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Excipient Lung Disease (Talc/Cellulose Granulomatosis)
Santiago Martínez-Jiménez, MD
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Pathology

          • Clinical Issues

            TERMINOLOGY

            • Synonyms

              • Excipient lung disease (ELD)
              • Angiocentric systemic granulomatosis
              • Pulmonary angiothrombotic granulomatosis
              • Pulmonary granulomatous vasculitis
              • Pulmonary foreign body angiogranulomatosis
              • Pulmonary mainline granulomatosis
              • Talc embolism
              • Foreign body microembolism
              • Foreign body granulomatosis
              • Intravascular talcosis
              • Ritalin lung
            • Definitions

              • Occlusion of pulmonary arterioles and capillaries by insoluble foreign body particles from intravenous (IV) injection of crushed tablets intended for oral use only, which leads to acute or chronic cor pulmonale
              • Oral tablets contain active and inactive components
                • Inactive components (excipients)
                  • Can be referred to as binders or fillers
                  • Provide stabilization, bulk, substance, or therapeutic enhancement
                  • Cellulose (most common)
                  • Talc (common but decreasing in frequency)
                  • Other (less common)
                    • Corn starch
                    • Cotton fibers
                    • Crospovidone
              • Ritalin (methylphenidate) contains talc
                • Associated with panlobular emphysema
                  • Likely triggered by drug itself with talc coadjuvancy
                    • Definite association of emphysema with IV Ritalin abuse
                    • Association of long-term appropriate oral Ritalin use with emphysema has been postulated

            IMAGING

            • General Features

              • Radiographic Findings

                • CT Findings

                  • Imaging Recommendations

                    DIFFERENTIAL DIAGNOSIS

                      PATHOLOGY

                      • General Features

                        CLINICAL ISSUES

                        • Presentation

                          • Natural History & Prognosis

                            • Treatment

                              DIAGNOSTIC CHECKLIST

                              • Consider

                                Selected References

                                1. Boonsarngsuk V et al: A case of recurrent pneumothorax related to oral methylphenidate. J Thorac Dis. 7(8):E255-7, 2015
                                2. Hamilton HH et al: The importance of microscopic examination of the lungs in decedents with sustained central intravascular catheters: a nine-case series. J Forensic Sci. 60(2):346-50, 2015
                                3. Rapello GV et al: Pulmonary emphysema induced by methylphenidate: experimental study. Sao Paulo Med J. 133(2):131-4, 2015
                                4. Altraja A et al: Pulmonary intravascular talcosis mimicking miliary tuberculosis in an intravenous drug addict. BMJ Case Rep, 2014
                                5. de Almeida RR et al: High-resolution computed tomographic findings of cocaine-induced pulmonary disease: a state of the art review. Lung. 192(2):225-33, 2014
                                6. Nguyen VT et al: Pulmonary effects of i.v. injection of crushed oral tablets: "excipient lung disease". AJR Am J Roentgenol. 203(5):W506-15, 2014
                                7. Bach AG et al: Imaging of nonthrombotic pulmonary embolism: biological materials, nonbiological materials, and foreign bodies. Eur J Radiol. 82(3):e120-41, 2013
                                8. Shrestha B et al: Sudden death by acute cor pulmonale from intravenous drug abuse during an inpatient admission: implications for unexplained in-hospital death. Clinical Pulmonary Medicine. 20(4): 192-5, 2013
                                9. Griffith CC et al: Intravascular talcosis due to intravenous drug use is an underrecognized cause of pulmonary hypertension. Pulm Med. 2012:617531, 2012
                                10. Pena E et al: Nonthrombotic pulmonary embolism: a radiological perspective. Semin Ultrasound CT MR. 33(6):522-34, 2012
                                11. Chute DJ et al: Angiocentric systemic granulomatosis. Am J Forensic Med Pathol. 31(2):146-50, 2010
                                12. Jorens PG et al: Nonthrombotic pulmonary embolism. Eur Respir J. 34(2):452-74, 2009
                                13. Ganesan S et al: Embolized crospovidone (poly[N-vinyl-2-pyrrolidone]) in the lungs of intravenous drug users. Mod Pathol. 16(4):286-92, 2003
                                14. Bendeck SE et al: Cellulose granulomatosis presenting as centrilobular nodules: CT and histologic findings. AJR Am J Roentgenol. 177(5):1151-3, 2001
                                15. Ward S et al: Talcosis associated with IV abuse of oral medications: CT findings. AJR Am J Roentgenol. 174(3):789-93, 2000
                                16. Diaz-Ruiz MJ et al: Cellulose granulomatosis of the lungs. Eur Radiol. 9(6):1203-4, 1999
                                17. Stern EJ et al: Panlobular pulmonary emphysema caused by i.v. injection of methylphenidate (Ritalin): findings on chest radiographs and CT scans. AJR Am J Roentgenol. 162(3):555-60, 1994
                                18. Pare JP et al: Long-term follow-up of drug abusers with intravenous talcosis. Am Rev Respir Dis. 139(1):233-41, 1989
                                19. Sudden death IV drug abuse
                                Related Anatomy
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                                Related Differential Diagnoses
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                                References
                                Tables

