UNUSUAL PATIENT -3

When I saw her for the first time I  felt bad . She was 37 years old white female who was admitted with pneumonia. She smoked only on few occasions. and was not alcoholic . , but was admitted on few occasions in the hospital. She had pneumonia and phlebitis in upper extremity on 2 previous occasions and was treated with meds . On exam she obese , weighed almost 250 lbs. was not in any distress . Her lungs sounded almost clear and her oxygen level was slightly lower. Her x-ray showed small nodular densities. I was not sure what was the cause of her recurrent pneumonia.
     I ordered ct scan . I also ordered some blood tests to check on her immunity, IgG , IgM, IgA etc. I also ordered test to r/o autoimmune disorders like lupus etc. The ct scan confirmed nodules -present in both lungs . So I decided to do bronchoscopy with biopsy--an endoscopy to get some lung tissue without any surgery. I also send samples for various micro organisms. The all cultures came back negative . So there was no infectious cause for the nodules-not at least on these cultures. The biopsy showed 'grannuloma ' i.e. cells in inflammation are seen in particular way as if the are surrounding 'culprit' in battlefield. These kind of arrangement is seen in conditions  like  TB, fungal infections, a disease called sarcoidosis or even in rheumatoid arthritis. But this lady had none of the other blood tests suggesting any of the conditions that I mentioned . She also had left hand phlebitis for no known reason.
     She was married and had a daughter age 6yrs . I decided to get chest surgeon.There was no way to treat this lady without definitive diagnosis. I could start steroids, thinking that this could be sarcoidosis.But I was reluctant to do this as she was Young and was obese.
       So the surgeon saw her did open lung biopsy . The report shocked me. The biopsy showed the granuloma    ,but the detail description was shocking . In the center of this inflammatory structure usually there cheesy material. Instead in this one there was TALK . Now I called the pathologist to confirm this .and he was quite sure. How could talk get in lung? We know that there are cases described where talc  granulomas,. have occurred in babies whose mother were using too much talcum powder on their babies after bathing them . Only real explanation that I had was not very palatable.  T had seen something like this when I was in training. Some drug addicts used to inject tablets dissolved in water in the vein ,thinking that this will give them kick that they could not get by taking narcotic pills.by mouth.But how can I ask this lady with husband and a child , that are you injecting pills ?. This would explain the phlebitis that she got 2 or 3 times . When one inject this kind of material it is likely to cause inflammation in the vein hence the phlebitis in left arm in this right handed lady.
       I discussed this with surgeon . He had no doubt about this cause as the possible explanation. So I talked to her and told her the biopsy report and the explanation . She did not accept . Did not want accept the strong evidence that she was injecting , so was discharged in couple of days. I had asked her to do the follow up in the office , as expected she did not come.