Acute respiratory distress syndrome secondary to talc pleurodesis

Boira, Ignacio; Galán Negrillo, Marta; Gañán Boscá, Alejandro

doi:10.1016/j.medcle.2023.06.015

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Administering more than 5 g is not recommended. Acute respiratory distress syndrome (ARDS) is a rare but serious complication.We report the case of a 65-year-old male, ex-smoker of 48 packs/year, with a history of right apical bullectomy for secondary pneumothorax in 2020 and right lower lobectomy for squamous cell carcinoma in 2021. The patient went to the emergency department for left chest pain. Chest X-ray (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a) showed a complete left pneumothorax and a 20-French chest drain was inserted. During admission he showed complete re-expansion without air leak (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b) and pleurodesis was performed with 4 g of talc using the slurry technique. At 48 h the patient showed clinical and radiological worsening with bilateral alveolar-interstitial infiltrates of diffuse distribution (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>c). Arterial blood gases (with FiO2: 40%) confirmed moderate ARDS (PaO2/FiO2: 147 mmHg). Blood cultures, urine cultures, sputum culture, urinary antigen test for pneumococcus and Legionella and serology for respiratory viruses were negative. Laboratory tests showed leucocytosis (13.6 × 109/L), neutrophilia and elevated C-reactive protein (300 mg/L), interleukin-6 (102 pg/mL [0−10 pg/mL]) and interleukin-8 (910 pg/mL [0−66 pg/mL]). Broad-spectrum antibiotic therapy was started with meropenem (1 g/8 h) and linezolid (600 mg/12 h) with poor clinical course, initiating high-flow oxygen therapy with nasal prongs (FiO2: 60% with 60 L/min flow) and systemic corticosteroids (1 mg/kg/day) showing good clinical and radiological response at 72 h (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>d).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Chemical pleurodesis is a procedure in which an irritant agent is applied to the pleural cavity, producing an intense inflammatory reaction that generates adhesions. In Europe, talc has an average particle size of 31 μm, with small particles (5−10 μm) having a greater response and complications. It can be insufflated by thoracoscopy or diluted through thoracic drainage using the slurry technique.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>Most complications are mild (fever, pain), but serious complications (pneumothorax, pneumonia, persistent air leak, pulmonary thromboembolism, empyema and ARDS) have been reported.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> In the 1980s and 1990s, talc pleurodesis testing in animal models found that small particles and large doses may predispose to the development of ARDS.<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a> The main hypothesis is its pulmonary and systemic dissemination inducing an inflammatory response. Talc has been obtained from bronchoalveolar lavage specimens, from multiple organs in autopsies and elevated serum and pleural fluid interleukin-8 (IL-8) have been reported as acute phase reactants.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> The incidence of ARDS secondary to talc pleurodesis is less than 1%, with almost all cases described in malignant pleural effusion. Advanced age and previous interstitial abnormalities are the main risk factors.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> The only large study in patients with pneumothorax is a multicentre clinical trial involving 418 European and South African patients, with no patient having ARDS at 30 days.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> The present case shows an exceptional complication of talc pleurodesis in a patient with pneumothorax that should be taken into account in the differential diagnosis for early detection and initiation of appropriate measures.FundingThis paper has not received funding of any kind.Conflict of interestThe authors declare that they have no conflict of interest directly or indirectly related to the contents of the manuscript." "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2886 "Ancho" => 3341 "Tamanyo" => 481257 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "a) Chest X-ray with complete left pneumothorax. b) Complete re-expansion of the pneumothorax after thoracic drainage. c) Bilateral diffusely distributed alveolar-interstitial infiltrates in the context of talc pleurodesis ARDS. d) Radiological improvement after initiation of systemic corticosteroids." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of thoracoscopic talc poudrage vs talc slurry via chest tube on pleurodesis failure rate among patients with malignant pleural effusions: a randomized clinical trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. Bhatnagar" 1 => "H.E.G. Piotrowska" 2 => "M. Laskawiec-Szkonter" 3 => "B.C. Kahan" 4 => "R. Luengo-Fernandez" 5 => "J.C.T. Pepperell" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jama.2019.19997" "Revista" => array:6 [ "tituloSerie" => "JAMA." "fecha" => "2020" "volumen" => "323" "paginaInicial" => "60" "paginaFinal" => "69" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31804680" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Safety of pleurodesis with talc poudrage in malignant pleural effusion: a prospective cohort study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.P. Janssen" 1 => "G. Collier" 2 => "P. Astoul" 3 => "G.F. Tassi" 4 => "M. Noppen" 5 => "F. Rodriguez-Panadero" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(07)60708-9" "Revista" => array:7 [ "tituloSerie" => "Lancet." "fecha" => "2007" "volumen" => "369" "paginaInicial" => "1535" "paginaFinal" => "1539" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17482984" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S092099641630007X" "estado" => "S300" "issn" => "09209964" ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Complications of thoracoscopic talc insufflation for the treatment of malignant pleural effusions: a meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "W. Zhang" 1 => "Y.L. Zhao" 2 => "S.J. Li" 3 => "Y.N. Zhao" 4 => "N.N. Guo" 5 => "B. 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Vol. 161. Issue 9.

Pages 411-412 (November 2023)

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