Charcoal lung. Bronchiolitis obliterans after aspiration of activated charcoal.

C G Elliott, T V Colby, T M Kelly and H G Hicks Chest 1989;96;672-674 DOI 10.1378/chest.96.3.672 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/96/3/672

CHEST is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright 1989 by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0012-3692

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selected reports
Charcoal
Bronchiolitis Aspiration
Charles Thomas Harry G. G. Elliott, Hicks, V Colby,

Lung*
Obliterans of Activated
M.D.
M.D. M.D4

emphysema look for the

worsened. a tracheal endoscopist bronchi. was PaCO2 suctioned. of 42.6 PEEP and of ft). she Her 120. late with and small 69 one later, HR, and 46,

Fiberoptic laceration. noted During Arterial mm The function was and returned rectal Chest PMNs, eosinophil. but Pa02 Hg, coma discharged of the

bronchoscopy A tracheal extensive next blood Pa02 resolved, She four 64 while 24 gas laceration charcoal hours, values mm was days breathing offever, was over band The no values PaCO2, Gram every both cells, chest new 35.6 stain six while revealed lower nine parenchymal she

was

performed was not of thin found, of

to both grey

,,

After Charcoal
Thomas M. Kelly, M.D.;t and

but sputum

staining 33 Hg remained extubated later with 02 cough, paradoxic lobes. lymphocytes, demonThe at ml improved at= 0.45 F1o2

mainstem of 7.46, with and after 7.41, safe (altitude and 44; motion was strated her

to a pH afebrile, 15 days a pH 4 LPM of

FC.C.P;t

of 62

FCC.P;t

5 cm H20 ventilatory PaCO2 admission

improved.

Activated

charcoal

usually

provides

effective

and

treatment
developed

for drug
bronchiolitis

overdose.
obliterans

We
and

describe
respiratory

a patient
failure

who

4,600

Six days headaches. and

complaining temperature examination rales 20

dyspnea, VR, sternal WBC one

following aspiration of activated charcoal. This patient had a markedly reduced vital capacity with roentgenographic evidence of airtrapping. Chest roentgenograms did not demonstrate the large amount of charcoal identified at postmortem examination. (Che8t 1989; 96:672-74)

40.3#{176}C; BP, 102/60;

inspiratory

9,700

basophil,

roentgenogram breathing mm Hg; showed 1 g, hours.

pneumatocoeles,

infiltrate ambient pH, 7.47; Gram-positive and Sputum erythromyculture were for Blood she was and

was

apparent.

Arterial

blood gas

I
ing

#{176} the

United

States, and of

more at sedative

than400,000 least and 28,000

suicide are

attempts successful. drug poison-

occur

annually;

air were P(A-a)02, cocci cm, and 1 g,

Pa02, 42 mm Hg; 34 mm Hg. Sputum Gram-negative were given alpha-streptococci. for Mycoplasma and DFA were on returned but rate the was lobes. muscles The without 02 4 LPM two heart 40 The arterial L. Severe and maximal was breathing from of 7.36; 0.3. to 76 mm positive per days stain bacilli. intravenously

Ceftizoxime,

Standard
includes
induced Aspiration

management
removal
emesis of following and gastric drug

tricyclic

of drug
the contents overdose,

from

the
of

stomach
activated

by

lavage
charcoal.23

or yielded
negative mycoplasma cultures

instillation represents

Complement and egionella L for Legionella growth. and later rate sternum Pco2 had respiratory was minute. Her

fixation antibodies species. A DNA probe were fever also abated, negative. and

a well-recognized

hazard

but

pulmonary

injury

following
reported. obliterative

the
We

aspiration
report a bronchiolitis CASE

of activated
16-year-old after aspirating

charcoal
patient who activated

has
developed

not

been

discharged hours. She afebrile, breathing both lower normal. pH was

erythromycin complaining 130 moved forcefully. increased acidosis measurements pressure a rate remained pressure Dead ventilator. 54.4; the next tidal and five volume beats Coarse

500 po mg every of per rales Result to wereFVC ventilation. of3&minute, greater between space was Her Pa02, weeks, increased 0.67. arterial 92 mm PaCO2 to to dyspnea. minute were of 51.4 ensued tidal

six
She and heard and was the over the exam Hg, L requiring and

charcoal.

