Document zoyjavgyBVZer5NgQL6RwXwX3

FILE NAME: Johnson & Johnson (JAJ) DATE: 1966 June DOC#: JAJ 138 DOCUMENT DESCRIPTION: Journal Article - Massive Talc Aspiration *7^ C 653 Massive Talc Aspiration Successful Treatment With Dexamethasone WALTKK T. Hl/OHES, MD, AN'D THOMAS KAI.MKK. MO. LOUISVILLE F a t a LIT IKS HAVE been reported fol lowing ihe aspiration of talcum powder in infants.1 The incidence uf nonfata! illness .from tlie inlialation of this dusting powder is unknown. Because of the ready availability of this substance and since the clinical mani festations from aspiration mimic those of acute infectious bronchiolitis, it is likely this etiologv may sometimes be overlooked in milder cases. Talc is hydrous magnesium silicate, and commercially, the mineral talc is usually mixed with other silicates such as serpentine, tremolite. anthophyllite. and other in gredients, predominantly carbonates. Talc is insoluble, chemically inert, and, in a fine state of subdivision, it is used topically as a "mechanical protective" It acts mainly by preventing friction and by absorbing mois ture, fnit otherwise lias no therapeutic ef fe c t^ Tnnaiatioii of talc oust may result in acute or chronic lung disease. Sudden massive in halation produces acute respiratory distress of the bronchiolitis fibrosa obliterans type4 which is often fatal. Sustained inhalation of significant amounts of talc can produce pneumoconiosis ( talcosis u The case herein presented is of the former ty|>e in which an infant accidently inhaled a large .amount of talc dusting powder and suffered acute re spiratory distress. The course of ihis in fant's illness, similar to the reported fatal cases, seemed to be favorably influenced by treatment with dexamethasone ( Decadron). Report of a Case A healthy 14--tiniiit 1i-i1.1 white male infant was playing with a can ..f taleniti powder on Sept 24, At ' am thi- mi alter wits attraeteti to the in tran t hcratise of coughing ;unl gasping. The face f.was covered hy uni the mouth was "raked" with kthe (mvvder He vomited a small amount and by tlO am appeared to he in slight respiratory distress. gjAfter receiving an emetic in a community hospital, he vva- returned home. By afternoon the infant !; Received for publication Jan .=>. 1966. 3 From the Department of Pediatrics, University of j^Louis'mte. School of Medicine. Louisville. ,, requests to 226 E C hestnut S t. Louisville |4 0 2 (^ ^ ^ r. Hughes). . Inter J D is Child-- was having mure difficulty in breathing and was taken to the family physician who administered an antibiotic to prevent infection. The dyspnea tint not abate ami the patient was admitted to Lotus, ville General Hospital at midnight. On examination the iniant was in moderate re spiratory distress, very restless, and irritable. The rectal temperature was 101 F (38.3 C) pulse. 160/ min; blood pressure. 120 (systolic) by palpation method; and the rate of respiration was 44/min. The mouth and pharynx were normal. There w as moderate intercostal and subcostal retraction. Air exchange was Iairly good but expiration wa- pro longed. No rales were detected. The abdomen was not distended, and the liver and spleen were not enlarged. There was no cyanosis hut the baby coughed frequently. A roentgenogram of the chest at the time of admission revealed no abnormalities other than signs of moderate hyperinflation. The hemoglobin was 8.(> gtn/100 cc; and the white Mood cell count was 17.fXl0/cti mm, with 517/ neutro phils, 37% lymphocytes, and 12% monocytes. The red blood cells were hypochromic and the hemato crit was i'K i .uni reticulocyte count, 1.4%. Di etary history substantiated the impression of iron-deficiency anemia. Upon admission the patient was placed in a tent with oxygen mist. There was no evident re sponse to 0.15 ml aqueous epinepherine injected subcutaneously. A dose of 300,000 units of pro caine penicillin G were administered twice daily. Isoproterenol ( lsuprel). 2.5 mg. was given orally every six hours. '1 wenty-loiir hours afte r the aspiration, the in fant was in -everc respiratory distress with marked retractions of the chest. He was slightly cyanotic and the respiratory rate vv;t,s between 80 and fK) per'minute. With the hope of enhancing bronchodilation and reducing inflammation, 2.0 nig of dexamethasone was administered intramuscularly and continued every 12 hours for seven doses. Within It to 12 hours after initiation of steroid therapy, improvement was definite and the re spiratory rate was between 40 and hO per minute. Continued improvement came rapidly and dyxaniethasonc was discontinued on Sept 29, 1965. On this date and afterward the infant was asympto matic and without respiratory distress. Examina tion on October 7 revealed no symptoms nor physical abnormalities; the rliest roentgenogram was normal, and the hemoglobin had increased to 12.0 gm/100 cc with oral iron