Inhalational Pulmonary Talcosis

Noninfectious Granulomatous Lung Disease: Radiological Findings and Differential Diagnosis

Granulomatous lung diseases (GLDs) are a heterogeneous group of pathological entities that can have different clinical presentations and outcomes. Granulomas are histologically defined as focal aggregations of activated macrophages, Langerhans cells, and lymphocytes, and may form in the lungs when the immune system cannot eliminate a foreign antigen and attempts to barricade it. The diagnosis includes clinical evaluation, laboratory testing, and radiological imaging, which especially consists of high-resolution computed tomography. bronchoalveolar lavage, transbronchial needle aspiration or cryobiopsy, positron emission tomography, while genetic evaluation can improve the diagnostic accuracy. Differential diagnosis is challenging due to the numerous different imaging appearances with which GLDs may manifest. Indeed, GLDs include both infectious and noninfectious, and necrotizing and non-necrotizing granulomatous diseases and the imaging appearance of some GLDs may mimic malignancy, leading to confirmatory biopsy. The purposes of our review are to report the different noninfectious granulomatous entities and to show their various imaging features to help radiologists recognize them properly and make an accurate differential diagnosis.

A 51-Year-Old Woman With Progressive Dyspnea and Diffuse Bilateral Pulmonary Nodules

CASE PRESENTATION

A 51-year-old woman was referred to our hospital with progressive dyspnea on exertion for 2 months after COVID-19 vaccination (ChAdOx1-S [recombinant] vaccine). She did not have a cough, fever, hemoptysis, weight loss, or night sweats. She had no history of arthritis, rash, photosensitivity, or other signs of autoimmune disease. Chest radiograph revealed diffuse ground-glass opacities and bilateral pulmonary nodules. She denied any history of smoking, contact with individuals infected with TB, relevant hobbies, or exposure to domestic animals. She had no relevant medical history, was previously healthy, and worked as a chef.

Pulmonary talcosis in the setting of cosmetic talcum powder use

Pulmonary talcosis is a rare pneumoconiosis that is difficult to diagnose and may progress to debilitating lung disease. Four types of talcosis are described in literature: talc-silicosis and talc-asbestosis secondary to inhalation in industry workers and talc-emboli in intravenous drug users that self-inject talc-containing oral tablets. Although found in common household products, talc is overlooked as a cause of pneumoconiosis. Talcosis caused by cosmetic face powder is even rarer. Here we discuss a woman in her 50s who developed talcosis from inhalation of cutaneous cosmetics two years prior, and how comprehensive history may be crucial in diagnosing this rare disease.

Imaging diagnosis of classical and new pneumoconiosis: predominant reticular HRCT pattern

Our understanding of the manifestations of pneumoconioses is evolving in recent years. Associations between novel exposures and diffuse interstitial lung disease have been newly recognized. In advanced asbestosis, two types of fibrosis are seen, probably related to dose of exposure, existence of pleural fibrosis, and the host factor status of the individual. In pneumoconiosis of predominant reticular type, nodular opacities are often seen in the early phase. The nodular pattern is centrilobular, although some in metal lung show perilymphatic distribution, mimicking sarcoidosis. High-resolution computed tomography enables a more comprehensive correlation between the pathologic findings and clinically relevant imaging findings. The clinician must understand the spectrum of characteristic imaging features related to both known dust exposures and to historically recent new dust exposures.

Noninfectious Granulomatous Diseases of the Chest

Granulomas are pathologically defined as focal aggregations of activated macrophages, Langerhans cells, and lymphocytes. Granulomas form in the lungs when the immune system barricades the substances it perceives as foreign but is unable to remove. Granulomas manifest with numerous imaging appearances in thoracic radiology, and their presence is a nonspecific finding. Granulomatous lung diseases comprise multiple entities with variable clinical manifestations and outcomes. Their imaging findings are rarely specific and can mimic malignancies, often triggering an extensive diagnostic workup. Radiologists must be familiar with the clinical manifestations and imaging findings of these entities to generate appropriate differential diagnoses. This review describes the imaging manifestations of various noninfectious, necrotizing, and nonnecrotizing granulomatous diseases that primarily affect the thorax. ©RSNA, 2020.

Imaging methods used in the assessment of environmental disease networks: a brief review for clinicians

Background

Across the globe, diseases secondary to environmental exposures have been described, and it was also found that existing diseases have been modified by exposure to environmental chemicals or an environmental factor that has been found in their pathogenesis. The Institute of Medicine has shared a permanent concern related to the nations environmental health capacity since 1988.

