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Excipient Lung Disease
Santiago Martínez-Jiménez, MD
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Pathology

          • Clinical Issues

            TERMINOLOGY

            • Abbreviations

              • Excipient lung disease (ELD)
            • Synonyms

              • 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 → acute or chronic cor pulmonale
              • Oral tablets contain active and inactive components
                • Inactive components (excipients)
                  • Also 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 use
                    • 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. Ovid: Sudden death IV drug abuse. Accessed July 2021. Reviewed July 2021. http://ovidsp.tx.ovid.com/
                                2. DiAngelo C et al: Clinically unsuspected injection drug abuse in hospitalized teens diagnosed on pathology. Pediatr Dev Pathol. 23(5):404-7, 2020
                                3. Boonsarngsuk V et al: A case of recurrent pneumothorax related to oral methylphenidate. J Thorac Dis. 7(8):E255-7, 2015
                                4. 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
                                5. Rapello GV et al: Pulmonary emphysema induced by methylphenidate: experimental study. Sao Paulo Med J. 133(2):131-4, 2015
                                6. Altraja A et al: Pulmonary intravascular talcosis mimicking miliary tuberculosis in an intravenous drug addict. BMJ Case Rep, 2014
                                7. 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
                                8. 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
                                9. Bach AG et al: Imaging of nonthrombotic pulmonary embolism: biological materials, nonbiological materials, and foreign bodies. Eur J Radiol. 82(3):e120-41, 2013
                                10. 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
                                11. Griffith CC et al: Intravascular talcosis due to intravenous drug use is an underrecognized cause of pulmonary hypertension. Pulm Med. 2012:617531, 2012
                                12. Pena E et al: Nonthrombotic pulmonary embolism: a radiological perspective. Semin Ultrasound CT MR. 33(6):522-34, 2012
                                13. Chute DJ et al: Angiocentric systemic granulomatosis. Am J Forensic Med Pathol. 31(2):146-50, 2010
                                14. Jorens PG et al: Nonthrombotic pulmonary embolism. Eur Respir J. 34(2):452-74, 2009
                                15. 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
                                16. Bendeck SE et al: Cellulose granulomatosis presenting as centrilobular nodules: CT and histologic findings. AJR Am J Roentgenol. 177(5):1151-3, 2001
                                17. Ward S et al: Talcosis associated with IV abuse of oral medications: CT findings. AJR Am J Roentgenol. 174(3):789-93, 2000
                                18. Diaz-Ruiz MJ et al: Cellulose granulomatosis of the lungs. Eur Radiol. 9(6):1203-4, 1999
                                19. 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
                                20. Pare JP et al: Long-term follow-up of drug abusers with intravenous talcosis. Am Rev Respir Dis. 139(1):233-41, 1989
                                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

                                          • Abbreviations

                                            • Excipient lung disease (ELD)
                                          • Synonyms

                                            • 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 → acute or chronic cor pulmonale
                                            • Oral tablets contain active and inactive components
                                              • Inactive components (excipients)
                                                • Also 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 use
                                                  • 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. Ovid: Sudden death IV drug abuse. Accessed July 2021. Reviewed July 2021. http://ovidsp.tx.ovid.com/
                                                              2. DiAngelo C et al: Clinically unsuspected injection drug abuse in hospitalized teens diagnosed on pathology. Pediatr Dev Pathol. 23(5):404-7, 2020
                                                              3. Boonsarngsuk V et al: A case of recurrent pneumothorax related to oral methylphenidate. J Thorac Dis. 7(8):E255-7, 2015
                                                              4. 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
                                                              5. Rapello GV et al: Pulmonary emphysema induced by methylphenidate: experimental study. Sao Paulo Med J. 133(2):131-4, 2015
                                                              6. Altraja A et al: Pulmonary intravascular talcosis mimicking miliary tuberculosis in an intravenous drug addict. BMJ Case Rep, 2014
                                                              7. 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
                                                              8. 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
                                                              9. Bach AG et al: Imaging of nonthrombotic pulmonary embolism: biological materials, nonbiological materials, and foreign bodies. Eur J Radiol. 82(3):e120-41, 2013
                                                              10. 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
                                                              11. Griffith CC et al: Intravascular talcosis due to intravenous drug use is an underrecognized cause of pulmonary hypertension. Pulm Med. 2012:617531, 2012
                                                              12. Pena E et al: Nonthrombotic pulmonary embolism: a radiological perspective. Semin Ultrasound CT MR. 33(6):522-34, 2012
                                                              13. Chute DJ et al: Angiocentric systemic granulomatosis. Am J Forensic Med Pathol. 31(2):146-50, 2010
                                                              14. Jorens PG et al: Nonthrombotic pulmonary embolism. Eur Respir J. 34(2):452-74, 2009
                                                              15. 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
                                                              16. Bendeck SE et al: Cellulose granulomatosis presenting as centrilobular nodules: CT and histologic findings. AJR Am J Roentgenol. 177(5):1151-3, 2001
                                                              17. Ward S et al: Talcosis associated with IV abuse of oral medications: CT findings. AJR Am J Roentgenol. 174(3):789-93, 2000
                                                              18. Diaz-Ruiz MJ et al: Cellulose granulomatosis of the lungs. Eur Radiol. 9(6):1203-4, 1999
                                                              19. 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
                                                              20. Pare JP et al: Long-term follow-up of drug abusers with intravenous talcosis. Am Rev Respir Dis. 139(1):233-41, 1989