talc is a phyllosilicate (Mg3 Si4 O10 (OH)2 ) used in the ago, to exclude pulmonary tuberculosis at a healthcare cosmetic and pharmaceutical industries. Occupational facility outside of the country. The chest radiograph at that exposure to pure talc during its production or industrial use time demonstrated miliary shadowing which seemed to remains to be a well-known aetiological factor in causing be highly suggestive of pulmonary tuberculosis. A CT scan pulmonary talcosis, symptoms of which may occur after of the thorax revealed two small cavitary lesions in the api- several years following exposure. 1 2 Other forms of pulmo- cal region of the right lung. She had no known exposure nary pneumoconiosis involve exposure to impure varieties to pulmonary tuberculosis. The rest of the history was of talc containing asbestiform fi bres and silica affecting unremarkable. mainly miners and intravenous drug misusers. Isolated Bronchoscopy did not reveal any endo-bronchial abnor- deliberate cosmetic talcum powder inhalation however, malities. Broncho-alveolar lavage was negative for myco- is a very rare entity precipitating pulmonary talcosis. bacteria and other infectious agents, and no neoplastic cells Cosmetic powders usually contain high-purity talc which were found. can produce restrictive pulmonary disease by parenchymal A screening laboratory examination, which included infl ammation, resulting in the radiographic reticular pat- complete blood count, liver and renal function tests, was tern of diffuse interstitial thickening with or without hilar normal. A chest radiograph showed nodular lesions in adenopathy. Patients typically present with non-specifi c both lungs. Spirometry and diffusion capacity of the lungs symptoms of chronic cough and progressive dyspnoea. for carbon monoxide was normal. The sputum smear and Radiologically, the lung fi elds may show fi ndings similar to culture were negative for mycobacteria. those in asbestosis, however sparing of costophrenic sulci On physical examination, she did not appear to be anx- and lung apices is typical of talcosis. Nodule confl uence ious or in respiratory distress. Her room-air oxygen satu- results in large opacities that resemble those in progres- ration was 98%. The pulse was 68/min, blood pressure sive massive fi brosis. 3 The natural history of this disease was 110/80mm Hg and respiratory rate was 20/min. She renders it to be gradually progressive in nature even when did not have a raised jugular venous pressure. Her cardiac exposure to talc has been abandoned since long. 1 2 Thus, examination was unremarkable. On auscultation of the many such cases are misdiagnosed simply because his- chest, the only signifi cant fi nding was diffuse inspiratory tory of environmental cosmetic talcum powder exposure crackles heard bilaterally. The rest of the systemic exami- is overlooked. This case report illustrates that obtaining a nation was unremarkable. pertinent history from the patient and use of appropriate A repeat chest radiograph CT chest a year later demon- investigative modalities lead to identifi cation of a disease strated bilateral nodular opacities throughout both lungs. process that began more than a decade ago. There was no hilar adenopathy or pleural effusion (fi gures 1 and 2 ). A tuberculin test resulted in a 10 mm induration. CASE PRESENTATION The patient was counselled regarding the need for antitu- A 24-year-old woman, having a 5 pack/year history berculous therapy and empiric treatment was initiated. of smoking in addition to recreational alcohol intake, employed as an executive at a local oil fi rm, presented to INVESTIGATIONS the pulmonology clinic with complaints of progressive A fi bre optic bronchoscopy under fl uoroscopy was per- dyspnoea and non-productive cough for more than a year. formed to evaluate the trachea-bronchial tree. The bron- She did not give any history of fever, sputum production, choscopy revealed clear airways with no narrowing of the BMJ Case Reports 2011; doi:10.1136/bcr.08.2011.4597 1 of 5 Figure 1 Bilateral infi ltrates with nodular opacities throughout both lungs. tracheal lumen. Trans-bronchial biopsies were obtained from Based on the patient’s history and the clinical, radiologi- the lingula and lower lobe of the left lung. Broncho-alveolar cal and histological fi ndings, the diagnosis of talc induced lavage from both lung apices was negative for mycobacte- interstitial lung disease (talcosis) was made as a result of rial, fungal or other infectious agents and neoplastic cells. purposeful inhalation of cosmetic talcum powder. The serial Microscopic examination of the tissue samples obtained chest radiographs displayed no signifi cant improvement from the trans-bronchial biopsy revealed patchy lym- and the nodular lesions in both lungs remained unchanged. phocytic infi ltrates along with histiocytes and multinu- It was agreed by the team of treating physicians that due cleated giant cells in the alveoli which appeared to be to the stable nature of the disease no treatment would be engulfi ng a polarisable foreign material ( fi gures 3 and 4 ). required. The patient was lost to follow-up. No epitheloid granulomas, asbestos bodies or neoplastic cells were observed. DISCUSSION Talc (a hydrous magnesium silicate) is a mineral widely DIFFERENTIAL DIAGNOSIS used in the ceramic, paper, plastics, rubber, paint and 4 The differential diagnosis of a smoker presenting with cosmetic industries. Thorel proposed in 1896 that talc progressive dyspnoea, non-productive cough and nodular inhalation could lead to nodular, interstitial and fi brotic 5 opacities on chest x-ray include tuberculosis, sarcoidosis, pulmonary disease. Depending on the composition of the hypersensitivity pneumonitis, Caplan syndrome, alveo- mineral dust inhaled and the duration of exposure, various lar haemorrhagic syndromes (Good pasture’s syndrome, intriguing patterns of restrictive respiratory pathologies systemic lupus erythematosus, Wegener granulomatosis, emerge. systemic necrotising vasculitis) certain pneumoconiosis as Talc induced pneumoconiosis can be divided into four asbestosis and silicosis and drug-induced lung disease variants. The fi rst two affect mainly miners or indus- trial workers exposed to a high-load of impure talc dust containing either silica or asbestiform fi bres. Known as OUTCOME AND FOLLOW-UP talc-silicosis and talc-asbestosis, these variants have patho- After a second fi bre optic bronchoscopy, an in-depth, logical and radiological fi ndings almost identical to silico- patient history was carried out at a subsequent visit to the sis and asbestosis. 6 The third variant is common among clinic. The patient admitted to sniffi ng cosmetic talcum intravenous drug misusers indulging in crushing oral tab- powder when she was 14 years old but had stopped after lets and using them parenterally resulting in a pulmonary 4 months of doing so. She also admitted to smoking mari- foreign body granulomatosis being precipitated via haema- juana and ‘shisha’ (Persian water-pipe). She denied any togenous spread. Abusers of intravenous drugs who inject intravenous drug abuse. talc or similar substances may experience a rapid decline 2 of 5 BMJ Case Reports 2011; doi:10.1136/bcr.08.2011.4597 Figure 2 Diffuse micronodular pattern with well-defi ned centrilobular nodules and diffuse ground-glass opacities. Figure 3 Perivascular and peribronchial fi broses with non-caseating foreign body granulomas are present within the fi brotic areas and in the alveolar septa. in pulmonary function when compared to abusers of non- pharmaceutical industries with the victims ranging from adulterated agents such as heroin. industrial workers to the unaware
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