Pathology cases — Pulmonary birefringent debris in an intravenous drug user

I know we’ve all seen this a thousand times, but I’m adding these images just in case someone needs it for a lecture.  These are sections of lungs from a chronic intravenous drug user, showing deposition of birefringent debris in vascular and alveolar walls.  This case is like most I’ve seen.  While in some cases there are frank granulomata, most of the time I seen the particles simply engulfed by macrophages, with a few of them being multinuclear.  I see microgranulomata occasionally and frank granulomata uncommonly.  A mistake I’ve seen some folk make is to call debris on the slide as “real” intravenous drug use debris.  My slides often have random birefringent debris scattered sparsely about.  You can tell the difference because artifactual debris are 1) usually out of the plane of focus, 2) not in alveolar or vascular walls, and 3) elicit no vital reaction.

In case there’s a non-physician reading this, these debris come from intravenous drug users not filtering their drugs well enough.  This is particularly a problem for those who grind up pills and attempt to dissolve them in water.  Frequently the debris is talc, but it can be anything.  The lungs are the natural place for filtering that kind of stuff out of the blood, though I’ve seen these lesions in the liver and spleen as well.

Here’s a medium power view.  Remember that you can bring up a larger version by either right clicking and opening the image in another tab, or double clicking on the image — depending on your browser and OS.

Here’s the polarized view:

A higher power view is below.  You can see pigmented (blue arrows) and clear debris surrounded by macrophages (green arrows), with rare multinucleated cells:


Another view:

Here’s a nice example, complete with a tiny little asteroid body.  Not as fancy as my previous example, but it’s cute.


As always free for use with or without attribution, though attribution is appreciated.  If you need a higher resolution copy, let me know.


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