Vol.2, No.7, 672-675 (2010)
doi:10.4236/health.2010.27101
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Health
Granulomatous interstitial lung disease in a long-term
drug abuser
Karen Laudenbach*, Jan Koch, Bernd Seese
Thoraxzentrum Bezirk Unterfranken, Münnerstadt, Germany; *Corresponding Author:
Received 3 March 2010; revised 14 April 2010; accepted 15 April, 2010.
ABSTRACT
It is the habit of some drug consumers to dis-
solve the powder of crushed pills, intended for
oral use, in water and inject this solution intra-
venously. Insoluble particles than obstruct pul-
monary vessels causing microscopic pulmo-
nary emboli. These foreign bodies migrate and
penetrate into the perivascular space and inter-
stitium, resulting in chronic inflammation and
foreign body giant cell reaction. As a result of
this a granulomatous interstitial fibrosis can
develop, which has also been described as pul-
monary talcosis. We are reporting the case of a
22 year old male with a history of long-term in-
travenous drug abuse. He presented to our
hospital complaining of dyspnoea, cough and
generalized weakness. We describe an exten-
sive diagnostic process concluded by an open
lung biopsy establishing a definitive diagnosis
of this rare granulomatous lung disease. This
case underlines the importance of a thorough
diagnostic work up and the pathogenic potentia l
of foreign material reaching the lung via blood
circulation in amongst the differential diagno-
ses of interstitial lung diseases, especially oc-
curring in this group of patients.
Keywords: Pulmonary Talcosis;
Granuloma tous Pneumoconiosis; Dr u g Abuse;
Heroin; Foreign Body Granuloma;
Interstitial Lung Disease
1. CASE REPORT
We report of a 22 year old male Patient with a history of
intravenous heroine use since he was 15 years old. His
general health had been deteriorating for some months.
At presentation he complained of increasing shortness of
breath on exertion, fatigue and fainting episodes.
2. PHYSICAL EXAMINATION
The patient seemed malnourished and overall in poor
health. On auscultation he had normal breath sounds. A
systolic murmur over the tricuspid valve area was noted.
Examination of the abdomen, musculoskeletal system
and nervous system was without pathological findings.
3. DIAGNOSTIC RESULTS
Chest Radiograph: Showed diffuse interstitial pulmonary
nodules.
Blood results: ACE 57 U/l (< 52), CRP 10.2 mg/dl,
specific IgG against mould and candida-negative, D-
Dimer 1.3 mg/l (< 0.3), BNP 1433pg/ml Serology for
Legionella and Mycoplasma-negative Anti-HCV-posi-
tive, HIV I and II-negative.
Arterial Blood Gases (ABG): pH: 7.48 pCO228 mmHg,
pO287 mmHg, Bicarbonate 22.8 mval/l. BE –1, 9.
Pulmonary Function Test: (Bodyplethysmography) Fo-
rced expiratory volume (FEV1) 2.2l (53% predicted),
vital capacity (VC) 2.82l (56%), FEV1/VC 78% (94%),
Total lung capacity (TLC) 4.67l (74%), Gas transfer
(TLCO) 5.24 m m ol /m i n/ kPas (47% ).
Echocardiography: Tricuspid regurgitation (Grade 3),
systolic pulmonary artery pressure (PAPsyst.) 37 mmHg
+ central venous pre ssure.
Electrocardiography: Sinusrhythm, Right bundle bran-
ch block
High-resolution-CT Thorax: diffuse interstitial and fine
micronodular infiltration in throughout both lungs (Fig-
ure 1).
Bronchoscopy: no abnormal findings. Bronchial aspi-
rate: scanty E.coli and Staphylococcus aureus. No acid
fast bacilli.
Bronchoalveolar lavage: some smoker macrophages,
otherwise unremarkable
Transbronchial biopsy: Evidence of extensive granu-
lomatous interstitial fibro sis.
Under polarized light: granulomas containing crystal-

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line birefringent material (Figure 2).
The patients overall condition improved with symp-
tomatic treatments. Over the following month he did
however continue to inject heroin. He also admitted to
inject a mixture of cigarette ashes and water into his
femoral vein on at least one occasion.
Six months later he was re-hospitalized due to right
sided chest pain, combined with acute dyspnoea, general
weakness and cough with brownish expectoration. He
was hypotensive (blood pressure 70/40 mmHg) with a
heart rate of 12 0 bpm.
4. FINDINGS
Blood results: CRP 8.6 mg/dl, D-Dimer 3.6 mg/l, E.coli
on sputum examination
Pulmonary function test (Bodyplethysmography): FEV1
1.04l (25% predicted), FEV1/VC 69% (83%), VC 1.49l
(30%), TL C 4.37l (69%).
ABG: pH 7.48 pCO2 23.7 mmHg pO2 54.4 mmHg
Figure 1. High resolution CT Thorax: diffuse interstitial mi-
cronodular pattern with conglomerate formation.
crystalline bi refri ngent materi al
Figure 2. left: H&E-stain, right: under polarized light, positive
birefringent material (2.5 × magnified).
Bicarbonate 17.5 mmol/l, BE –4, 4.
High resolution CT Thorax: progressive diffuse inter-
stitial, micronodular changes throughout both lungs.
Bilateral small single nodules, one in the right lower
lobe measuring 13 mm, one right paracardial measuring
10 mm.
Ventilation/Perfusion scintigraphy 12 days after hos-
pitalization: no evidence of new or old pulmonary em-
boli.
Doppler ultrasound of the legs: no pathological find-
ings.
Under symptomatic treatment including antibiotics
according to sensitivities and oxygen-therapy his condi-
tion and cardiopulmonary status stabilized within a few
days. Blood gas analysis returned to normal. A short
course of systemic Corticosteroids (Prednisolon at a
dose of 0.5 mg/ kg b odyweight) was gi ven .
In order to establish a definitive diagnosis the patient
underwent an open lung biopsy a month later. Tissue
sample were obtained from the right lower lobe (S6/9)
and the right uppe r l obe.
Macroscopically the lung had a fine granular appear-
ance. The cut surface presented small up to 4 mm sized
brown nodules and a tumourous conglomerate in the
specimen from left lower lobe.
Histologically there was strong granulomatous in-
flammation caused by foreign material with surrounding
interstitial fibrosis. The appearances were in keeping
with a pulmonary talcosis (drug abuser lung). The speci-
men from the upper lobe showed a patchy pneumonia
with multiple foci of abscess formation.
5. DISCUSSION
Chest radiography and high resolution CT showed a dif-
fuse interstitial lung disease. The pulmonary function
test demonstrated moderately severe restrictive and ob-
structive airflow and a reduction in diffusion capacity.
Patchy pneumonic changes seen in the histological
specimen were felt to be of a secondary nature. A primary
bacterial or tuberculous origin of the manifest interstitial
changes could be excluded. There was nothing in the
patient’s history to suggest extrinsic allergic alveolitis.
Serology for that purpose was also negative.
Transbronchial biopsy as well as open lung biopsy
demonstrated histological evidence of granulomatous in-
flamemation surrounding typical foreign body giant cells.
In the centre of these granulomas parts of blood vessels
and capillaries could be seen suggesting that foreign
material reached the lung via venous circulation. (Figure
4) This histological finding is typical for an intravenous
pulmonary talcosis (drug abuser lung).
Drug users often inject the powder of crushed pills,