REPORT white arrival nasogastric clear sorbitol) later,

cardiac rhythm

paradoxically, cardiac mm of 0.86

previously was combative.

healthy (Pamelor). A

16-year-old Upon 16 French until with minutes Cardiopulmonary

woman in of a grand pill was mal blood the

took tube

approximately room, placed, Activated through accompacounafter (673 arrival,

ventilation

respiratory was and the

contracted

60 nortriptyline
she the charcoal nasogastric nied
tershock

emergency was given seizure and DC pressure fragments.

7.38. Spirometric

stomach (75 cardiac

restored

was g, tube. arrest. Drug transferred and was

lavaged Actidose Ten

and FEy,, 0.64 the tracheal intubation ventilatory of H20. 400 ml, Static and

Spontaneous volume 60 volume two gas while 565 to ml, tidal blood Hg progresthan cm tidal Within

measurements thoracic

included inspiratory performed. compliance

resuscitation and only Hospital. amitriptyline Upon

pressure

a stable

and 20 30 ml!

90 minutes.
She (p eak volume revealed chest and were F1o2 14.4 and chest *From of Utah, Hospital
tAssociate
=

screen to supported 52 rate

=

detected the H20, breaths LDS plateau per

p.g/dL). she

was

cm H20. Tracheotomy was (VDNT) ratio while weeks, values she were: was pH

spontaneously the PaCO2, Hg,

comatose
=

with positive minute). wheezes alveolar mm expiratory 86 PMNs, pneumothorax, LDS Departments Rochester, showed Hg,

weaned

pressure

cm 18

pressure 37 = over infiltrate Arterial and two a wide but

cm H20,
Chest all within blood Pa02 lymphs, QRS subcutaneous and Pathology, of54 The lung

tidal fields. both lungs

700 ml,
scattered

auscultation

end-expiratory disclosed PaCO2 positive ten band The the of5l.5 end cells, ECG right ofMedicine, City; Mayo and the Clinic, pneumothorax.

breathing, F1o2, Asively increased

During

roentgenogram a right pH 0.8 x 10 one tube the subpulmonic of7.40, without with eosinophil. drained Departments Salt Lake and the
Professor.

pressure.

and ventilatory rate remained 24 per minute. Dead space gas values volume ratio was 0.72. Chest roentgenogram and computerized mm Hg attomography examination disclosed pneumatocoeles predominantly WBC was in the left upper lobe. Mechanical ventilation was reinstituted. mono, weeks later, VD/VT A perfusion except in seen University LDS admission in the and Respiratory failure 14 weeks was the 0.90. cystic bronchi progressed, after her A perfusion left upper during and suicide she lung lobe. fiberoptic died attempt. ten scan revealed was Charcoal

Two normal not after

one tachycardia.

segmental

bronchoscopy. weeks

Hospital of MN.

Postmortem The
LDS Hospital, airways was in

Examination

lPathologist. Reprint requests: Salt Lake City

autopsy
all accompanied

revealed
regions by of

extensive
the lung bronchiolitis

charcoal
(Fig top).1, obliterans

deposition
Histologically, with fibrous

along
this

the

Dr Elliott. 84143

Pulmonary

Division,

oblitera-

672

Charcoaf

Lung (Elliott

et a!)

