1979, British Journal of Radiology, 52, 586-588 Case reports ACKNOWLEDGMENT
The authors gratefully acknowledge the secretarial assistance of Angela Hattaway in the preparation of this manuscript. REFERENCES
MEINDOK, H., and LANGER, B., 1976. Liver scan in BuddChiari syndrome. Journal of Nuclear Medicine, 17, 365— 368. POLLARD, J. J., and NEBESAR, R. A., 1967. Altered hemo-
dynamics in the Budd-Chiari syndrome demonstrated by selective hepatic and selective splenic angiography. Radiology, 89, 236-243.
CHAYES, Z., KEONIGSBERG, M., and FREEMAN, L., 1974. The
hot hepatic abscess. Journal of Nuclear Medicine, 15, 305307.
SALVO, A. F., SCHILLER, A., ATHANASOULIS, C , GALDABINI,
GOONERATNE, N. S., BUSE, M. G., QUINN, J. L., and SELBY,
J., and MCKUSICK, K. A., 1977. Hepatoadenoma and
J. B., 1977. "Hot spot" on hepatic scintigraphy and focal nodular hyperplasia: pitfalls in radiocolloid imaging. radionuclide venacavography. American Journal of RoentRadiology, 125, 451-455. genology, Radiation Therapy and Nuclear Medicine, 129, STAAB, E. V., HARTMAN, R. C , and PARROTT, J. A., 1975. 447-450. Liver imaging in the diagnosis of hepatic vein thrombosis LEE, K. E., PRESTON, D. F., MARTIN, N. L., and ROBINSON, in paroxysmal nocturnal hemoglobinuria. Radiology, 117, R. G., 1976. Angiographic documentation of systemic341-348. portal venous shunting as a cause of a liver scan "hot spot" VOLPE, J. A., and JOHNSTON, G. S., 1970. "Hot" hepatic in superior vena caval obstruction. American Journal of hemangioma. A unique radiocolloid-concentrating liver Roentgenology, Radiation Therapy and Nuclear Medicine, scan lesion. Journal of Surgical Oncology, 2, 373-377. 127, 637-639. YEH, E. L., POHLMANN, G. P., and MEAD, R. C , 1976. MCLAUGHLIN, W. T., 1976. Liver scan in Budd-Chiari Liver-heart imaging in evaluation of hepatic focal defect. syndrome. Journal of Nuclear Medicine, 17, 1019. Journal of Nuclear Medicine, 16, 896-898.
Pulmonary disease caused by the Inhalation of cosmetic talcum powder By I. P. Wells, M.R.C.P., F.R.C.R., P. A. Dubbins, B.Sc, F.R.C.R. and W. F. Whimster, M.R.C.P., M.R.C.Path. Departments of Diagnostic Radiology and Pathology, King's College Hospital, London, S.E.6 {Received August, 1978 and in revisedform January, 1979) The inhalation of talc, a chemical compound of hydrous magnesium silicate, has long been known to cause pulmonary infiltrates (Porro and Levine, 1946; Messite, etal., 1959). As mined, and as used as a lubricant in the leather, rubber and paper industries talc contains considerable impurities including asbestos. Heavy exposure to this industrial grade talc produces radiological changes which include interstitial reticulo-nodular shadowing and pleural plaques (Fraser and Pare, 1970). Hildick-Smith (1976) in a recent review of the biology of talc points out that domestic talc does not contain impurities, and that people working with this pure talc do not develop pulmonary disease. Work with animals has also failed to show pulmonary disease even after massive exposures to domestic talc (Wagner et al., 1977). The domestic use of talc might therefore not be expected to constitute a health hazard since not only is the talc used of cosmetic grade, but also the exposure is infrequent and of short duration. We report a case of chronic pulmonary disease apparently the result of excessive use of domestic talcum powder.
suspected but staining and culture of the sputum for tubercle bacilli were repeatedly negative. The Mantoux test was negative at 1 in 10 000 dilution. Exercise tolerance worsened during June and therapy with Rifampicin and Isoniazid was started for a presumptive diagnosis of tuberculosis. Four months later the chest radiograph showed extension of the right apical shadowing and partial collapse with consolidation of the left upper lobe (Fig. 1). Bronchoscopy revealed the left main bronchus to be
CASE REPORT
A 41-year-old housewife was first seen in March, 1973 when she was complaining of shortness of breath on exercise. A chest radiograph showed a small area of illdefined shadowing at the right apex. Tuberculosis was
FIG. 1 Chest radiograph showing shadowing at the right apex and collapse of the left upper lobe.
