1. Roy Temes MD MBA, Joseph Lahorra MD, Inderjit Gill MD, Joseph Tomashefski Jr. MD, Thomas Rice MD

2.  26 year old with progressing interstitial lung disease over 1.5 years  Reformed IV drug user, HIV negative

3.  Robotic wedge biopsy, discharged following day  Pathology: Talc induced pulmonary granulomas (TIPG)  Cultures (including AFB) negative

4. Cause: Injected tablet adulterants and fillers (talc, cellulose, fibers, other) Result: Loss of pulmonary vasculature, pulmonary hypertension, RVH Treatment (1): Medical: Steroids (inhaled budesonide), vasodilators (hydralazine) Treatment (2): Surgical: Lung transplantation Outcome: Pulmonary insufficiency and/or death

5.  Include TIPG in differential diagnosis of interstitial disease in appropriate clinical setting  Findings pathognomonic for drug abuse