Downloaded from chestjournal.chestpubs.org by guest on August 12, 2010 1989 American College of Chest Physicians

too thick has

little

of

an

effective of

nontoxic activated with

substance charcoal

Aspiration and gastric trachea but obliterans massive our

of

suspension been associated tube first report respiratory of activated physiologic

contents and case and as-

obstruction

of

the girl,

endotracheal is the

in

an of

eight-month-old extensive failure

bronchiolitis

progressive piration Several case the rence of air deserve larger of

associated with

charcoal. and roentgenographic First, were and suggest hypoxemia, diffuse initial respiratory follows the not the that wheezing prominent, subsequent charcoal reduced infiltrates presentation. distress aspiration on These total chest features and although demonstration obstructed smaller thoracic roentgenogram features a dedisorder compliof this of occur-

emphasis. airways pneumothorax

obstruction the

trapping Arterial and bilateral the the adult

airways. ance,

characterized scribe which

syndrome, of gastric

commonly

contents.6

The
tion the liquid

difference
of larger charcoal the resembled from a pathogenetic large diameter

between
airways of suspension initial ARDS, the role

this
reported adult in

presentation by Pollack
airvays the present and subsequent history charcoal hvpoxemia acidosis in of the

and et
and

the may
use of

obstrucreflect
a more

al
the case.

Although features substantially ported bronchiolitis the first three

physiologic the

roentgenographic course ARDS production improved caused over decreased normal and pneumatothe charcoal and of which roentgenothe diverged and supof during by next although suggesting comtwo

natural for Arterial but of

obliterans. weeks, increases The vital lung The capacity

hypercapneic VD/VT was ensued severely remained chest chest

progressive months. roentgenographic air puted trapping.

volumes standard

roentgenograms demonstrated detected

tomography but neither in the

of

the technique

coeles,
remained graphic sis7 and

lungs. suggested

These

physiologic diagnoses dysplasia to of aspiration activated charcoal eg, drug reaction. contents of

observations adult

bronchiolectarather charcoal. in and/or clearly our mathan

bronchopulmonary obliterans due role The surface, granulomatous other gastric for the accompanied associated food and lavage that was favors the the only

bronchiolitis The case exact remains

pathogenetic uncertain. to fibrosing alone, its

charcoal particles particles, Conceivably, alone,

terial
induced the concert Bronchiolitis hypercapnea 1 . Top, Gross photograph of the lung at autopsy showing extensive charcoal deposition in a centrilobular distribution (arrows) along medium-sized and small airways. Histologically, the charcoal deposition is centered on small airways and associated with scarring and fibrous obliteration of the bronchioles (bronchiolitis obliterans) and a prominent giant cell reaction (hematoxylin-eosin x 30 (center) and 400 (bottom).
FIGURE

adsorbed
a charcoal were

or

both

in

responsible obliterans has been

bronchiolitis
by with but hypoxemia aspiration not

obliterans.
and of with The of activated present with charcoal. in massive bronchigastric

contents of gastric

containing contents gastric and and scarring

particles#{176} activated preceded charcoal material role

aspiration fact that

charcoal. administration was

thorough charcoal amounts olar

associated for the

a pathogenetic

tion some ded black (Fig there

and
foci, within

stenosis

of

most

of

the

small

airways

(Fig center). 1,

In Embedamounts cell reaction and

The
When of contents, Under with tion. with

treatment
cardiopulmonary postural these simultaneous If massive

of

this
arrest drainage

disorder
accompanies of rapid pressure aspiration may

begins
reflux secretions intubation should

with
of is of the

prevention.
gastric not possible. trachea aspirabronchoscopy

bronchiolectasis the
No

was scar with at the DIScUSSIoN

an

accompanying tissue were body food

feature. massive giant was noted,

bronchiolar associated
material

material 1, bottom). was no

a foreign with time of death.

circumstances, cricoid charcoal and reaction. lavage

consistent

decrease occurs,

pneumonia

suctioning

decrease

the

extent

of

the

Activated of most toxic

charcoal ingestions. large

is

valuable It is

agent commonly given to

for

the believed

treatment to

subsequent be After this

ADDENDUM report was submitted, we identified a report of

innocuous,

and

doses

are

avoid

administering

CHEST

I 96

I 3 I SEPTEMBER,

1989

673

Downloaded from chestjournal.chestpubs.org by guest on August 12, 2010 1989 American College of Chest Physicians

respiratory
coal (Menzies

failure
DC,

complicating
Busuttil A,

aspiration
Prescott

LF.