586
JULY
1979
Case reports narrowed with inflamed walls. Biopsy of the bronchial wall revealed epithelioid and giant cell systems compatible with sarcoidosis or tuberculosis but no caseation or acid-fast bacilli were present however. Steroids (5 mg Prednisone t.d.s.) were added to the therapy at this time. After some slight improvement there was again deterioration in exercise tolerance and a dry cough developed in May 1974. The radiograph remained unchanged although respiratory function tests were abnormal (VC 2.15 L, FeV 1.15 L, FeV% 54%). A Kveim test and numerous pre-
cipitins including those for aspergillus were negative. Steroid therapy was stopped. In September, 1974 the chest radiograph revealed illdefined medium sized nodules throughout the lungs with poor definition of the heart borders and hila (Fig. 2A and B). An open lung biopsy was performed. As a result of the pathology of the lung tissue obtained the anti-tuberculous therapy was stopped. The patient on direct questioning admitted to very heavy use of talcum powder over many years. She was in the habit of dusting the whole body with talc at least once daily. The talc had been applied in a small unventilated room likely to favour inhalation. The talc use was stopped, since when the patient's condition has remained unchanged. She remains short of breath and her chest radiograph has remained virtually unchanged over the last four years. PATHOLOGY
A piece of firm grey tissue 3 x 2 . 5 x 1 cm was received. Histologically there were numerous granulomata and extensive fibrosis. The granulomata showed no necrosis, but multinucleate giant cells were plentiful. Staining and culture for acid fast bacilli were negative. With polarized light many birefringent particles were seen, often within the giant cells (Fig. 3). The residual tissue was macerated and the residue inspected by electron microscopy which revealed particles consistent with talc. This was confirmed by the X-ray diffraction pattern. DISCUSSION
A review of the literature has revealed only three previous reports of pulmonary disease referable to the use of cosmetic talc in adults. Nam and Gracey (1972) report the case of a negro man who had smothered his bed with talc at night for 20 years. He developed pulmonary fibrosis detected at autopsy. Moskowitz (1970) reports a woman who developed dyspnoea and pulmonary reticulo-nodular shadowing after many years as a tester of talc aerosols and Fraser and Pare (1970) report the case of a 31-yearold woman who developed pulmonary symptoms with mediastinal lymphadenopathy, nodular shadowing and areas of consolidation on the radiograph. She had been in the habit of inhaling lavender talc directly from her cupped hands. Despite the experimental proof to the contrary, it would seem that very rarely cosmetic talc may be implicated in the causation of pulmonary disease. Perhaps an unidentified additional intrinsic factor is necessary before cosmetic talc becomes harmful. Certainly in our case the use of talc has been excessive. The radiograph may show widespread interstitial nodulation with or without line shadows. There may by lymphadenopathy, and fibrosis has developed in three of the four published cases. The clinical and radiological features therefore are not specific and in particular the differential diagnosis from sarcoid and tuberculosis may be difficult. We would suggest however that a careful history regarding talc usage is FIG. 2. taken in patients with resistant pulmonary infiltrates (A) Chest radiograph showing widespread ill-defined noduof unknown aetiology. Adequate histological studies lation. (B) Detail from left upper zone. 587
VOL.
52, No. 619 Case reports
FIG. 3. Histological section of open lung biopsy showing foreign body giant cells. Some of these contain birefringent crystalline material (arrows). H. & E. X 200. Polarized light.
MOSKOWITZ, R. L., 1970. Talc pneumoconiosis, a treated case. Chest, 58, 37-41. NAM, K., and GRACEY, D., 1972. Pulmonary talcosis from cosmetic talcum powder. Journal of the American Medical REFERENCES Association, 221, 452-453. FRASER, R. G., and PARE, J. A. P., 1970. Diagnosis of Disease of the Chest, pp. 937-938 (W. B. Saunders, Philadelphia- PORRO, F. W., and LEVINE, N. M., 1946. Pathology of talc pneumoconiosis with report of autopsy. North New York London). HILDICK-SMITH, L., 1976. The biology of talc. British Medical Journal, 3, 23-25. Journal of Industrial Medicine, 33, 217-230. WAGNER, J. C , BERRY, G., COOKE, T. J., HILL, R. J., and MESSITE, J., REDDIN, G., and KLEINFELD, M., 1959. PulSKIDMORE, J. W., 1977. Animal Experiments with Talc. monary talcosis, a clinical and environmental study. Proc.of4th International Symposium on Inhaled Particles American Medical Association Archives of Industrial and Vapours. Edinburgh, September 1975 (Pergamon Health, 20, 408. Press, Oxford).
as outlined in our case are necessary to confirm the diagnosis of domestic talc pneumoconiosis.