Main body

Contemporary imaging methods in the last 15 years started reporting alterations in different human systems such as the central nervous system, cardiovascular system and pulmonary system among others; evidence suggests the existence of a human environmental disease network. The primary anatomic regions, affected by environmental diseases, recently assessed with imaging methods include Brain (lead exposure, cerebral stroke, pesticide neurotoxicity), uses MRI, DTI, carotid ultrasonography and MRS; Lungs (smoke inhalation, organophosphates poisoning) are mainly assessed with radiography; Gastrointestinal system (chronic inflammatory bowel disease), recent studies have reported the use of aortic ultrasound; Heart (myocardial infarction), its link to environmental diseased has been proved with carotid ultrasound; and Arteries (artery hypertension), the impairment of aortic mechanical properties has been revealed with the use of aortic and brachial ultrasound.

Conclusions

Environmental epidemiology has revealed that several organs and systems in the human body are targets of air pollutants. Current imaging methods that can assess the deleterious effects of pollutants includes a whole spectrum: radiography, US, CT and MRI. Future studies will help to reveal additional links among environmental disease networks.

Commentary on "Assessment of Health Risk From Historical Use of Cosmetic Talcum Powder"

In response to recent litigation, Colgate Palmolive hired Exponent to determine if various samples of their cosmetic talc products contained asbestos. Anderson et al., Exponent employees, claim to report the findings of these analyses in their paper "Assessment of Health Risk from Historical Use of Cosmetic Talcum Powder." The microscopist who reviewed the samples found four anthophyllite fibers. One of the authors of Anderson et al., Patrick Sheehan, who is not a microscopist, directed the reviewing microscopist to alter the report and add the qualification that "…this classification was inconclusive due to the small number counted." Deviations from the referenced analytical methods, however, would account for the small number of fibers counted relative to the limit of detection. Anderson et al., reported that "no asbestos fibers were detected in any of the eighteen samples analyzed" based on the report's altered conclusions.

Beyond Pulmonary Embolism; Nonthrombotic Pulmonary Embolism as Diagnostic Challenges

Nonthrombotic pulmonary embolism (NTPE) is less well understood and is encountered less frequently than pulmonary embolism from venous thrombosis. NTPE results from embolization of nonthrombotic material to the pulmonary vasculature originating from many different cell types as well as nonbiologic or foreign materials. For many radiologists NTPE is a challenging diagnosis, presenting nonspecific or unusual imaging findings in the setting of few or unusual clinical signs. The aim of this paper is to review the pathophysiology of diverse causes of NTPE, which should aid radiologists to better understand and, more importantly, diagnose these infrequent events.

Imaging of Occupational Lung Disease

Occupational lung diseases span a variety of pulmonary disorders caused by inhalation of dusts or chemical antigens in a vocational setting. Included in these are the classic mineral pneumoconioses of silicosis, coal worker's pneumoconiosis, and asbestos-related diseases as well as many immune-mediated and airway-centric diseases, and new and emerging disorders. Although some of these have characteristic imaging appearances, a multidisciplinary approach with focus on occupational exposure history is essential to proper diagnosis.

Cocaine-induced pulmonary changes: HRCT findings

Objective:

To evaluate HRCT scans of the chest in 22 patients with cocaine-induced pulmonary disease.

Methods:

We included patients between 19 and 52 years of age. The HRCT scans were evaluated by two radiologists independently, discordant results being resolved by consensus. The inclusion criterion was an HRCT scan showing abnormalities that were temporally related to cocaine use, with no other apparent causal factors.

Results:

In 8 patients (36.4%), the clinical and tomographic findings were consistent with "crack lung", those cases being studied separately. The major HRCT findings in that subgroup of patients included ground-glass opacities, in 100% of the cases; consolidations, in 50%; and the halo sign, in 25%. In 12.5% of the cases, smooth septal thickening, paraseptal emphysema, centrilobular nodules, and the tree-in-bud pattern were identified. Among the remaining 14 patients (63.6%), barotrauma was identified in 3 cases, presenting as pneumomediastinum, pneumothorax, and hemopneumothorax, respectively. Talcosis, characterized as perihilar conglomerate masses, architectural distortion, and emphysema, was diagnosed in 3 patients. Other patterns were found less frequently: organizing pneumonia and bullous emphysema, in 2 patients each; and pulmonary infarction, septic embolism, eosinophilic pneumonia, and cardiogenic pulmonary edema, in 1 patient each.