ofactivated Br J Med 1988;

char-

297:459-60).
ACKNOWLEDGMENT:

Paddock

Laboratories,

The Inc.

authors thank for financial

Mr. Bruce Paddock support of the

of color

dial disease. We report an unusual case where persisting hypereosinophilia were found.
CASE REPORT

of
and

endomyocardial myocardial

fibrosis activity

photographs.
REFERENCES 1 2 Fleming 70:13-16 Plum In: F, Posner JB. JB, WB Principles Disturbances Smith Saunders oftoxicology. basis In: to BS, the Chernow critically PR, of LH, of consciousness eds. Cecils Company, In: and of 2070 LS, 7th 1599-601 CR, patient. Fields Ann Al. Emerg KN, syndrome: 1983; 98:593-97 Bronchiolectasis-a 285:931-34 Bronchopulmonary 1983; 127:117-20 Kuck EJ. The and the an cardiac per film of stomach peripheral revealed to enlargement At cardiac (maximal pulmonary Br Med1982; J Hogg JC. Dis Baird with risk eds. The Baltimore: Aspiration Med M, Gilman ed. mediarousal. Wyngaarden TC. Suicide, the hush-hush killer. Postgrad A 49-year.old dyspnea woman

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earlier,
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textbook
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she had developed coronary arteriography revealed a normal coronary

anginal

pain

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anunaltered
which

been performed, nevertheless, responsiveness

anginal

cine.
3 Klaasen AG, New 4 June Williams 5 Ebllack of 6

Philadelphia:
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toms
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showing

scant

sympto therapy with

The pharmacological Macmillan lkisoning.

therapeutics, Lake B, ill

Publishing

Company,

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Willdns, Dunbar charcoal AA, Hamman et al. Adult JF,

1983; 667-68 Holbrook contents. andgastric 1W, Good respiratory Ann Crow Fligiel Am JW, Respir JH. Med 1977;
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time, moderate idiopathic hypereosinophilia was found. Nine years later, a dyspneicsyndrome supervened, which became progressive and insensitive to therapy with digitalis and diuretics. At a new clinical examination, rales were audible atbasal the pulmonary fields; at cardiac auscultation a grade /6 holosystolic 4
murmur, axilla,
(10,250/cu

antagonists (78Wcu mm)

At that

best was found.

heard rate

over Relevant (37

the itral m laboratory mm)

area and

and data white

conducted included blood an

to cell and for to

the increased count

activated

1981;
Fowler Eberle common

10:528-29 JT, Benson

distress Med CJ. DJ, C, A,

sedimentation mm),

degranulated
Following
leukemias abnormal idiopathic

with evident hypereosinophilia (18 percent) eosinophils in the blood (20 percent).
investigations, tests chronic the and pulmonary ofthe catheterization ECG for parasitic increase showed T-wave congestion left trial a including infection markers and Among sinus tachycardia low and QRS voltages A abnormalities. cardiomegaly, pulmonary mm allergic and and

predispositions. Nunn Golden DJ, than JW, 2.5. ofartificial

extensive

tumor reaction,

7 Slavin
8 9 Churg dysplasia Schwartz pulmonary greater 10 Wynne contents.

J, Dore
S.

complication

ventilation. Rev Respir GibbsCP, Dis of aspiration

of eosinophils was syndrome.

attributed
noninvasive (110 in chest

J,

hypereosinophilic left atrial

in the adult. Wynne consequences

examinations, minute),

beats
the x-ray due mostly

Hood CI, gastric of

1980;

hypertrophy,
diffuse

contents

at pH

leads,

AmRev

121:119-26 aspiration

Modell

Respiratory 87:466-74

chamber.
a moderate hypertension

Ann Intern

Persisting Hypereosinophilia and Myocardlal Activity in the Fibrotic Stage of Endomyocardial Disease*
Andrea
Gianfederico An unusual

was recorded, with increased left ventricular end-diastolic pressure (22 Hg) mm showingatypical square-root aspect. Left ventricular angiography presented an ace-of-hearts configuration with amputation of the arterial
50

pressure,

Hg)

apex.

