, 14 tweets, 7 min read Read on Twitter
How about a #Tweetorial with no ending? A document that can be added to at any time? Can it work? Let’s find out!

This #pathtweetorial will address the entity know as “talc granulomatosis” and review the literature, including old papers!

#pathology #pulmpath #granuloma
I did a quick search to find the first time “talc granulomatosis” was used as a term for lung lesions caused by excipients in pills, and came across this 1970 paper. Were Hopkins and Taylor the first to coin the term? Correct me if I’m wrong @yro854

But first, let me give you a taste of what talc granulomatosis looks like, courtesy of Extra Super Duper Pathologist @DrjohninNE

The main finding is foreign body granulomas surrounding birefringent particulate matter (excipients) in the interstitium

You can imagine how those innumerable tiny nodules might look on CT. Yes, they can mimic a “miliary” appearance and be mistaken for TB or fungal infection.

In my experience, the diagnosis is almost never suspected prior to biopsy, either by clinicians or by radiologists
Do you know why Hopkins and Taylor called this talc granulomatosis? Because Ritalin (methylphenidate) tablets contained talc, and the material in the granulomas had the “typical appearance of talc”

Both the patients they reported admitted injecting crushed Ritalin tablets 😰
G. Bruce Hopkins and Dean G. Taylor we’re both pathologists! Kudos to them ! No clinicians or radiologists on this landmark paper. There’s a moral/lesson in there somewhere 😜🤓
Here’s a beautiful example of the excipient known as crospovidone, which is pretty common in pills nowadays. It’s purple, very pretty, and coral-like but it’s NOT birefringent.

One of my pet peeves in teaching is when teachers introduce a new term with no explanation or back story whatsoever! And I just did it myself!

You’re wondering “what the heck o sauce is an excipient”? Here’s the answer:

This beautiful tweet by lung Pathologist @mitra_mehrad illustrates the excipient that’s probably most commonly encountered in this condition nowadays: microcrystalline cellulose. This one is birefringent, just like talc. On H&E, it’s similar to talc.

Sorry, in tweet 6 that should be “were” not “we’re”. Darn autocorrect!
This @NEJM report highlights some recurring themes in cases of talc granulomatosis:

🔴 opiate use
🔴 IV access allowing injection of pills
🔴 innumerable nodules on imaging
🔴 crospovidone on biopsy
🔴 need to treat underlying opiate abuse

I like the term “excipient lung disease” as it’s more inclusive and accurate than talc granulomatosis. This paper uses the term and is a good review of the radiologic findings.

Basically, this can manifest as miliary or centrilobar nodules.

If you like to learn via video rather than traditional text, here’s a free YouTube video on talc granulomatosis for you:
Apologies for the erroneous link in tweet 12. The correct link for the talc granulomatosis YouTube video is:

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