British Journal of Industrial Medicine 1984;41:84-87
Pulmonary granulomatous reaction: talc
pneumoconiosis or chronic sarcoidosis?
P TUKIAINEN,' J NICKELS,2 E TASKINEN,3 AND M NYBERG4
From the Department ofPulmonary Diseases,' Helsinki University Central Hospital, the Institute of
Occupational Health,2 the Transplantation Laboratory,3 University ofHelsinki, and Aurora Hospital,4
ABSTRACT A chronic pulmonary granulomatous reaction was associated with an almost identical
clinical picture in two patients exposed to talc. In both patients lung biopsy showed the deposition
of talc particles and a heavy granulomatous reaction. At the time of diagnosis the Kveim test
result was negative in both patients, urinary calcium excretion was normal, and there were no
extrapulmonary manifestations and no response to steroid treatment. These findings point
against sarcoidosis. The serum angiotensin-converting enzyme level, however, was raised in both
patients. It was concluded that the patient who was exposed to talc in the rubber industry had a
true talc pneumoconiosis. The other patient, who was exposed to cosmetic talcum powder,
suffered from chronic sarcoidosis with talc deposition in the lungs, since an enlarged axillar lymph
node containing granulomatous inflammation was discovered after two years' follow up. These
cases show that it may be extremely difficult to differentiate between chronic sarcoidosis and talc
pneumoconiosis even after careful clinical and histological analysis.
True talc is a hydrous magnesium silicate. Depen-
ding on where it is mined, commercially available
talc also contains varying amounts of asbestos
minerals which form chains or fibres and may there-
fore have an asbestos like effect on the lungs. Owing
to the widespread industrial and private use of talc
and talcum powder much interest has been directed
to the biological effects of this mineral, which have
been reported to cause pneumoconiosis in people
employed in talc mills and talc mines, and in workers
using talc in production processes-for example, in
the rubber industry.'
Although widely used as a dusting powder, talc is
not generally considered a health hazard when
exposure is limited to cosmetic application at home.
excessive use of cosmetic talc in adults.2-5 In all
these cases the question arises whether it was a true
talc pneumoconiosis or talc deposition and coinci-
granulomatous reaction in a patient who had used
cosmetic talcum powder for several years. As a
Received 5 November 1982
Accepted 10 January 1983
comparison we describe a patient who was exposed
to talc in the rubber industry and who showed a
chronic granulomatous lung reaction which we
believe represents true talc pneumoconiosis.
A 58 year old woman had a history of myomectomy
in 1952, cholecystectomy in 1968, and hysterectomy
in 1977. She had been a smoker for 20 years. In
April 1977 she was operated on because of a
traumatic leg fracture. As a complication she had
thrombosis in the left femoral vein and pulmonary
embolism. The symptoms and signs of embolism
disappeared during treatment with anticoagulants.
Chest radiography was normal at that time. The
patient was in good condition until summer 1980
when she began to suffer from dry cough, dyspnoea,
tachycardia, and low grade fever. In November
1980 crepitant rales were heard at the bases of the
opacities. Spirometry showed normal lung volumes.
Diffusing capacity was lowered (DLCo 64% of pre-
dicted). The sedimentation rate was 38 mm/h. The
cell count, differential and
Pulmonary granulomatous reaction: talc pneumoconiosis or chronic sarcoidosis?
alkaline phosphatase, serum calcium, urinary cal-
cium excretion, and urine analysis. Serum lysozyme
was slightly raised (27 mg/l (normal 20 mg/l)) and
serum angiotensin converting enzyme (ACE) was
normal (38 U/l). Mantoux 10 TU was negative.
The concentration of serum immunoglobulins, C3
and C4, and the titres of cryoprecipitins, direct
Coombs-test, Latex-fixation test, Waaler-Rose, and
antinuclear antibodies were normal. The Kveim test
result was negative.
Three months later, in February 1981, laboratory
results were the same as before, except that the
serum ACE was raised (70 U/l). For diagnostic pur-
poses an anterolateral thoracotomy was performed.