588
The authors gratefully acknowledge the secretarial assistance of Angela Hattaway in the preparation of this manuscript. REFERENCES
MEINDOK, H., and LANGER, B., 1976. Liver scan in BuddChiari syndrome. Journal of Nuclear Medicine, 17, 365— 368. POLLARD, J. J., and NEBESAR, R. A., 1967. Altered hemo-
dynamics in the Budd-Chiari syndrome demonstrated by selective hepatic and selective splenic angiography. Radiology, 89, 236-243.
CHAYES, Z., KEONIGSBERG, M., and FREEMAN, L., 1974. The
hot hepatic abscess. Journal of Nuclear Medicine, 15, 305307.
SALVO, A. F., SCHILLER, A., ATHANASOULIS, C , GALDABINI,
GOONERATNE, N. S., BUSE, M. G., QUINN, J. L., and SELBY,
J., and MCKUSICK, K. A., 1977. Hepatoadenoma and
J. B., 1977. "Hot spot" on hepatic scintigraphy and focal nodular hyperplasia: pitfalls in radiocolloid imaging. radionuclide venacavography. American Journal of RoentRadiology, 125, 451-455. genology, Radiation Therapy and Nuclear Medicine, 129, STAAB, E. V., HARTMAN, R. C , and PARROTT, J. A., 1975. 447-450. Liver imaging in the diagnosis of hepatic vein thrombosis LEE, K. E., PRESTON, D. F., MARTIN, N. L., and ROBINSON, in paroxysmal nocturnal hemoglobinuria. Radiology, 117, R. G., 1976. Angiographic documentation of systemic341-348. portal venous shunting as a cause of a liver scan "hot spot" VOLPE, J. A., and JOHNSTON, G. S., 1970. "Hot" hepatic in superior vena caval obstruction. American Journal of hemangioma. A unique radiocolloid-concentrating liver Roentgenology, Radiation Therapy and Nuclear Medicine, scan lesion. Journal of Surgical Oncology, 2, 373-377. 127, 637-639. YEH, E. L., POHLMANN, G. P., and MEAD, R. C , 1976. MCLAUGHLIN, W. T., 1976. Liver scan in Budd-Chiari Liver-heart imaging in evaluation of hepatic focal defect. syndrome. Journal of Nuclear Medicine, 17, 1019. Journal of Nuclear Medicine, 16, 896-898.
Pulmonary disease caused by the Inhalation of cosmetic talcum powder By I. P. Wells, M.R.C.P., F.R.C.R., P. A. Dubbins, B.Sc, F.R.C.R. and W. F. Whimster, M.R.C.P., M.R.C.Path. Departments of Diagnostic Radiology and Pathology, King's College Hospital, London, S.E.6 {Received August, 1978 and in revisedform January, 1979) The inhalation of talc, a chemical compound of hydrous magnesium silicate, has long been known to cause pulmonary infiltrates (Porro and Levine, 1946; Messite, etal., 1959). As mined, and as used as a lubricant in the leather, rubber and paper industries talc contains considerable impurities including asbestos. Heavy exposure to this industrial grade talc produces radiological changes which include interstitial reticulo-nodular shadowing and pleural plaques (Fraser and Pare, 1970). Hildick-Smith (1976) in a recent review of the biology of talc points out that domestic talc does not contain impurities, and that people working with this pure talc do not develop pulmonary disease. Work with animals has also failed to show pulmonary disease even after massive exposures to domestic talc (Wagner et al., 1977). The domestic use of talc might therefore not be expected to constitute a health hazard since not only is the talc used of cosmetic grade, but also the exposure is infrequent and of short duration. We report a case of chronic pulmonary disease apparently the result of excessive use of domestic talcum powder.
suspected but staining and culture of the sputum for tubercle bacilli were repeatedly negative. The Mantoux test was negative at 1 in 10 000 dilution. Exercise tolerance worsened during June and therapy with Rifampicin and Isoniazid was started for a presumptive diagnosis of tuberculosis. Four months later the chest radiograph showed extension of the right apical shadowing and partial collapse with consolidation of the left upper lobe (Fig. 1). Bronchoscopy revealed the left main bronchus to be
CASE REPORT
A 41-year-old housewife was first seen in March, 1973 when she was complaining of shortness of breath on exercise. A chest radiograph showed a small area of illdefined shadowing at the right apex. Tuberculosis was
FIG. 1 Chest radiograph showing shadowing at the right apex and collapse of the left upper lobe.
