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Conference Proceeding

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Critical Care Medicine


INTRODUCTION: Patient is a 73 year old female with past medical history of colon cancer status post colectomy/ ileostomy with ileal conduit on chronic total parenteral nutrition (TPN) who presented to the hospital for fatigue and hypotension. She reported that the night prior, she had an 8 hour lapse in her memory and a sensation of dyspnea. In the ED, she was hypotensive and hypoxic. CTA of the chest was notable for a small and nonocclusive right lower lobe embolism, massive right heart strain with RV/LV 1.5 as well as innumerable bilateral centrilobular micronodules. The above findings were not present on a scan done one month prior and neither was the echocardiograph finding of sudden onset pulmonary hypertension with RVSP 55. In the setting of central venous access used for TPN and no signs of infection, consideration was given to crystalline induced microemboli. A bronchoscopy was performed which showed polarizable material with occlusive granulomatous inflammation along the vessel walls and confirmed the diagnosis of excipient lung disease. DESCRIPTION: Excipient lung disease is classically associated with IV injection of crushed oral tablets such as narcotics and stimulants. Excipients such as microcrystalline cellulose and talc consist of inert filler materials which aid in the binding of the active particles of the medications. When these agents are deposited in the pulmonary vasculature, there is an angiogranulomatous reaction resulting in micronodules and microemboli which can potentiate cor pulmonale and sudden cardiac arrest. DISCUSSION: Excipient lung is a rare and often missed diagnosis. When the disease process is considered, it is typically attributed to injection of illicit drugs or controlled substances, yet this case illustrates the importance of recognizing TPN as a potential cause. Although most formulations of TPN have microcrystalline cellulose which do not cause any adverse reactions, this patient’s infusion resulted in acute pulmonary hypertension, cor pulmonale and diffuse occlusive pulmonary granulomatous micronodules. This etiology is crucial to keep in the differential because although uncommon, it can cause pulmonary fibrosis and pulmonary hypertension which can result in poor functional status, decreased lung compliance, heart failure and possible cardiac arrest.




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