Document jB1GRy7906gjRKmJ6amzGdQmR

and impaired CSF resorptive capacity corticosteroid therapy may be effective but it was not in this case Because of the persistence of elevated CSF pressure a lumbarperitoneal diversionary shunt procedure was successful removal of the large vascular malformation was not attempted SUMMARY A vascular malformation caused prominent intracranial hypertension by impairing CSF resorptive capacity rather than by its mass effect or ventricular obstruction It was successfully treated by diversionary shunt References . Paterson JH Mckisanck W A clinical survey of intracranial ang~-nmas with special reference in their mode of progressin and surgical irea ment Brain 233-266 233-266 1956 Jubiision : Rechneest CSF aburpena aburpena svodrome Lancet 418 420418 420418 420 . 1973 301-312 3 Johnson 1. Paterson A Benign intracranial hypertension hypertension If CSF pressure and circulation Brain 97 1974 4 Dandy WE Intracranial pressure without brain tumor Ann Surg 106 492-513 1937 5 Arseni C. Constantinescu A. Chrescu M The pseudotumiral form of respiraties encephalopathy Confin Neurof 117-121 1968 ti Mathew NT Meyer JS Out O Increased cerebral blandt volume in benign intracranial hypertension hypertension Neurology 25 646-649 1975 3. Bercaw Bl Green M ransport of intrathecal of 1 131 RISA in benign intracranial hypertension hypertension Neurology 20 787-790 1970 1 aa 8 ha . Ume e Vew a eT ep we we ob AS lee NE Slee TING PRCT ta Pulmonary Talcosis as a Result of Massive Aspiration of Baby Powder TERRY P. CRUTHIRDS MD FRANCIS H. COLE MO and RAPHAEL N. PAUL MD Memphis Tenn In 1954 Cless and sive aspiration of associates added Anger reported a fatal case of masbaby powder In 1962 Molnar and to the literature another instance and in 1963 Jenkinsreported a third case in which death resulted shortly after aspiration Hughes and Kalmer in 1966 recorded survival of an infant in whom recovery was associated with administration of dexamethasone this patient was asymptomatic with a normal chest film two weeks after the acute episode The purpose of this paper is to record progressive inflammatory disease of the lung as a sequel to massive aspiration of baby powder CASE REPORT A year white girl was admitted to LeBonheur Children's Hospital in November 1966 for evaluation of lung disease noted by an orthopedic surgeon who had discovered the changes of hypertrophic ostenarthopathy while treating her for a bruise of the left foo1 On admission to the hospital the patient appeared chronically ill but in no distress There was no cevanosis but clubbing of the fingers and toes was noticed The only other significant physical finding was a loud pulmonic second sound The child had apparently been in good health until about three years before admission when she began having frequent sore throats and colls Approximately 2years before admis- sion she was hospitalized for pneumonia Her parents were later told that the infection was cured but that her lungs were scarred they were told that this was of no consequence The child continued to have frequent respiratory infections ac companied by grade ever cough and moderate dyspnea until January 1966 since that time improve It had been observed that than her playmates Neither cyanosis her the nor condition appeared to girl tired more easily edema was ever noted The child had a poor appetite with frequent early morning vomiting Chest discomfort 425 not present and morning cough was not productive Several years before the apparent onset of the present illness there were possible episodes of measles pneumonia and acute rheumatic fever Admission laboratory values were within normal limits PPD skin test was negative as were complement fixation tests for histoplasmosis blastomycosis and coccidioidomycosis The roentgenogram of the chest on admission Fig ) showed Read before the Section on Chest Diseases Southern Medical Association Sixty ninth Annual Scientific Meeting Miami Beach Fla Now 16-19 1975 From the Departments of Pathology Surgery and of Tennessee College of Medicine Memphis Tenn Reprint requests to Department of Pathology St. Pediatrics L~niversity Jmeph Hospital 220 Overton Ave Memphis Tenn 98105 Dr. Cruthirds widespread widespread progression chronic chronic inflammatory disease disease of the process was discerned of by the lungs comparison S ow with previous films Results of bronchoscopic examination bronchograms and dectrocardiogram were essentially within normal limits An open biopsy of the lingula of the left lung revealed multiple nonconfluent nodules throughout the lung The impression at the time of the thoracotomy was that these nodules were caseDIIS The cultures from the hing tissue for acid bacilli fungi and pyogens were negative The postoperative course was relatively uneventful and the patient was discharged