CASE STUDIES IN TOXICOLOGY Series Editor: Lewis S. Nelson, MD

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CASE STUDIES IN TOXICOLOGY
Series Editor: Lewis S. Nelson, MD
Inhalation of Baby Powder
Talc is harmless if it is ingested or applied topically, yet the consequences can be severe—and
even deadly if it is inhaled. In this case, a child presents emergently with a diffuse bronchiolar
inflammatory reaction after acute talcum powder inhalation.
Fiona M. Garlich, MD, and Lewis S. Nelson, MD
Case
A previously healthy 11-month-old boy is brought by his
mother to the ED approximately 20 minutes after he inhaled baby powder during a diaper change. The mother
states that immediately after the exposure, the infant had
an episode of coughing in which he “turned blue,” but
then he rapidly improved. Upon arrival to the ED, he is
noted to be tachypneic, with a respiratory rate of 40 to 60
breaths/min. His oxygen saturation is 98% on room air,
and his vital signs include a blood pressure of 90/55 mm
Hg; heart rate, 104 beats/min; and temperature, 37.1°C.
Findings on a chest radiograph are unremarkable. In the
ED, the patient receives empiric prednisone and is admitted for overnight observation in the pediatric ward. He is
discharged well the next day.
One day later, the patient returns to the ED with grunting respirations, subcostal retractions, diffuse crackles, a
respiratory rate of 60 breaths/min, oxygen saturation of
92%, and a temperature of 39.4°C. His white blood cell
count is 20,000 cells/µL. Arterial blood gas analysis reveals a pH of 7.4; Pco2, 32 mm Hg; and Po2, 85 mm
Hg. A repeat chest radiograph (Figure 1) demonstrates
increased bronchovascular markings and hyperinflation,
suggesting a diffuse bronchiolar inflammatory reaction.
No focal infiltrates are seen. Upon the treating physician’s
Dr. Garlich is a fellow in medical toxicology in the
department of emergency medicine at the New York
University School of Medicine in New York City and the New
York City Poison Control Center. Dr. Nelson is an associate
professor in the department of emergency medicine and
director of the medical toxicology fellowship program at
the New York University School of Medicine and the New
York City Poison Control Center. He is also a member of the
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request, the parents bring in the container of baby powder.
It contains talc, at a concentration of 81%.
What is talc?
Talc is hydrated magnesium silicate (Mg3Si4O10(OH)2), a
pearly white, naturally occurring mineral found geologically in deposits around the world. It is the softest mineral on earth, and its name is derived from the Arabic
talq, meaning “pure.” Talc has been used for millennia
and is currently included in a myriad of industrial and
consumer products, including plastic, paint, cosmetics,
lubricants, pharmaceuticals, gymnastic chalk, decorative
soapstone, and talcum powder or baby powder. Talcum
powder, which consists of finely ground talc, has soothing, lubricating, and absorptive properties when applied
to the skin. Because of these attributes, talcum powder
was introduced in 1893 for use as baby powder. Paradoxically, talc is used medically as a pleurodesis agent
to prevent recurrent pneumothorax, due to its ability to
incite a localized inflammatory reaction when applied to
the pleural surfaces.
What are the symptoms and complications
of acute talc inhalation?
While ingestion or topical application of talc produces
a benign effect, the substance acts as an irritant when
it is inhaled.1 Findings can range from cough, sneezing, and transient dyspnea to cyanosis, severe respiratory distress, respiratory failure, and even death.1,2 Many
cases of symptomatic talc inhalation have been reported,
primarily in infants and preschool-aged children.3 Most
inhalation incidents occur at the time of a diaper change,
but such events have also occurred when the child accidentally inverted the talcum powder container or when
older children were mimicking the use of powder on a
JANUARY 2011 | EMERGENCY MEDICINE 17
CASE STUDIES IN TOXICOLOGY
Figure 1. Repeat chest radiograph showing hyperinflation and increased bronchovascular markings,
evidence of a diffuse bronchiolar inflammatory reaction.
younger sibling.3 The onset of consequential symptoms
is often delayed several hours from the time of inhalation,1 as in the case of our patient, but may occur more
rapidly following massive inhalational exposure. Subsequently, pneumonitis, bronchiolitis, diffuse pulmonary
infiltrates, acute lung injury, bronchiolar obstruction,
or pneumonia from bacterial superinfection can occur,
leading to severe pulmonary compromise, including
acute respiratory distress syndrome. The reported mortality in severe talc pulmonary toxicity ranges from 20%
to 33% in case series.1,4
What is the pathophysiology of pulmonary
injury in acute talc inhalation?
Talc is insoluble in water, causing drying of the mucous
membranes of the tracheobronchial tree when it is inhaled. This results in impairment of the normal ciliary
function that is required to clear particulate matter from
the airways.1 Edema and inflammation of the bronchial
epithelium occur, leading to a pattern typical of acute
lung injury. Inhalation of talcum powder can also cause
18 EMERGENCY MEDICINE | JANUARY 2011
mechanical obstruction of the small airways.2 Mice that
inhaled talcum powder were found on autopsy to have
bronchioles obstructed with talc, and histologic examination of the bronchial epithelium revealed hemorrhage,
edema, and desquamation.2 Furthermore, adsorption of
surfactant to the magnesium silicate powder may contribute to pulmonary injury.1,2
What therapeutic options exist for the
treatment of acute pulmonary injury
caused by talc inhalation?