586
JULY
1979
Case reports narrowed with inflamed walls. Biopsy of the bronchial wall revealed epithelioid and giant cell systems compatible with sarcoidosis or tuberculosis but no caseation or acid-fast bacilli were present however. Steroids (5 mg Prednisone t.d.s.) were added to the therapy at this time. After some slight improvement there was again deterioration in exercise tolerance and a dry cough developed in May 1974. The radiograph remained unchanged although respiratory function tests were abnormal (VC 2.15 L, FeV 1.15 L, FeV% 54%). A Kveim test and numerous pre-
cipitins including those for aspergillus were negative. Steroid therapy was stopped. In September, 1974 the chest radiograph revealed illdefined medium sized nodules throughout the lungs with poor definition of the heart borders and hila (Fig. 2A and B). An open lung biopsy was performed. As a result of the pathology of the lung tissue obtained the anti-tuberculous therapy was stopped. The patient on direct questioning admitted to very heavy use of talcum powder over many years. She was in the habit of dusting the whole body with talc at least once daily. The talc had been applied in a small unventilated room likely to favour inhalation. The talc use was stopped, since when the patient's condition has remained unchanged. She remains short of breath and her chest radiograph has remained virtually unchanged over the last four years. PATHOLOGY
A piece of firm grey tissue 3 x 2 . 5 x 1 cm was received. Histologically there were numerous granulomata and extensive fibrosis. The granulomata showed no necrosis, but multinucleate giant cells were plentiful. Staining and culture for acid fast bacilli were negative. With polarized light many birefringent particles were seen, often within the giant cells (Fig. 3). The residual tissue was macerated and the residue inspected by electron microscopy which revealed particles consistent with talc. This was confirmed by the X-ray diffraction pattern. DISCUSSION
A review of the literature has revealed only three previous reports of pulmonary disease referable to the use of cosmetic talc in adults. Nam and Gracey (1972) report the case of a negro man who had smothered his bed with talc at night for 20 years. He developed pulmonary fibrosis detected at autopsy. Moskowitz (1970) reports a woman who developed dyspnoea and pulmonary reticulo-nodular shadowing after many years as a tester of talc aerosols and Fraser and Pare (1970) report the case of a 31-yearold woman who developed pulmonary symptoms with mediastinal lymphadenopathy, nodular shadowing and areas of consolidation on the radiograph. She had been in the habit of inhaling lavender talc directly from her cupped hands. Despite the experimental proof to the contrary, it would seem that very rarely cosmetic talc may be implicated in the causation of pulmonary disease. Perhaps an unidentified additional intrinsic factor is necessary before cosmetic talc becomes harmful. Certainly in our case the use of talc has been excessive. The radiograph may show widespread interstitial nodulation with or without line shadows. There may by lymphadenopathy, and fibrosis has developed in three of the four published cases. The clinical and radiological features therefore are not specific and in particular the differential diagnosis from sarcoid and tuberculosis may be difficult. We would suggest however that a careful history regarding talc usage is FIG. 2. taken in patients with resistant pulmonary infiltrates (A) Chest radiograph showing widespread ill-defined noduof unknown aetiology. Adequate histological studies lation. (B) Detail from left upper zone. 587
VOL.
52, No. 619 Case reports
FIG. 3. Histological section of open lung biopsy showing foreign body giant cells. Some of these contain birefringent crystalline material (arrows). H. & E. X 200. Polarized light.
MOSKOWITZ, R. L., 1970. Talc pneumoconiosis, a treated case. Chest, 58, 37-41. NAM, K., and GRACEY, D., 1972. Pulmonary talcosis from cosmetic talcum powder. Journal of the American Medical REFERENCES Association, 221, 452-453. FRASER, R. G., and PARE, J. A. P., 1970. Diagnosis of Disease of the Chest, pp. 937-938 (W. B. Saunders, Philadelphia- PORRO, F. W., and LEVINE, N. M., 1946. Pathology of talc pneumoconiosis with report of autopsy. North New York London). HILDICK-SMITH, L., 1976. The biology of talc. British Medical Journal, 3, 23-25. Journal of Industrial Medicine, 33, 217-230. WAGNER, J. C , BERRY, G., COOKE, T. J., HILL, R. J., and MESSITE, J., REDDIN, G., and KLEINFELD, M., 1959. PulSKIDMORE, J. W., 1977. Animal Experiments with Talc. monary talcosis, a clinical and environmental study. Proc.of4th International Symposium on Inhaled Particles American Medical Association Archives of Industrial and Vapours. Edinburgh, September 1975 (Pergamon Health, 20, 408. Press, Oxford).
as outlined in our case are necessary to confirm the diagnosis of domestic talc pneumoconiosis.
588
