Frishman, William H

Hanmantgad, Madhura

Mondal, Pratik

Roarke, Dennis

Solangi, Zeeshan

Sule, Sachin

Yandrapalli, Srikanth

English

The Touro College and University System

Touro Scholar NYMC Faculty Posters Faculty Spring 3-29-2017 Pulmonary Micro-Embolism of Foreign Material Causing Acute Right Ventricular Failure and Cardiac Arrest Pratik Mondal Srikanth Yandrapalli Dennis Roarke Madhura Hanmantgad Zeeshan Solangi New York Medical College, zeeshan_solangi@nymc.edu See next page for additional authors Follow this and additional works at: https://touroscholar.touro.edu/nymc_fac_posters  Part of the Cardiology Commons Recommended Citation Mondal, P., Yandrapalli, S., Roarke, D., Hanmantgad, M., Solangi, Z., Frishman, W. H., & Sule, S. (2017). Pulmonary Micro-Embolism of Foreign Material Causing Acute Right Ventricular Failure and Cardiac Arrest. Retrieved from https://touroscholar.touro.edu/nymc_fac_posters/14 This Poster is brought to you for free and open access by the Faculty at Touro Scholar. It has been accepted for inclusion in NYMC Faculty Posters by an authorized administrator of Touro Scholar. For more information, please contact daloia@nymc.edu. Authors Pratik Mondal, Srikanth Yandrapalli, Dennis Roarke, Madhura Hanmantgad, Zeeshan Solangi, William H. Frishman, and Sachin Sule This poster is available at Touro Scholar: https://touroscholar.touro.edu/nymc_fac_posters/14 Pulmonary Micro-Embolism of Foreign Material Causing Acute Right Ventricular Failure and Cardiac Arrest  Pratik Mondal, MD; Srikanth Yandrapalli, MD; Dennis Roarke, MD; Madhura Hanmantgad, MD; Zeeshan Solangi, MD;  William Frishman, MD; Sachin Sule, MD.  Department Of Medicine, New York Medical College, Westchester Medical Center, Valhalla, NY Introduction  Case Description  Discussion  Pulmonary granulomatosis from foreign body micro-embolism has been described in literature since the 1950s under different terminologies like talc granulomatosis, excipient lung disease, pulmonary foreign body angiogranulomatosis, etc. It is seen when crushed oral tablets are used intravenously. Tablets contain excipients like talc, cellulose, etc., which are insoluble inert particulate filler. Administered intravenously, these particles lodge in the pulmonary arterioles and capillaries triggering a foreign body response which may vary from a granulomatous reaction resulting in slowly progressive fibrosis and pulmonary hypertension to an acutely fatal reaction leading to small vessel thrombosis and occlusion leading to acute right sided heart failure and cardiac arrest.   With the current epidemic of intravenous drug abuse, we believe that pulmonary granulomatosis from foreign body micro-embolism is appreciably prevalent.  A high level of suspicion is needed to diagnose this potentially fatal disease. Diagnosis is attained by a lung biopsy.  Systemic and inhaled steroids have shown to decrease symptom severity.  The only way to prevent the progression of disease is to stop intravenous drug use, with lung transplantation being the only definitive treatment.  There needs to be more research to assess diagnostic and treatment modalities.  Whether ventilation/perfusion imaging would be a more sensitive study to demonstrate the perfusion defect in the pulmonary arterioles, and whether this disease can be considered a subset of chronic thromboembolic pulmonary hypertension and symptomatically be treated with pulmonary arterial vasodilators is still to be assessed.  Hospital Course  Autopsy Findings  Left lower leg: between outer elastic wrap and inner white wrap is an empty normal saline syringe.  No evidence of infection. Heart: No significant atherosclerosis, left anterior descending artery tunnels into the myocardium 0.1cm to 0.2cm  Lung: Parenchyma markedly congested with edema, with patent arteries at the hilum. Within the pulmonary arteriole there was presence of polarizable foreign material with cellular response.  Microbiology and Toxicology : Autopsy blood cultures growing peptinophilus asaccharolyticus, other cultures negative. Blood positive for oxycodone, acetaminophen, fluoxetine, mirtazapine and gabapentin, urine positive for oxycodone. Gastric contents negative for opioids.  Cause of Death: Pulmonary micro-embolism of foreign material. It was retrospectively concluded that he had been injecting crushed medications through his central line. A 32-year old incarcerated man with a history of intravenous drug abuse presented to the ER with fever and knee pain. He recently had surgical debridement of a left tibial abscess and was discharged with a central venous catheter for antibiotic administration. Emergent surgical exploration of the left knee showed uninfected tissue.  On day 2, he developed chest tightness, shortness of breath (SOB), and was found to be hypoxemic.  ECG, echocardiogram, computed tomography of chest, infectious workup, and MRI of left knee were unrevealing.  He continued to have fevers despite broad spectrum antibiotics. On day 7, chest tightness and SOB acutely worsened. ECG showed sinus tachycardia and diffuse up-sloping ST segment elevations. Arterial pO2 was 50mm Hg.  Echocardiogram showed severe right ventricular dilatation and dysfunction.  He was emergently transferred to the ICU after which he turned cyanotic and unresponsive with pulseless electrical activity. Despite aggressive resuscitative efforts, return of spontaneous circulation was not achieved. Tissue plasminogen activator was administered during resuscitation.  Fig 1. EKG showing sinus tachycardia with diffuse up-sloping ST elevations Fig 2. Autopsy – gross knee findings Fig 3. Artery within the lung demonstrating foreign material Fig 4. Polarizable Foreign Material References:   1. Agarwal et al; Pulmonary talc granulomatosis masquerading as massive pulmonary embolism. Int J Surg Pathol. 2009. 2. Atlee WE; Talc and cornstarch emboli in eyes of drug abusers. JAMA. 1972. 3. Caceres M et al; An unusual presentation of spontaneous pneumothorax secondary to talc-induced pulmonary granulomatosis. Ann Thorac Surg. 2009.  4. Douglas FG et al; Foreign particle embolism in drug addicts: respiratory pathophysiology. Ann Internal Med. 1971. 5. Lamb D et al; Starch and talc emboli in drug addicts’ lung. J Clin Path. 1972. 6. Nguyen VT et al; Pulmonary effects on intravenous injection of crushed oral tablets. ‘Excipient Lung Disease’. AJR. 2014.  

Pulmonary Micro-Embolism of Foreign Material Causing Acute Right Ventricular Failure and Cardiac Arrest

https://touroscholar.touro.edu/cgi/viewcontent.cgi?article=1014&amp;context=nymc_fac_posters

Pulmonary Micro-Embolism of Foreign Material Causing Acute Right Ventricular Failure and Cardiac Arrest

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