The primary goal in the treatment of patients with acute
talcum powder inhalation is to maintain adequate ventilation and oxygenation. Supplementary oxygen should be
administered as needed; intubation and mechanical ventilation may be required. A trial of inhaled bronchodilators is reasonable as appropriate, although data to support
their use have not been reported. Corticosteroids, either
oral or parenteral, are frequently administered in an attempt to mitigate the local inflammatory response. While
the benefits of steroids have not been confirmed in clinical
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trials, there was a trend towards mortality benefit in a retrospective review.4 Generally accepted regimens include
methylprednisolone 0.5 to 1 mg/kg IV every 6 hours, or
prednisone/prednisolone 1 to 2 mg/kg/day orally, both
for a total of 3 to 5 days. Bronchoalveolar lavage may be
beneficial in the setting of massive talc inhalation, but its
use has only been anecdotally reported.1,4
Is talc still used in baby powder?
Many parenting guides recommend against the use of
talcum powder for infants. Cornstarch-based baby powder—which is noninflammatory and associated with
substantially lower risk if inhaled—was introduced in response to public awareness of the dangers of lung injury
from talcum powder. However, talc-containing products
are still readily available at many retail locations. They are
often labeled simply as “baby powder” and are found sideby-side with cornstarch-based diaper powder in the baby
care aisle (Figure 2). Some talcum powder containers have
warnings cautioning against the dangers of inhalation,
but many do not. The labeling of these products may be
unclear or easily overlooked, leading to the interchangeable use of talcum and cornstarch powders. Though the
incidence of talcum powder inhalation has decreased, it
still poses a significant public health risk. The American
Association of Poison Control Centers reported that in
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Figure 2. Baby powders containing talc are often
labeled simply as “baby powder” (left). In many
stores, they can be found on the same shelf with
cornstarch-containing powders (right).
2008 there were 2,526 exposures to powders made of talc;
87% of these occurred in children younger than 6 years.5
Besides acute inhalation, what other causes
of talc-related pulmonary toxicity exist?
The chronic inhalation of talc dust has long been associated with chronic pulmonary disease in talc miners and
JANUARY 2011 | EMERGENCY MEDICINE 19
CASE STUDIES IN TOXICOLOGY
industrial workers. Chronic inhalation of talc dust in the
industrial setting can lead to talcosis, a condition characterized by chronic bronchitis, interstitial fibrosis, and/
or granuloma formation.1 Naturally occurring talc often
contains contaminating minerals such as crystalline silica and tremolite asbestos, which can lead to pulmonary
damage in miners who are exposed to it. The resulting
conditions, termed talcosilicosis and talcoasbestosis, are
clinically and radiographically similar to silicosis and asbestosis, respectively.
Pulmonary toxicity resulting from the IV injection of
talc-containing xenobiotics has also been described in the
medical literature.1,6 One means of drug abuse involves
crushing, solubilizing, and filtering oral medications and
injecting them intravenously. Talc is a common component of many tablet formulations and thus can be inadvertently injected if the filtering step is inadequate. The
talc crystals are retained in the pulmonary capillary bed
and produce angiothrombosis, granulomas, and interstitial fibrosis, which may lead to pulmonary hypertension
and cor pulmonale.1,6
20 EMERGENCY MEDICINE | JANUARY 2011
Case Conclusion
The patient was treated with IV methylprednisolone,
along with ceftriaxone as empiric coverage for possible
bacterial pneumonia. He was admitted to the pediatric
ICU, where he improved clinically during the next 2 days.
Intubation and advanced ventilatory support were not required, and the patient was discharged on hospital day 3
to complete a 5-day course of oral prednisolone. EM
References
1. Hollinger MA. Pulmonary toxicity of inhaled and intravenous talc. Toxicol
Lett. 1990;52(2):121-127.
2. Motomatsu K, Adachi H, Uno T. Two infant deaths after inhaling baby
powder. Chest. 1979;75(4):448-450.
3. Pairaudeau PW, Wilson RG, Hall MA, Milne M. Inhalation of baby
powder: an unappreciated hazard. BMJ. 1991;302(6786):1200-1201.
4. Brouillette F, Weber ML. Massive aspiration of talcum powder by an
infant. Can Med Assoc J. 1978;119(4):354-355.
5. Bronstein AC, Spyker DA, Cantilena LR Jr, et al. 2008 Annual Report of
the American Association of Poison Control Centers’ National Poison Data
System (NPDS): 26th Annual Report. Clin Toxicol. 2009;47(10):911-1084.
6. Arnett EN, Battle WE, Russo JV, Roberts WC. Intravenous injection
of talc-containing drugs intended for oral use. A cause of pulmonary
granulomatosis and pulmonary hypertension. Am J Med. 1976;60(5):711718.
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