nine days after operation The surgical specimen was a 1.3 1.2 10 cm irregular mass of firm gray tissue with small areas of aerated parenchyma An impression of defined nodularity was given Microscopic examination revealed extensive confluent fibrosis and hyalinization with large areas in which pulmonary paren chvina was obliterates Fig 2 Recognizable small arteries and FIGURE 1. Admission inflammatory infiltrate chest film demonstrating diffuse bilateral chronic 620 May 1977 SOUTHERN MEDICAL JOURNAL Vol 70 No. arte 3 the for ine "-,, cle Cry idle wit api tie wit cat ph 0 re ve ik "" i] o i C I 1 1 0048667 JNJ 000321942 a . a Eosinophils prom- arterioles had thickened walls and very small lumina There was a tendency for peribronchiolar distribution of the periphery of the nodules changes and at were occasional aggregates of foreign multinucleated giant cells There was inent inflammatory infiltrate mostly mononuclear were relatively conspicuous Within many of the giant cells were defts filled with staining structures which crystalline Fig 3 On polarization these appeared to be identified as doubly refractile bodies foci were easily with a length of up to Fig 4 The size varied approximately 100 and a width of up to approximately 2 u After intensive questioning concerning the possibility of aspira- tion of foreign material the when the mother remembered an episode patient then approximately 2 years of age got into a can of baby powder and aspirated quite a bit She physician at which time was seen by cated There were no apparehnotspitalization was not thought indi- sequelae This young woman is now a year college student reportedly carrying on usual activities without years after thoracotoniy Chest film difficulty nine ray taken last year Fig 5 16 years after the episode of aspiration resembles that taken eight years previously There is prominence in the hypertension the pulmonary conus suggestive of pulmonary region of DISCUSSION ' The major ingredient in most brands of baby powder is talc and we believe our patient had talc coniosis This disease is pneumo- encountered as an occupational hazard in the mining and processing of talc as well as ! pes oar 2 mdramaaticalgy nification FIGURE 4. Photomicrograph of same emphasizes the biretractile ^ 400 partially polanzed field as Figure 3. Polarization libers present H & E. original _ in numerous industries in which tale is used The term talc pneumoconiosis may be a misnomer as it is likely that impurities such as tremolite or silica are the fibrogenic agents responsible Talcosis is generally characterized by gray nodules concentrated within the lower lobes of the lungs Microscopically the foreign material is incorporated in the more fixed parts of the alveolar walls around terminal air especially passages smaller blood vessels septa and beneath the pleura Fibers resembling asbestos bodies are often found In the case reported by Molnar et al dis- closed an autopsy acute bronchitis and bronchiolitis with bronchial lumina filled with granular material con- taining talc The changes were interpreted as those of early bronchiolitis obliterans Despite the wide use of baby powder . aspiration of CA ae! e germ Fe ate sow & on nine FIGURE 1. Chear fim predominantly increased radiolucency of the radiolucency of lower lung lfuineglds present Extensive perhaps prominent upper upper efter min Extensive fields is is lung The pulmonary fibrosis Cruthirds et al 2 PULMONARY TALCOSIS 827 0048668 JNJ 000321943 me ee omer ew ee tt oe on rere the material is either infrequent or infrequently reported within the United States This case illustrates the serious consequences that may result although the patient has recovered from the acute episode and has been asymptomatic for several years One of the most bizarre cases of talc pneumoconiosis was reported by Nam and Gracey in 1972. Although death was from an unrelated disease the patient had developed extensive talcosis as a result of liberal use of cosmetic talcum powder over a period of 20 years The authors stated that they had been unable to find in the literature a case of pulmonary talcosis associated with the use of cosmetic d^,,stingpowder SUMMARY sequel Progressive diffuse pulmonary fibrosis as a to massive aspiration of baby powder talc is documented The diagnosis should be considered in idio pathic pulmonary fibrosis in childhood and adult life References Gless D. Anger R Ersenkungsind Ersenkungsind Durch Kindermeras Phny 22 SNS TD 1954 Aspiration Aspiration visti Kinderpuder LS. J Muinai JJ Narbenwan .. Eati ... Falak aspiration aspiration of prwider by a clubl N Engl Med 206-31637 206-31637 206-31637 1962 talcum 3 Jenkins MQ Dusing powals inhalation inhalation JNC Med Form 59:62 1963 Hughes W. Kahnen with alexamethasoner alexamethasoner alexamethasoner talk aspration