The lung showed a diffuse nodular consistency. A
biopsy specimen was taken from the lingula. Cul-
tures for tuberculosis, bacteria, and fungi were nega-
Histological examination showed a heavy
inflammation (fig 1) consisting of epitheloid and
giant cells forming granules, macrophages, lym-
fibrosis. Numerous birefringent particles were dis-
covered inside the giant cells (fig 1). For elemental
electron probe microanalysis 5 ,tm thick tissue sec-
tions of the lung were deparaffinised in xylene,
mounted on carbon coated nylon grids by conduc-
tive carbon cement, and examined by scanning elec-
tron microscopy (SEM) in a graphite holder (JEM-
100 CX electron microscope fitted with a Princeton
Gamma-Tech PGT System III energy dispersive x
ray microanalyser). The foreign body material inside
the granulomas contained magnesium and silicon in
combination with chlorine, calcium, iron, and zinc
(fig 2), characteristic of talc.
Because the examinations pointed to the possibil-
ity of talcosis a careful inquiry was undertaken into
the dust exposure of the patient. She had applied
non-powdering talc on her face for 20 years and
after that, talcum powder two to three times a day
during a 10 year period, usually in an unventilated
room. The total amount of powder used was two
boxes a year. In the patient's own opinion the
amount of powder used was not excessive enough to
cause any disease. Elemental analysis of two differ-
ent commercially available talcum powder pre-
parations was also carried out. Electron probe
microanalysis of these preparations showed mag-
nesium, aluminium, silicon, potassium, iron, and
zinc (fig 3).
In March 1981, treatment with prednisolone was
started with an initial dose of 40 mg. The dose was
gradually lowered to 10 mg a day over a period of
four months. When the treatment was discontinued
after nine months no improvement of pulmonary
function or radiographs was observed. The serum
angiotensin values fell to normal during the steroid
treatment (26 U/1) but rose again after treatment
ceased (77 U/l).
After two years' follow up an enlarged axillar
lymph node was noticed. A biopsy specimen showed
A 55 year old woman had smoked 10 cigarettes a
day for 30 years. From 1958 to 1968 she had packed
rubber balls and was exposed to the talc used as a
dusting agent to prevent adhesion of the balls.
During the first five years after exposure she began
to suffer insidiously from dyspnoea. In April 1973 a
chest radiograph showed diffuse nodular opacities;
lung auscultation was normal. All the following var-
iables were within normal limits: sedimentation rate,
haemoglobin, white cell count, differential and
alkaline phosphatase, serum calcium, daily urinary
calcium excretion, urine analysis, titres of latex
crystal inside a giant cell (b) van Gieson, x 230 (a), x 1200 (b).
Open lung biopsy specimen ofcase I showing heavy granulomatous inflammation (a) with strongly birefringent
Tukiainen, Nickels, Taskinen, and Nyberg
birefringent crystal showing magnesium (Mg), silicon (Si),
chlorine (Cl), calcium (Ca), iron (Fe), and zinc (Zn)
characteristic oftalc. Copper (Cu) is derivedfrom
Electron probe microanalysis from a pulmonary
antinuclear antibodies. Mantoux 10 tuberculin unit
(TU) was positive. Spirometry showed normal lung
volumes (FVC 107% of predicted), but diffusing
capacity was lowered (DLco 60% of predicted). The
Kveim test result was negative.
A lung biopsy was performed with a transthoracic
TruCut needle in the right lower lobe. The biopsy
particles were found, most of them
double-refractile and resembling talc particles (fig
4b). Some ferruginous bodies were also seen. The
alveolar spaces were patent.
In July 1973 treatment with prednisolone was
started with an initial dose of 40 mg. The dose was
gradually lowered and the treatment was terminated
after two months because no objective improvement
available talcum powder preparation showing magnesium
(Mg), aluminium (Al), silicon (Si), potassium (K), iron
(Fe), and zinc (Zn). Copper (Cu) is derivedfrom
Electron probe microanalysis from a commercially
perivasculargranulomatous inflammation. Haematoxylin &
eosin, original magnification x 150. (b) Numerous
birefringent particles in polarised light in areas of
TruCut needle biopsy specimen ofcase 2. (a) A
was observed in the chest radiograph or in pulmo-
In April 1980 spirometry showed normal lung
volumes (FVC 84% of predicted) and diffusing
capacity was lowered (DLco 51% of predicted). At
that time serum ACE was slightly raised at 49
,u mol/l (normal 40 ,umol1).
