Pulmonary microcrystalline cellulose deposition from intravenous injection of oral medication in a patient receiving parenteral nutrition

Ott, Michael; Khoór, András; Scolapio, James S.; Leventhal, Jack P.

doi:10.1177/014860710302700191

Cited by 11 publications

(11 citation statements)

References 5 publications

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“…The results demonstrated that the unique component producing the gangrene was the microcrystalline cellulose, while the injection of pure codeine was harmless. Furthermore, pulmonary microcrystalline cellulose deposition from intravenous injection of codeine tablets has been reported in a patient receiving parenteral nutrition (10). The histological section of the transbronchial biopsy revealed embolism caused by microcrystalline cellulose.…”

Section: Discussionmentioning

confidence: 95%

Irreversible Ischemic Hand Following Intraarterial Injection of Zolpidem Powder

Chang

Lin

2003

Journal of Toxicology: Clinical Toxicology

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Intraarterial injections of crushed oral formulations of drugs may cause acute, severe ischemia, and gangrene. A 24-yr-old woman developed severe ischemia of the right hand following arterial self-injection of a crushed zolpidem tablet. The first four digits of her right hand remained gangrenous even after treatment with heparinization, vasodilators, prostacyclin, and hyperbaric oxygen. Zolpidem tablets contain microcrystalline cellulose, an approved structural element in tablets for humans that has also been found to be a potent embolic agent. Microvascular embolization related to the microcrystalline cellulose may have contributed to the ischemia of the patient's hand.

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Section: Discussionmentioning

confidence: 95%

Irreversible Ischemic Hand Following Intraarterial Injection of Zolpidem Powder

Chang

Lin

2003

Journal of Toxicology: Clinical Toxicology

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“…3,4,6 Microcrystalline cellulose can be stained with Congo red and Grocott's methenamine silver, aiding in the diagnosis. 4,6,7 There is no specific treatment for foreign body granulomatosis with the exception of lung transplantation. 3 Pulmonary hypertension associated with foreign body granulomatosis should be treated with vasodilators.…”

Section: Discussionmentioning

confidence: 99%

Illicit narcotic injection masquerading as acute pulmonary embolism

et al. 2013

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A 23-year-old male presented from a nursing home with hypotension, tachycardia, diaphoresis and electrocardiographic evidence of right ventricular strain that was confirmed by echocardiography. His differential diagnosis included sepsis and pulmonary embolism. A high-resolution computed tomography scan demonstrated no pulmonary emboli but did demonstrate multiple bilateral pulmonary nodules. Upon questioning he admitted to injecting a long-acting narcotic that had been manually macerated, dissolved in saline, and injected through an indwelling intravenous line. Lung biopsy findings were consistent with cellulose-induced perivascular granulomatosis. Cellulose granulomatosis can be seen in patients who inject medications designed for oral use and should be considered in patients who present with acute pulmonary hypertension.

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“…Although the insoluble excipients are harmless if ingested, intravenous injection results in embolization of these compounds to the pulmonary arterial circulation causing occlusion, thrombosis, and inflammation of the artery branches and microvasculature. [9][10][11][12][13][14] Pharmaceutical agents used in this manner have included acetaminophen/hydrocodone, codeine, hydromorphone, propoxyphene, methadone, tripelennamine, methylphenidate, and pentazocine. 10,[13][14][15][16] An all-inclusive list of drugs with a high likelihood for abuse and the excipients they contain is outside the scope of this brief case report.…”

Section: Discussionmentioning

confidence: 99%

“…[9][10][11][12][13][14] Pharmaceutical agents used in this manner have included acetaminophen/hydrocodone, codeine, hydromorphone, propoxyphene, methadone, tripelennamine, methylphenidate, and pentazocine. 10,[13][14][15][16] An all-inclusive list of drugs with a high likelihood for abuse and the excipients they contain is outside the scope of this brief case report. However, Micromedex Healthcare Series Online, 17 an on-line drug database, is a useful resource that lists the excipients for many drugs, as reported by the manufacturers.…”

Section: Discussionmentioning

confidence: 99%

Intravenous Injection of Pharmaceutical Tablets Presenting as Multiple Pulmonary Nodules and Declining Pulmonary Function in an Adolescent With Cystic Fibrosis

et al. 2006

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Here we present the unusual case of an adolescent with cystic fibrosis presenting with declining pulmonary function and diffuse micronodular pulmonary disease. This case illustrates the radiographic and pathologic findings associated with the intravenous injection and pulmonary arterial embolization of insoluble pharmaceutical-tablet constituents. The number of first-time users reporting nonmedical use of prescription pain relievers is increasing dramatically, especially in adolescents. Recognition of both the diagnostic imaging features and histologic features on lung biopsy are critical steps for early diagnosis, intervention, and potential prevention of sudden death in these at-risk patients. P ROGRESSIVE LUNG DISEASE is the major cause of morbidity and mortality in patients with cystic fibrosis (CF). 1 Declining pulmonary function is a common diagnostic challenge for physicians caring for children and adults with CF. Exacerbations of CF lung disease are usually caused by recurrent pulmonary infections (bacterial, fungal, and viral), excessive mucus secretion in the lungs, impaired mucociliary clearance, and progressive bronchiectasis. 2 Pulmonary manifestations of CF on chest imaging commonly include peribronchial thickening, hyperinflation, bronchiectasis, pulmonary infiltrates, and cystic lesions with abscess formation. 3,4 Diffuse bilateral micronodular disease is uncommon in this clinical setting and raises an extended differential diagnosis, including infectious bronchiolitis, diffuse panbronchiolitis, granulomatous infection (mycobacteria, fungi), pneumoconiosis, sarcoidosis, hypersensitivity pneumonitis, Langerhans cell histiocytosis, foreign body-induced necrotizing vasculitis, and metastatic disease. 5,6 Here we present the unusual case of an adolescent with CF presenting with declining pulmonary function and diffuse micronodular pulmonary disease resulting from intravenous injection and pulmonary arterial embolization of pharmaceutical-tablet constituents. CASE REPORTAn 18-year-old white female with CF, poorly controlled CF-related diabetes mellitus, and a permanent intravenous port presented with a 6-month history of recurrent episodes of increasing cough, decreasing energy, progressive exercise intolerance, worsening hypoxemia, and progressively declining pulmonary-function tests (PFTs) despite aggressive use of inpatient and outpatient intravenous antibiotics, mucolytics, and airway-clearance techniques.A computed tomography (CT) scan of her chest revealed centrilobular, clustered micronodular opacities and multiple areas of larger patchy opacities (Fig 1A). Mosaic attenuation was present; however, it was unclear whether this was a result of airway disease or vascular disease. There was also moderate, cylindrical bronchiectasis with peribronchial thickening and mucoid impaction consistent with the patient's underlying diagnosis of CF. Transbronchial biopsies and a subsequent open lung biopsy revealed peribronchial foreign body giant-cell reaction to polarizable crystalline material resembling cal...

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Pulmonary microcrystalline cellulose deposition from intravenous injection of oral medication in a patient receiving parenteral nutrition

Cited by 11 publications

References 5 publications

Irreversible Ischemic Hand Following Intraarterial Injection of Zolpidem Powder

Irreversible Ischemic Hand Following Intraarterial Injection of Zolpidem Powder

Illicit narcotic injection masquerading as acute pulmonary embolism

Intravenous Injection of Pharmaceutical Tablets Presenting as Multiple Pulmonary Nodules and Declining Pulmonary Function in an Adolescent With Cystic Fibrosis

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