esixessful treatment Child 11 653-654 1966 Pulamnays 653-654 % Sami K. Gravey DR PulamnaPuylamnsays tal^>zises from cosmetic takim : 492-493 powder 133 221 492-493 1972 1972 . Cardiac Arrhythmia and Hypopotassemia in Association With Lithium Carbonate Overdose MOHAMMAD A. HABIBZADEH MD and NICKOLAS H. ZELLER MD Phoenix Ariz FOR OVER 100 YEARS lithium salts have been used in the treatment of various disorders including rheumatism gout hyperthyroidism diabetes mellitus and as a salt substitue in patients with congestive heart failure These rises however proved unrewarding and were associated with significant significant toxic effects Therapeutic efficacy of fichium sadis in the treatment of depressive psychosis recently recently has been appre ciated Lithium has a narrow therapeutic range and multiple side effects may develop when the serum concentration reaches or exceeds upper therapeutic levels 2.0 to 25 liter Foxic serum levels of lithium can prove fatal Therapeutic serum lithium levels do not appear to have significant significant significant cardiotoxic effects but at toxic levels serious cardiac disorders and arrhythmias may develop develop which require particular attention CASE REPORT A year man was taking 300 mg of with no bistory of GitelGiitelioovasculvar aGitselciouvalscaulrar disease disease lithium carbonate carbonate d fie the treatoient treatoient of a psychiatric disorder Four hours before admission ^ re took 120 tablets was in 3i gim of this preparation On arrival arrival mn acute distress Die skin arah mucous at the hospital mucous membranes membranes were well divilated and blood pressure teniperative was was 123/84 mm normal lungs were clear Hg The heart rate 11.35 min with abnormalities regular sinus elythm There WIK no on palpation 4 , a, uscultation Except for cardia lateral gaze The misstagimus there were no abnormal neinologi findings sertun BUN hemoglobin and hematocrit values BUDO normal Chesi mentgenogram was negative The serum lithium level was 3 mEq liter one hour after admission three foms after admission it had fallen to 22 laborators and clinical cliniccalinlical data are surfined mEq Other surfined in the Lable pertinent Hospital Course aminoplys On admission to the hospital gastric lavage was instituted This was followed by oral administration of 60 ind of Fleet Phospho sodium biphosphate and sodium and activated charcoal Intravenous infusion of plusphate li ng of aminoplys in 500 of mowmal saline rate of f^nhous was began admission and continueit bin the serum Juhum 38 hous Twelve hours after sane queers tlvorpoprent ter Ute mEspliter mEsplimEtspelitrer with and the potassium in 2,4 lner This was sous bradyvandia at a rate of FF is imin and venirivulo venirivulo escape indioventricular indioventricular rhything at ) indioventricular indioventricular without without significani significani cimica cimica svimptomis ^ igE. Ar a rate The associated periods of of 32min idioventricu- ^ ar r^ythm r^ yythm r^ yythm had a left hamille branch branch block block pattern This pattern lasted chloride following fusant Jew how's of potassium potassium potassium and terminated terminated following chloride chlorcihlodriede solution Be intravenous intravenous insimus bradycardia puisisted lo over 38 boins in potassium ibig in 17 mkq and the fourth day spite of a retum if the serum a b^>lumdeve at 0,3 m gliter the patien's bean rate was 80 Babble Babble A month later while while the patiem was taking 1500 mg of imipraDAME bychochikunle bychochikunle Fulranch Fulranch per day nomnvasive cardiac evaluation was performeil Die sysia u time intervals revealed a prolonged ejection LVET = 1038/257 = value of 97/269 = 0,36 phaseflet ventricular ejection time 0.01 as compared with a predictet here were im abnormalities on his verture verture apexe phone and echocardiogramis echocardiogramis echocardiogramis echocardiogramis DISCUSSION The development of sinus bradycardia and idio ventricular rhythm in the presence of marked hypo- kalemia in this case was rather unusual This occurred when the lithium level was at low therapeutic range 0.66 mEq The patient did not receive diuretics during the course of treatment and the drop in the serum potassium from 4.3 liter to 2.4 mEq within 12 hours could not be explained by gastric lavage and intravenous fluid infusi^n alone Hypoka- Jemia due to gastric lavage and loss of hydrochloric acid is associated with hypochloremic alkalosis This pa tient had a serum pH of 7.46 and the serum chloride levels were normal Table The development of hypokalemia may have been in part due to the toxic effects oflithium on the kidney and excessive potassium excretion Low serum potassium causes increased automaticity especially of the latent pacemaker fibers This is probably due to decreased potassium conduc- 0048669 JNJ 000321944