Conclusions:

Pulmonary changes induced by cocaine use are varied and nonspecific. The diagnostic suspicion of cocaine-induced pulmonary disease depends, in most of the cases, on a careful drawing of correlations between clinical and radiological findings.

AS, Zanetti G, Marchiori E. Can chest high-resolution computed tomography findings diagnose pulmonary alveolar microlithiasis?

OBJECTIVE

The present study was aimed at retrospectively reviewing high-resolution computed tomography (HRCT) findings in patients with pulmonary alveolar microlithiasis in order to evaluate the frequency of tomographic findings and their distribution in the lung parenchyma.

MATERIALS AND METHODS

Thirteen patients (9 females and 4 males; age, 9 to 59 years; mean age, 34.5 years) were included in the present study. The HRCT images were independently evaluated by two observers whose decisions were made by consensus. The inclusion criterion was the presence of abnormalities typical of pulmonary alveolar microlithiasis at HRCT, which precludes lung biopsy. However, in 6 cases lung biopsy was performed.

RESULTS

Ground-glass opacities and small parenchymal nodules were the predominant tomographic findings, present in 100% of cases, followed by small subpleural nodules (92.3%), subpleural cysts (84.6%), subpleural linear calcifications (69.2%), crazy-paving pattern (69.2%), fissure nodularity (53.8%), calcification along interlobular septa (46.2%) and dense consolidation (46.2%).

CONCLUSION

As regards distribution of the lesions, there was preferential involvement of the lower third of the lungs. No predominance of distribution in axial and anteroposterior directions was observed.

Talcosis in soapstone artisans: high-resolution CT findings in 12 patients

AIM

To describe the high-resolution computed tomography (HRCT) features of pneumoconiosis observed in soapstone artisans.

MATERIALS AND METHODS

The present study included 12 soapstone artisans with chest radiography abnormalities consistent with the diagnosis of pneumoconiosis, in accordance with the International Labour Office classification. All patients had undergone HRCT, and the images were retrospectively analysed by two chest radiologists, who reached decisions in consensus.

RESULTS

All patients presented with interlobular septal thickening. Small centrilobular nodules (75%) and ground-glass opacities (67%) were also common findings. The distributions of abnormalities were predominantly diffuse. No pleural abnormality was found.

CONCLUSION

The HRCT abnormalities observed in this group of soapstone artisans are similar to those of pure talc pneumoconiosis.

Spectrum of high-resolution computed tomography imaging in occupational lung disease

Damage to the lungs caused by dusts or fumes or noxious substances inhaled by workers in certain specific occupation is known as occupational lung disease. Recognition of occupational lung disease is especially important not only for the primary worker, but also because of the implications with regard to primary and secondary disease prevention in the exposed co-workers. Although many of the disorders can be detected on chest radiography, high-resolution computed tomography (HRCT) is superior in delineating the lung architecture and depicting pathology. The characteristic radiological features suggest the correct diagnosis in some, whereas a combination of clinical features, occupational history, and radiological findings is essential in establishing the diagnosis in others. In the presence of a history of exposure and consistent clinical features, the diagnosis of even an uncommon occupational lung disease can be suggested by the characteristic described HRCT findings. In this article, we briefly review the HRCT appearance of a wide spectrum of occupational lung diseases.

Pulmonary talcosis 10 years after brief teenage exposure to cosmetic talcum powder

Pulmonary talcosis is a rare but debilitating variant of pneumoconiosis often presenting with isolated non-specific symptoms of progressive exertional dyspnoea or cough. Occupational exposure to talc dust and intravenous drug abuse are well-recognised aetiological factors with only a few cases related to cosmetic talc exposure being reported to date. The authors report a case of a young woman in whom a mere 4 month ritual of inhaling cosmetic talcum powder led to full-blown pulmonary talcosis being diagnosed 10 years later. The importance of a taking a pertinent history relating to environmental exposures in all patients presenting with respiratory symptoms is re-established here.

