Fatal foreign-body granulomatous pulmonary embolization due to microcrystalline cellulose in a patient receiving total parenteral nutrition: all crystals are not what they seem

Abstract

Pulmonary foreign-body granulomatous embolization has been described secondary to crystal precipitation in total parenteral nutrition (TPN) as well as when pharmaceutical tablets are crushed and injected intravenously. Extensive granulomatous embolization may cause pulmonary hypertension and death due to acute cor pulmonale. We report the case of a 34-year old woman who had been receiving TPN post-operatively secondary to complications of a paraesophageal hernia repair. During and following receiving TPN, she experienced episodes of hypoxia, tachycardia, fever, and hypotension. Computed tomography scans of the thorax showed centrilobular nodules, tree-in-bud and ground-glass opacities, as well as findings of pulmonary hypertension. Following an episode of hypoxia she was found unresponsive and died despite resuscitative efforts. Microscopic examination of the lungs following post-mortem examination revealed occlusive granulomatous inflammation of the pulmonary arterial vasculature by crystalline material. The morphologic and histochemical patterns of the crystals were suggestive of microcrystalline cellulose, a finding that was confirmed by energy dispersive X-spectroscopy and infrared spectroscopy. Ancillary tests did not support that the crystalline material was the result of TPN precipitation. Foreign-body granulomatous embolization leading to acute core pulmonale may occur as a complication of both intravenous injection of oral medications as well as of TPN crystallization. The source of crystalline material may be difficult to discern based solely on morphological assessment or by histochemical staining. Ancillary studies such as energy dispersive X-spectroscopy or infrared spectroscopy should be performed to definitively discern the two entities.

Rapid development of pulmonary hypertension and right ventricular failure due to large vessel intravascular microcrystalline cellulosis in an intravenous drug user

“…The slow, more typical development of PH in intravenous drug abusers may be challenging to recognize. However, as seen here and in previous reports, 3–5 the echocardiographic demonstration of RV dysfunction coupled with the CT demonstration of micronodularity, and mosaic attenuation, in a patient at risk for intravenous injection should raise a clinician’s suspicion of this process. While there is no clear treatment, cessation of exposure should be encouraged in an attempt to avoid progression to life-threatening disease.…”

Parenteral administration of oral medications in lung transplant recipients: An underrecognized problem

“…Early and more recent reports of pulmonary intravascular MCC are restricted to case reports and small series which typically describe patients with a history of intravenous drug abuse . Other studies have reported MCC secondary to parenteral injection of oral pain medication in patients receiving total parenteral nutrition (TPN) . Embolization of MCC to lung allografts may damage pulmonary arterial vasculature, eliciting impressive fibroinflammatory reactions.…”

“…Pulmonary intravascular MCC and crospovidone can show variable patterns of inflammation such as granulomatous vasculitis or little/no inflammatory infiltrate if the material was recently embolized (acute setting; Figure A) . Damage to small muscular arteries and arterioles leads to obliteration of the vessel lumina, which may result in pulmonary hypertension .…”

Hematoidin crystals in sputum smears: Cytopathology and clinical associations

“…[ 38 ] Pulmonary crystal-storing histiocytosis, often seen in conjunction with the underlying myeloma or low -grade B-cell lymphoma, to date, has only been reported in a fine -needle aspiration sample. [ 39 ] Exogenous crystals that may be encountered in lung samples include material from aspiration (e.g., talc, barium),[ 40 ] embolization (e.g., total parenteral nutrition),[ 41 ] and drugs (e.g., clofazimine). [ 42 ] Anthracosis and pneumoconiosis-associated crystals (e.g., silicosis) are best identified in tissue specimens.…”