                                Tables

                                KEY FACTS

                                • Terminology

                                  • Imaging

                                    • Top Differential Diagnoses

                                      • Pathology

                                        • Clinical Issues

                                          TERMINOLOGY

                                          • Synonyms

                                            • Excipient lung disease (ELD)
                                            • Angiocentric systemic granulomatosis
                                            • Pulmonary angiothrombotic granulomatosis
                                            • Pulmonary granulomatous vasculitis
                                            • Pulmonary foreign body angiogranulomatosis
                                            • Pulmonary mainline granulomatosis
                                            • Talc embolism
                                            • Foreign body microembolism
                                            • Foreign body granulomatosis
                                            • Intravascular talcosis
                                            • Ritalin lung
                                          • Definitions

                                            • Occlusion of pulmonary arterioles and capillaries by insoluble foreign body particles from intravenous (IV) injection of crushed tablets intended for oral use only, which leads to acute or chronic cor pulmonale
                                            • Oral tablets contain active and inactive components
                                              • Inactive components (excipients)
                                                • Can be referred to as binders or fillers
                                                • Provide stabilization, bulk, substance, or therapeutic enhancement
                                                • Cellulose (most common)
                                                • Talc (common but decreasing in frequency)
                                                • Other (less common)
                                                  • Corn starch
                                                  • Cotton fibers
                                                  • Crospovidone
                                            • Ritalin (methylphenidate) contains talc
                                              • Associated with panlobular emphysema
                                                • Likely triggered by drug itself with talc coadjuvancy
                                                  • Definite association of emphysema with IV Ritalin abuse
                                                  • Association of long-term appropriate oral Ritalin use with emphysema has been postulated

                                          IMAGING

                                          • General Features

                                            • Radiographic Findings

                                              • CT Findings

                                                • Imaging Recommendations

                                                  DIFFERENTIAL DIAGNOSIS

                                                    PATHOLOGY

                                                    • General Features

                                                      CLINICAL ISSUES

                                                      • Presentation

                                                        • Natural History & Prognosis

                                                          • Treatment

                                                            DIAGNOSTIC CHECKLIST

                                                            • Consider

                                                              Selected References

                                                              1. Boonsarngsuk V et al: A case of recurrent pneumothorax related to oral methylphenidate. J Thorac Dis. 7(8):E255-7, 2015
                                                              2. Hamilton HH et al: The importance of microscopic examination of the lungs in decedents with sustained central intravascular catheters: a nine-case series. J Forensic Sci. 60(2):346-50, 2015
                                                              3. Rapello GV et al: Pulmonary emphysema induced by methylphenidate: experimental study. Sao Paulo Med J. 133(2):131-4, 2015
                                                              4. Altraja A et al: Pulmonary intravascular talcosis mimicking miliary tuberculosis in an intravenous drug addict. BMJ Case Rep, 2014
                                                              5. de Almeida RR et al: High-resolution computed tomographic findings of cocaine-induced pulmonary disease: a state of the art review. Lung. 192(2):225-33, 2014
                                                              6. Nguyen VT et al: Pulmonary effects of i.v. injection of crushed oral tablets: "excipient lung disease". AJR Am J Roentgenol. 203(5):W506-15, 2014
                                                              7. Bach AG et al: Imaging of nonthrombotic pulmonary embolism: biological materials, nonbiological materials, and foreign bodies. Eur J Radiol. 82(3):e120-41, 2013
                                                              8. Shrestha B et al: Sudden death by acute cor pulmonale from intravenous drug abuse during an inpatient admission: implications for unexplained in-hospital death. Clinical Pulmonary Medicine. 20(4): 192-5, 2013
                                                              9. Griffith CC et al: Intravascular talcosis due to intravenous drug use is an underrecognized cause of pulmonary hypertension. Pulm Med. 2012:617531, 2012
                                                              10. Pena E et al: Nonthrombotic pulmonary embolism: a radiological perspective. Semin Ultrasound CT MR. 33(6):522-34, 2012
                                                              11. Chute DJ et al: Angiocentric systemic granulomatosis. Am J Forensic Med Pathol. 31(2):146-50, 2010
                                                              12. Jorens PG et al: Nonthrombotic pulmonary embolism. Eur Respir J. 34(2):452-74, 2009
                                                              13. Ganesan S et al: Embolized crospovidone (poly[N-vinyl-2-pyrrolidone]) in the lungs of intravenous drug users. Mod Pathol. 16(4):286-92, 2003
                                                              14. Bendeck SE et al: Cellulose granulomatosis presenting as centrilobular nodules: CT and histologic findings. AJR Am J Roentgenol. 177(5):1151-3, 2001
                                                              15. Ward S et al: Talcosis associated with IV abuse of oral medications: CT findings. AJR Am J Roentgenol. 174(3):789-93, 2000
                                                              16. Diaz-Ruiz MJ et al: Cellulose granulomatosis of the lungs. Eur Radiol. 9(6):1203-4, 1999
                                                              17. Stern EJ et al: Panlobular pulmonary emphysema caused by i.v. injection of methylphenidate (Ritalin): findings on chest radiographs and CT scans. AJR Am J Roentgenol. 162(3):555-60, 1994
                                                              18. Pare JP et al: Long-term follow-up of drug abusers with intravenous talcosis. Am Rev Respir Dis. 139(1):233-41, 1989
                                                              19. Sudden death IV drug abuse