Acute respiratory distress syndrome (ARDS) secondary to talc pleurodesis

Abstract

A 66-year-old lady was admitted with neck swelling and breathlessness for a number of weeks, although she previously had been well. On examination, she had a bilateral goitre and bilateral pleural effusions. Chest radiograph confirmed superior mediastinal enlargement, bilateral effusions and multiple nodular infiltrates. Computed tomography of the neck and chest demonstrated heterogeneous enlargement of the thyroid, multiple pulmonary nodules and bilateral effusions. Ultrasound-guided biopsy of the thyroid confirmed follicular carcinoma of the thyroid. A 12 French gauge chest drain was inserted into the larger right effusion. Pleural fluid cytology confirmed metastatic follicular carcinoma of the thyroid. As her breathlessness was felt to be at least partly due to her pleural effusions, talc pleurodesis using 4 g of graded sterile talc (Steritalc®, Novatech, La Ciotat, France) was performed. The following day, she became much more breathless, developed progressive type 1 respiratory failure and multilobar pulmonary infiltrates. Diagnosis was consistent with acute respiratory distress syndrome (ARDS). Despite broad-spectrum antibiotics and corticosteroids, she deteriorated progressively and died 5 days after talc administration. Reports of ARDS secondary to intrapleural talc have been reported [1], though death is rare [1,2]. Aetiology of ARDS is thought to be related to dose [1] and particle size of talc [1]. In this case, the recommended dose and particle size were used, yet the patient died. This case is important since it emphasises that caution must be exercised, even when using a recommended talc preparation. It has been suggested that the presence of respiratory failure and extensive metastases may be associated with a higher incidence of ARDS [1]. Perhaps this requires further evaluation, either by questionnaire survey of respiratory physicians/oncologists or via reporting agencies such as the UK's Yellowcard system. Until then, caution must be urged with talc pleurodesis, especially in patients with respiratory failure or advanced malignancy.