Talc used in the manufacture of cosmetic talcum
powder is normally of high purity. Nevertheless, x
ray diffraction analysis of 21 powders obtained
through retail channels in the United States showed
that few of them consisted of pure talc. Quartz, ran-
ging from 2% to 5% was found in eight, while one
sample contained 35%. Detectable amounts of
fibrous tremolite and anthophyllite were reported to
Epidemiological studies indicate that prolonged
exposure to cosmetic grade talc is not associated
with the development of pneumoconiosis, though
exposure to industrial grade talc may result in this
Exposure to talc causes three distinct types of
Pulmonary granulomatous reaction: talc pneumoconiosis or chronic sarcoidosis?
lesion depending on the composition of the "talc." '
Ill defined nodular lesions are associated with a
relatively high quartz content in the lungs. Diffuse
interstitial fibrosis is associated with exposure to talc
anthophyllite, or other fibrous minerals. Foreign
body granulomas are obviously caused by pure talc.
An extensive use of talcum powder was reported
in association with pure talc pneumoconioses.2-5
The histological changes were identical in all these
amounts of interstitial fibrosis.
Although one of our patients (case 1) had used
talcum powder for 10 years, usually in a small
unventilated room, the amount of talc was obviously
not as excessive as in the patient previously repor-
ted. Therefore, the question arises whether our case
is an example of talc pneumoconiosis or of talc
deposition in the lungs with coincidental sarcoidosis.
Neither of our patients showed extrapulmonary
manifestations compatible with sarcoidosis. The
Kveim test result was negative and urinary calcium
excretion was normal. No improvement was obser-
ved during treatment with steroids even though the
histological alterations were mainly inflammatory.
On the other hand, both patients had raised values
for serum ACE, which is known to be raised in
about 75% of patients with active sarcoidosis.9
Other diseases with raised ACE levels are Gauher's
disease, leprosy, berylliosis, Lennert's lymphoma,
lymphangioleiomytomatosls, Mycobacterium intra-
cytoma with lung involvement, and Q fever. Farber
et al reported raised levels of ACE in a case of talc
pneumoconosis in a pentazocine abuser (drug con-
taining talc as filler).'0 Thus the possibility of talc
pneumoconiosis cannot be excluded on the bases of
raised ACE alone. Epitheloid cells are known to
excrete ACE,9 thus this might be an unspecific
phenomenon independent of the aetiology of the
granulomas seemed to be able to produce ACE.
In both our patients histological examination
showed excessive amounts of birefringent dust par-
ticles in the lung tissue and foreign body granulomas
and talc particles in the cytoplasm of giant cells.
Except, perhaps, for the talc containing giant cells,'
these findings do not establish any causal relation-
ship between talc and the disease.
In our patients the quantity of dust exposure
seemed to be important in the differential diagnosis
of sarcoidosis and talc pneumoconiosis before the
detection of granulomatous inflammation of an axil-
lar node in case 1. The patient who handled talc
powdered rubber balls had an exposure that may be
classified as typical, and therefore we believe the
patient had a true talc pneumoconiosis. The patient
who used talcum powder at home had an exposure
that was not unusual. Therefore the quantity of dust
exposure seems to be insufficient, even though the
quantity of dust in the lung tissue was excessive. We
believe that this patient represents a case of chronic
sarcoidosis and coincidental talc deposition in the
Our report shows that even after careful clinical
and laboratory examination together with analysis
of lung biopsy specimens
difficult to differentiate between chronic sarcoidosis
and talc pneumoconiosis.
it may be extremely
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7Kleinfeld M, Messite J, Zaki MH. Mortality experiences among
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Rubino GF, Scansetti G, Piolatto G, Gay G. Mortalityand mor-
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Farber HW, Mathers JAL Jr, Glauser FL. Gallium scans and
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