Pulmonary talcosis caused by intravenous methadone injection

A 38-year-old woman presented to our pulmonology clinic with complaints of progressive dyspnea and dry cough for more than three months. She denied fever or weight loss. On physical examination, she presented as hypoxemic, with a room air oxygen saturation of 92% and an RR of 24 breaths/min. Pulmonary function tests showed that spirometric values were within normal limits, but there was a slight increase in residual volume (127% of predicted), as well as a reduction in DLCO (70% of predicted). Other laboratory test results were normal. A CT of the chest showed bilateral centrilobular nodules, most of them showing tree-in-bud appearance, scattered diffusely in the lung parenchyma (Figures 1A and 1B). After the CT examination, flexible bronchoscopy was then performed. Cultures of BALF were negative. Transbronchial biopsy performed in the left lower lobe showed multinucleated giant cell granulomas with birefringent foreign material, compatible with talc (Figures 1C and 1D). The centrilobular nodules were determined histopathologically to be tiny foreign body particles lodged in the centrilobular arterioles and perivascular space.