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

Abstract

Intravascular foreign body deposition in the form of talc or microcrystalline cellulose is an uncommon but increasing cause of pulmonary hypertension given the current opioid epidemic. Earlier cases describe the effect of talc introduced via intravenous injection of crushed pills when deposited throughout the lungs, typically in the capillaries or distal pulmonary arterioles. An angiogranulomatous reaction ensues with pulmonary vascular remodeling and the gradual development of pulmonary hypertension. Although the use of talc in the manufacture of tablets has largely been replaced with alternative inert binders including microcrystalline cellulose, a similar angiogranulomatous reaction and vascular remodeling can occur. We report a case of intravascular microcrystalline cellulosis that rapidly progressed to fatal pulmonary hypertension over months characterized by occlusion of more proximal pulmonary arterioles in an intravenous drug user.

Macroscopic identification of visceral titanium pigment in an intravenous drug user

“…Excipient lung disease refers to the foreign body reaction in pulmonary arterioles that was seen in this case associated with injecting crushed tablets and their filler material (excipient) [12,13].…”

“…Systemic dissemination of injected foreign material may also be facilitated by paradoxical embolization through intra‐cardiac shunts such as a patent foramen ovale or via intrapulmonary shunting [11]. Excipient lung disease refers to the foreign body reaction in pulmonary arterioles that was seen in this case associated with injecting crushed tablets and their filler material (excipient) [12,13].…”

Fatal Excipients

“…Comparatively, a rare case report described rapid fatal pulmonary hypertension within months in IV drug users with ELD. 9…”

“…Clinically, patients with ELD can present with acute and/or chronic pulmonary hypertensive changes (ie, cor pulmonale) as well as intoxication by the drug itself 8–11 . Dyspnea in the context of hypoxemia, right heart failure with pulmonary artery dilation, and centrilobular nodules on imaging modalities would be one such presentation 12,13 .…”

“…4,6,7 Clinically, patients with ELD can present with acute and/or chronic pulmonary hypertensive changes (ie, cor pulmonale) as well as intoxication by the drug itself. [8][9][10][11] Dyspnea in the context of hypoxemia, right heart failure with pulmonary artery dilation, and centrilobular nodules on imaging modalities would be one such presentation. 12,13 Decedents with ELD may not present with a history of drug abuse or be found in settings commonly encountered with an overdose of an illicit substance, such as heroin.…”