Images in Clinical Medicine

Pulmonary Foreign-Body Granulomatosis

Dustin A. Staloch, J. Stephen Hedley

N Engl J Med 2017; 377: 1273

A 31-year-old woman who was receiving long-term total parenteral nutrition after having undergone Roux-en-Y gastric bypass that was complicated by small-bowel resection presented to the pulmonology clinic with exertional dyspnea that had progressed over the course of 1 year. She had normal oxygen saturation while breathing ambient air and was not in respiratory distress. Breath sounds were normal in all lung fields, with no wheezing, ronchi, or crackles. Computed tomography of the chest revealed diffuse, innumerable centrilobular nodules in both lungs (Panel A). A lung-biopsy sample obtained by video-assisted thoracoscopic wedge resection revealed perivascular aggregates of histiocytes and foreign-body giant cells with abundant basophilic foreign material in coral-like structures (Panel B). The material was confirmed by mucicarmine staining to be crospovidone, an inactive ingredient present in many oral medications. The patient received a diagnosis of pulmonary foreign-body granulomatosis, which can occur after injection or nasal inhalation of pulverized tablets, often opioids or stimulants, that contain inert fillers such as crospovidone, talc, or cellulose. She reported that she had been using the vascular access for her total parenteral nutrition to inject oral opiates that had been previously prescribed for her after abdominal surgery. Although the best available treatment for pulmonary foreign-body granulomatosis has not been established, treatment of the underlying opioid-use disorder is critical. At follow-up 6 months after the patient’s initial presentation (3 months after diagnosis), her dyspnea remained unchanged and was not limiting her daily functioning.

一名31岁女性患者在Roux-en-Y胃旁路手术及小肠切除术后长期应用胃肠外营养。患者因劳累后呼吸困难进行性加重一年就诊于呼吸科门诊。患者吸空气时氧饱和度正常，且无呼吸窘迫。听诊呼吸音正常，未闻及哮鸣音、干啰音或湿啰音。胸部CT显示双肺弥漫性多个小叶中心型结节（图A）。经胸腔镜行肺活检楔形切除部分肺组织，病理检查显示血管周围组织细胞及异物巨细胞聚集，其中有众多的珊瑚样结构的嗜碱性异物（图B）。黏蛋白卡红染色证实该物质为交聚维酮，这是很多口服药中含有的一种无活性成分。患者被诊断为肺异物肉芽肿，这种疾病见于注射或经鼻吸入含有交聚维酮、滑石粉或纤维素的粉片（常为阿片类或兴奋剂）。患者承认曾使用供完全胃肠外营养的血管通路注射腹部手术后开具的口服阿片类药物。尽管肺异物肉芽肿的最佳治疗尚不明确，但针对使用阿片的疾病治疗十分关键。在患者就诊6个月后随访（确诊3个月后）发现，患者呼吸困难未缓解，但其每日活动并未受限。