K. Laudenbach et al. / HEALTH 2 (2010) 67 2-675
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
674
intended for oral use, dissolved in water. These often
contain a particular filler such as talc, starch o r cellulose,
magnesium stearate and silica [1,2]. Insoluble particles
obstruct pulmonary arteries and capillaries causing mi-
croscopic pulmonary emboli. In the following stage these
foreign bodies migrate and penetrate into the perivascu-
lar space and interstitium where they cause chronic in-
flammation and provoke a foreign body giant cell reac-
tion [3]. The result is a gr anu lo matous in terstitial fib r o sis
(drug abuser lung). The physician is confronted with a
broad clinical spectrum ranging from no symptoms up to
fulminant disease and death. Common symptoms are
cough, progressive dyspnoea and weight loss [4].
Auscultation may be unremarkable or reveal discrete
bibasal crackles.
Sometimes patients present with mild or moderate
hypoxia. Pulmonary function tests can be restrictive or
obstructive. A typical diagnostic finding is an impair-
ment of gas transfer [5].
Chest x-ray may be normal, but might show compact
diffuse masses [6]. Transbronchial biopsy or surgical lung
biopsy will confirm the diagno sis of pulmonary talcosis.
The characteristic histological finding would be a granu-
lomatous inflammatory reaction, with foreign material
enclosed in typical foreign body giant cells (Figure 3).
Following long term drug abuse there are a range of
patterns in which talcosis can be seen on CT. They con-
sist of fine micronodular pattern, conglomerate parahilar
masses on a background of micronodularity, ground
glass attenuation, and panacinar or centrilobular emphy-
sema. These patterns frequently appear in combination
[7].
Other manifestations include pneumothorax, pulmo-
nary hypertension, pulmonary fibrosis and chronic res-
piratory failure in the final stage [3]. Up to 80% of long
term drug abusers can develop a talc retinopathy. Over
23% of intrav en ou s drug add icts show evid en ce of sep tic
emboli [8].
Silicosis and sarcoidosis are the two most important
differential diagno ses to be considered . Due to the po ssi-
bility of a coexisting HIV infection miliary tuberculosis
should also be thought of and excluded by bronchial lav-
age.
Miliary metastases and opportunistic respiratory in-
fections such as Pneumocystis jirovecii, CMV or atypi-
cal pneumonia (Legionella and Chlamydia) are further
important differential diagnoses. An extrinsic allergic al-
veolitis should be excluded by serology and history tak-
ing.
Reports on the natural course and treatment of talc
granulomatosis are scarce. Pare et al. described irrever-
sible progression of radiographic abnormalities, even after
long term abstinence [3]. The most important therap eutic
crystals
Figure 3. Foreign body granuloma with crystals (10 × magni-
fied).
forei
g
n material
Figure 4. Pulmonary vessel with intraluminal foreign material.
intervention however is to stop any further intravenous
drug use, smoking cessation and adequate treatment of
significant pu lmonary hypertension.
Smith et al. describe a positive response to treatment
with corticosteroids, initially at a dose of 60 mg Predni-
solone daily [4]. In some severe cases of talcosis lung
transplantation could be considered, providing complete
drug abstinence can be confirmed [9].
6. CONCLUSIONS
Interstitial lung disease needs thorough and often exten-
sive diagnostic clarification.
Whilst inhaled environmental and industrial agents
represent an important factor in the pathogenesis of this
disease group, we must also consider substances and
foreign material reaching the lung via blood circulation
and other pathways as described in this case.
It illustrates very well the importance of completing
the diagnostic process, reminding the physician of this

K. Laudenbach et al. / HEALTH 2 (2010) 67 2-675
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675
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rare cause of granulomatous lung disease in a specific
high risk population.
Openly accessible at
7. ACKNOWLEDGEMENTS
There is no conflict of interest. The corresponding author confirms,
there is no liability to any of the firms mentioned in this article. The
presentation is independent and the conten t remains neutral.
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