Pulmonary talcosis: imaging findings

Talc is a mineral widely used in the ceramic, paper, plastics, rubber, paint, and cosmetic industries. Four distinct forms of pulmonary disease caused by talc have been defined. Three of them (talcosilicosis, talcoasbestosis, and pure talcosis) are associated with aspiration and differ in the composition of the inhaled substance. The fourth form, a result of intravenous administration of talc, is seen in drug users who inject medications intended for oral use. The disease most commonly affects men, with a mean age in the fourth decade of life. Presentation of patients with talc granulomatosis can range from asymptomatic to fulminant disease. Symptomatic patients typically present with nonspecific complaints, including progressive exertional dyspnea, and cough. Late complications include chronic respiratory failure, emphysema, pulmonary arterial hypertension, and cor pulmonale. History of occupational exposure or of drug addiction is the major clue to the diagnosis. The high-resolution computed tomography (HRCT) finding of small centrilobular nodules associated with heterogeneous conglomerate masses containing high-density amorphous areas, with or without panlobular emphysema in the lower lobes, is highly suggestive of pulmonary talcosis. The characteristic histopathologic feature in talc pneumoconiosis is the striking appearance of birefringent, needle-shaped particles of talc seen within the giant cells and in the areas of pulmonary fibrosis with the use of polarized light. In conclusion, computed tomography can play an important role in the diagnosis of pulmonary talcosis, since suggestive patterns may be observed. The presence of these patterns in drug abusers or in patients with an occupational history of exposure to talc is highly suggestive of pulmonary talcosis.

Uncommon occupational lung diseases: high-resolution CT findings

OBJECTIVE

The purpose of this article is to describe the high-resolution CT (HRCT) features of uncommon occupational lung diseases.

CONCLUSION

HRCT plays an increasing role in the evaluation of occupational lung diseases. We present several cases of unusual occupational lung diseases and their HRCT findings. The diseases studied were siderosis, talcosis, berylliosis, calcicosis, hypersensitivity pneumonitis (due to wheat flour and isocyanates), and Ardystil syndrome. The characteristic HRCT findings together with clinical features and related occupational history improve the diagnostic accuracy of these diseases.

Case report: silicatosis in a carpet installer

CONTEXT

Chronic exposure to talc in the course of carpet installation can result in pneumoconiosis.

CASE PRESENTATION

We present a case of a young carpet installer who was diagnosed with silicatosis of the lung. Review of occupational history revealed that the patient had been working as a carpet installer for approximately 15 years, since he was 15 years of age. The patient was exposed to talc in the course of his work.

DISCUSSION

Exposure to talc in the course of carpet installation has not been reported as a possible cause of pneumoconiosis. In this article we review different causes of silicatosis and discuss chronic exposure in the course of carpet installation and development of pneumoconiosis. In addition, we also review the relevance of mycobacterial infection in cases of silicosis and silicatosis.

RELEVANCE TO CLINICAL OR PROFESSIONAL PRACTICE

Exposure to talc in the course of carpet installation should be added to conditions that can cause pneumoconioses, specifically silicatosis of the lung.

Inhalational Talc Pneumoconiosis: Radiographic and CT Findings in 14 Patients

OBJECTIVE

The purpose of this study was to evaluate the radiographic and CT findings of inhalational talc pneumoconiosis.

CONCLUSION

Large opacities of talc pneumoconiosis progress more often than do small opacities. The CT findings of talc pneumoconiosis overlap those of silicosis and asbestosis.

Pneumoconiosis: comparison of imaging and pathologic findings

Pneumoconiosis may be classified as either fibrotic or nonfibrotic, according to the presence or absence of fibrosis. Silicosis, coal worker pneumoconiosis, asbestosis, berylliosis, and talcosis are examples of fibrotic pneumoconiosis. Siderosis, stannosis, and baritosis are nonfibrotic forms of pneumoconiosis that result from inhalation of iron oxide, tin oxide, and barium sulfate particles, respectively. In an individual who has a history of exposure to silica or coal dust, a finding of nodular or reticulonodular lesions at chest radiography or small nodules with a perilymphatic distribution at thin-section computed tomography (CT), with or without eggshell calcifications, is suggestive of silicosis or coal worker pneumoconiosis. Magnetic resonance imaging is helpful for distinguishing between progressive massive fibrosis and lung cancer. CT and histopathologic findings in asbestosis are similar to those in idiopathic pulmonary fibrosis, but the presence of asbestos bodies in histopathologic specimens is specific for the diagnosis of asbestosis. Giant cell interstitial pneumonia due to exposure to hard metals is classified as a fibrotic form of pneumoconiosis and appears on CT images as mixed ground-glass opacities and reticulation. Berylliosis simulates pulmonary sarcoidosis on CT images. CT findings in talcosis include small centrilobular and subpleural nodules or heterogeneous conglomerate masses that contain foci of high attenuation indicating talc deposition. Siderosis is nonfibrotic and is indicated by a CT finding of poorly defined centrilobular nodules or ground-glass opacities.