therapy. Comment The case presented here followed a course similar to all the reported cases of fatal talc aspiration up to the time when therapy with dexamethasone was initiated. Improvement Vol 111, June 1066 JNJTALC000438719 * i tr TALC ASPIRATION--HUGHES & KALMER 654 appeared to follow administration of this drug The most recently reported case by Jenkins3 in 1963 was that of a 14-monthold infant, who had coughing and some respiratory distress immediately after aspira tion of talcum powder, and was hospitalized five hours later with grunting respiration with a rate of 48/min and intercostal retrac tion Respiration became increasingly more labored and finally ceased ten hours after the aspiration. Molnar and coauthors case was a 22-month-old Negro boy whose re 2. Adrenocortical steroids produce con siderable temporary improvement in bepd* liosis,7 similar in some respects' to talcosis. 3. An inflammatory reaction occurs in bronchi and bronchioles which might be re duced by dexamethasone. If the favorable response to treatment was due to use of the steroid, it was probably due to the anti-inflammatory effect of the drug. Failure of response to epinepherine used prior to dexamethasone would suggest simple bronchodilation was not responsible for the spiratory rate reached 90/mm, seven hours improvement. after admission, and death occurred 20 hours In conclusion, it is strongly urged that after aspiration of the talcum powder. Cless talcum powder be removed from the en and Anger's 1 case followed an identical vironment of children and the traditional as course. Antibiotics, oxygen mist, digitalis, sociation of talcum powder and babies be morphine, and epinepherine had no demon abandoned. It has no medicinal value: strable effect on these cases. Pathologically, lesions of bronchitis and acute bronchiolitis have been demonstrated in the fatal cases, with pulmonary edema, focal atelectasis, and compensatory emphy wherever placed it serves as a foreign bod>. and at least three deaths and an unknown morbidity have resulted from this silicate powder. sema. The bronchial and bronchiolar lumens Sum m ary and alveoli may be filled with a homogenous basophilic matrix embedded with leukocytes, epithelial fragments, and refractile particles. Complete desquamation of the epithelium in many bronchi is seen with various grada tions of edema, hyperplasia, and squamous metaplasia. The submucosa is swollen and A case is presented of a 14-month-old in fant who aspirated talcum powder, became severely dyspneic, and was successfully treated with dexamethasone. The clinical course is compared to the three fatal cases reported in the literature. There is no justi often infiltrated with polymorphonuclear fication for the use of talcum powder in in leukocytes and ref ractile particles of talc. fant care. The pathological changes seen in talc pneu moconiosis have been described as both Generic and T rade Names of Drugs cellular and fibrotic reactions affecting pri D exam ethasone-- D ecadron, D eronil, D exam eth, marily the alveoli, smaller bronchioles, and Gammacorten, H exadrol. arterioles.5 ... Umbilical granuloma has been described secondary to the free use of talcum powder Isoproterenol--A ludrm e, Isuprcl. Procaine penicillin G--D epo-Penicillin, pen, IVycillin. , Lento- over the trunk arid diaper areas of newborn REFERENCES infants.0 Surgeons are familiar with granu t Cless, D., an d A nger, R.: E rstickungstod Durch lomatous reactions in the peritoneum from A spiration von K inderpuder, K inderaerztl P rax 22: glove talc. Also, skin granulomas may result from talc deposited in an incision site. Reasoning that led to the use of dexa- 506-508 (M arch ) 1954. 2. M olnar, J J .; N a th en so n , G .; a n d E d b erg , _S.: F a ta l A sp ira tio n o f Talcum P ow der By a Child, Kef E n g J M ed 266:36-37 (Ja n 4) 1062. methasone in this case was as follows. 1 Talc pneumoconiosis resulting from chronic exposure to talc in industry requires at least ten years before pulmonary fibrosis 3. Jenkins. M.Q.: D usting Powder Inhalation, S S Carolina M ed Assoe 59:62 (F e b ) 1963. 4 La Due, J.S .: Bronchiolitis Fibrosa Obliterans. A n h In tern M ed 68:663-673 (O ct) 1941. 5. K leinfeld, M., e t a l: T alc P n e u m o n c o n io s is . A rrh of clinical significance appears. It would seen that if, in an acute aspiration, the in fant could survive two or three days, the re spiratory- tract would clear itself of most of E nviron H ealth 7:101-115 (Ju ly ) 1963. 6. C reery, R.D.G.; McClure. D M.; and R utherford. R j \ Talc G ranulom a of the Umbilicus. Lancet 1 :667 668 (M arch 30) 1957. 7 K ennedy. B.J.. et al: Effect of Adrenocortico the foreign material and further damage tropic Horm one ( ACTH) on Beryllium Granulom ato V..,. . j - **-j A.fOd IRC / 1TaK\ 1QR1- Ka nn lilrfflv i nie ruad--V o l 111, June 1966 JNJTALC000438720