In

addition, and

it

showed a left

a preserved severe (3/4) ventricular

left

ventricular At biopsy histologifindings,

systolic the was

function
end cally undertaken,

a moderately with extraction dense hemodynamic, endomyocardial to

mitral

regurgitation.
consisting

ofcatheterization, ofthickened, of by

endomyocardial tissue. and was which histologic entertained, included

Frustaci,

M.D.; Fbssati,

KaJAr Abdulla, M.D.; and Ugo Manzoli,

Abdel

M.D.; M.D.

of fivefragments collagen angiographic, fibrosis surgery, valve (Bjork-Shiley

Following

a and the replace-

case
an

of endomyocardial
idiopathic

fibrosis
hypereosinophilic

is

reported

diagnosis
patient ment and made this logic At

complicating
Persisting

syndrome.

was submitted
a prosthetic

mitral left ventricular

hypereosinophilia, degranulated eosinophils in the blood, and myocardial activity have been found accompanying the fibrotic phase of endomyocardial disease. This occurrence supports the unitarian theory on tropical and temperate endomyocardial disease and suggests such a in condition the use of steroids or cytotoxic drugs inaddition to surgery. (Cheat 1989; 96:674-75)

27) and
approach and

endocardial
of Metras a good was analysis

decortication
et al. The postoperative however, thought imbalance of surgical to be

following the
patient recovery some possibly was chest

tolerated

ofDubost et al8 procedure the well. She hadood symptomatic g was to a careful a still morphopresent; of persistence

improvement; hematologic microscopic

discomfort correlated and

(hypereosinophilia),

samples

undertaken.

that Lofflers endocarditis2 endocardium consisting of collagen tissue, fibroelastic tissue, and and Davies endomyocardial fibrosis are different phases granulation tissue was observed, together with fibrous septae linking ofthe same pathologic process.7 Separation ofthese entities the endocardium with the myocardium (Fig 1). These are the has been accomplished for many years on the basis of the characteristic histologic features of endomyocardial fibrosis. In the myocardium, in addition to the increase of interstitial disappearance of degranulated eosinophils in the blood, as fibrous tissue and some areas of fibrous replacement, several of foci in the heart ofpatients inthe fibrotic phase of ndomyocare
recently

has been

examination

typical a

three

zonal

layering of

recognized

inflammatory *Fmm and the Departments ofCardiology (Drs. Frustaci and Manzoli) eosinophils, mononuclear
occasionally

infiltrates, were cells showed found. were

consisting The close of fraying degranulated to

predominantly degranulated the 2). (Fig activity Due steroid adjacent eosinophils

of degranulated eosinophils myocytes to the in treatment persistence the blood (predniand other which

Cardiac

Italy;
Heart

Reprint
Gemelli,

Surgery (Dr. Possati), Catholic University Rome, and the Department of Pathology (Dr. Abdulla), National Hospital, London, England. requests: Ds Frustaci, Cardiology Department, Policlinico Largo Gemelli 8, 00168, Rome, Italy

areas
with

of

hypereosinophilia presence

and the

of myocardial

674

Per&sting

HypereonopMia

and

Myocard1 ActMty(Frustac!eta!)

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Charcoal lung. Bronchiolitis obliterans after aspiration of activated charcoal. C G Elliott, T V Colby, T M Kelly and H G Hicks Chest 1989;96; 672-674 DOI 10.1378/chest.96.3.672 This information is current as of August 12, 2010
Updated Information & Services Updated Information and services can be found at: http://chestjournal.chestpubs.org/content/96/3/672 Cited Bys This article has been cited by 4 HighWire-hosted articles: http://chestjournal.chestpubs.org/content/96/3/672#related-urls Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.chestpubs.org/site/misc/reprints.xhtml Reprints Information about ordering reprints can be found online: http://www.chestpubs.org/site/misc/reprints.xhtml Citation Alerts Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to the right of the online article. Images in PowerPoint format Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online figure for directions.

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