Figure 1: Ill-defined, mass-like density in the right middle lobe of the lung.

Mentions: Laboratory results including complete blood count, renal function and liver function tests were all within normal limits. Human immunodeficiency virus (HIV) serology was negative. A chest X-ray (Figure 1) showed an ill-defined density close to the right heart border, and a computed tomography (CT) scan (Figure 2) confirmed a 4.5 × 2.2 cm opacity in the medial aspect of the right middle lobe, with emphysematous changes and spiculated opacities in both lung fields suspicious for malignant spread. A CT scan of the abdomen and pelvis was unremarkable.

Krimsky WS, Dhand S - J Med Case Reports (2008)

Bottom Line: Computed tomography confirmed a probable mass with further speculated opacities in both lung fields suspicious for malignant spread.The history and imaging findings in a chronic smoker were initially strongly suggestive of malignant disease, and we recommend that talc-induced lung disease is considered in any patient with multiple scattered pulmonary lesions and a history of intravenous drug use.Confirmation of the disease by biopsy is essential, but unfortunately there are few successful proven management options for patients with worsening disease.

Affiliation: Johns Hopkins University School of Medicine, Baltimore, MD, USA. krimskyw@dfmc.org

Abstract: Pulmonary talc granulomatosis is a rare disorder characterized by the development of foreign body granuloma secondary to talc exposure. Previous case reports have documented the illness in current intravenous drug users who inject medications intended for oral use. We present a rare case of the disease in a patient with a distant history of heroin abuse who presented initially with history and imaging findings highly suggestive of malignancy.A 53-year-old man reported a 4-month history of increasing dyspnea and weight loss. He had a long history of smoking and admission chest X-ray revealed a density in the right hemithorax. Computed tomography confirmed a probable mass with further speculated opacities in both lung fields suspicious for malignant spread. Biopsies obtained using endobronchial ultrasound-guided aspiration returned negative for malignancy and showed bronchial epithelial cells with foreign body giant cell reaction and polarizable birefringent talc crystals.This case demonstrates a rare presentation of talc granulomatosis three decades after the last likely exposure. The history and imaging findings in a chronic smoker were initially strongly suggestive of malignant disease, and we recommend that talc-induced lung disease is considered in any patient with multiple scattered pulmonary lesions and a history of intravenous drug use. Confirmation of the disease by biopsy is essential, but unfortunately there are few successful proven management options for patients with worsening disease.