Contact Us    Contact Us     |     Feedback
MOBILE VIEW  | 

TALC

Export To Excel

Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Talc is a relatively inert, insoluble crystalline powder that is a topical lubricant, absorbent, and protectant.

Specific Substances

    1) French chalk
    2) Soapstone
    3) Steatite
    4) Talcum
    5) CAS 14807-96-6
    6) BC 127
    7) LO MICRON TALC USP, BS 2755
    8) LO MICRON TALC, BC 1621
    9) NATIVE HYDROUS MAGNESIUM SILICATE
    10) POWDERED HYDROUS MEGNESIUM SILICATE
    11) TALC (POWDER), CONTAINING NO ASBESTOS FIBERS
    1.2.1) MOLECULAR FORMULA
    1) Mg3Si4O10(OH)2 3MgO.4SiO2.H20

Available Forms Sources

    A) FORMS
    1) The composition of talc differs widely from one geological deposit to another, as well as within individual deposits. The main component is that of a crystalline hydrated magnesium silicate generally in the form of plates; however, individual talc particles could also be fibrous, acicular, laminar, or granular. Natural talc may contain quartz, tremolite, anthophyllite, asbestos, chrysotile, or other impurities in varying amounts, though there are some talc deposits consisting almost entirely of platiform talc crystals without significant presence of other materials or crystals (ACGIH, 1991; Clayton & Clayton, 1993).
    2) When talc is isolated as a pure mineral, it is composed of 63.6% silicon dioxide, 21.89% magnesium oxide and 4.75% water, though it rarely approaches this theoretical purity as an industrial commodity (HSDB , 1999).
    3) Talc is available in the following grades: crude, washed, air-floated, USP, fibrous (99.5%, 99.95%) (HSDB , 1999).
    B) SOURCES
    1) Talc can be produced by grinding natural steatite, soapstone, or pyrophyllite ores (Ashford, 1994).
    2) Natural talc is extracted through open pit or underground mining. Other mineral substances in varying amounts can be separated from talc by mechanical means such as floatation or elutriation. The pure talc can then be finely powdered prior to treating with boiling diluted hydrochloric acid, washing well, and drying (HSDB , 1999).
    C) USES
    1) Talc is used as a dusting powder (to control rashes or in cosmetics) and as filler for paper, rubber, soap, and roofing asphalt; it is used as a pigment in paints, varnishes, putty, plaster, and rubber. Talc can also be found in chewing gum, medicinal and toilet preparations, electrical insulation, insecticides, lubricants, polishing compounds, slate pencils and crayons, and vitamin supplements (Ashford, 1994; Budavari, 1996; Lewis, 1997; Lewis, 1998; Sittig, 1991).

Overview

Life Support

    A) This overview assumes that basic life support measures have been instituted.

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) BACKGROUND: Talc is a relatively inert, insoluble crystalline powder that is a topical lubricant, absorbent, and protectant.
    B) USES: Talc is used as a dusting powder (to control rashes or in cosmetics) and as filler for paper, rubber, soap, and roofing asphalt; it is a mineral widely used as a pigment in paints, ceramics, varnishes, putty, plaster, rubber and the cosmetic industries. Talc can also be found in chewing gum, medicinal and toilet preparations, electrical insulation, insecticides, lubricants, polishing compounds, slate pencils and crayons, and vitamin supplements. When talc is isolated as a pure mineral, it is composed of 63.6% silicon dioxide, 21.89% magnesium oxide and 4.75% water, though it rarely approaches this theoretical purity as an industrial commodity. Talc is available in the following grades: crude, washed, air-floated, USP, fibrous (99.5%, 99.95%).
    C) TOXICOLOGY: Relatively inert, insoluble crystalline powder used topically as a lubricant, absorbent, and protectant. It is not a primary skin irritant and does not produce sensitization. When deposited in tissue, talc particles are physical irritants which produce intense inflammatory reactions.
    D) EPIDEMIOLOGY: Exposure to commercial talcum powder is relatively common; serious toxicity has caused fatal acute talc inhalation exposure but these events are uncommon. The incidence of accidental inhalation of talc by infants was approximately several thousand cases nationwide per year as of the early 1980s. It is unclear if the incidence has declined, but the use of creams and lotions are likely more efficacious for diaper care in infants.
    E) WITH POISONING/EXPOSURE
    1) ACUTE INHALATION: Acute aspiration of talc causes cough, dyspnea, tachycardia, tachypnea, sneezing, vomiting, cyanosis, and pulmonary edema which may be delayed up to several hours. Asphyxia and cardiorespiratory arrest may occur following severe aspiration.
    2) CHRONIC INHALATION of industrial talc dusts or body talc produces talcosis due to talc, silica, and asbestos (talc pneumoconiosis) characterized by a productive cough, dyspnea, rales, diminished breath sounds, limited chest expansion, interstitial fibrosis, and granulomas.
    3) INTRAVENOUS INJECTION of talc-containing tablets or capsules produces foreign body vascular granulomatas (microemboli) at the site of intramuscular or subcutaneous injection and widespread arterial wall granulomas.
    4) SYSTEMIC GRANULOMATOSIS has been reported in IV drug abusers. Angiothrombotic pulmonary arterial hypertension and cor pulmonale may develop. Mild retinal hemorrhage may occur following IV injection of talc or talc containing products. Pulmonary effects include nonproductive cough, fever, dyspnea, and granulomatosis. Subtle x-ray changes may develop showing symmetrical hilar and perihilar interstitial infiltrations which are only minimally reversible. As the disease progresses, typical findings on chest CT include large and irregular attenuated nodules ("ground glass") in the middle and upper part of the lung following intravenous abuse of oral drugs. These nodules can evolve into large masses or consolidations and panlobular emphysema can develop in the lower lobes likely following years of abuse.
    5) OPEN WOUNDS: When talc is applied to open wounds or contaminates wounds during surgery, it can cause a severe granulomatous reaction. Talc should not be applied to broken skin. It is a severe eye irritant and has caused symblepharon, serious enough to require surgical correction.
    0.2.4) HEENT
    A) WITH POISONING/EXPOSURE
    1) Mild retinal hemorrhage may occur following IV injection of talc or talc containing products.
    0.2.20) REPRODUCTIVE
    A) At the time of this review, no reproductive studies were found for talc in humans.
    B) Talc was classified as pregnancy category B. Talc was fetotoxic, but not teratogenic, when given orally to pregnant rabbits.
    0.2.21) CARCINOGENICITY
    A) The International Agency for Research on Cancer (IARC) rates talc as having "Animal Inadequate Evidence" and "Human Inadequate Evidence." This places talc in IARC's Group 3 (not classifiable); from Monograph 42, Supplement 7; 1987. The National Toxicology Program's (NTP) Carcinogenesis Studies find "clear evidence" for the rat via inhalation, and "no evidence" for the mouse via inhalation (LOLI, 1999) (RTECS , 1999).
    B) Talc containing asbestos at greater than 1% may be a human carcinogen; when it contains asbestos fibers, it is a confirmed human carcinogen and has experimental tumorigenic data (Lewis, 1996). Earlier studies have suggested an association between talcum powder use and endometrial cancer risk; however, later studies do not suggest an association with talc use and an increased risk of endometrial cancer.
    C) Individuals investigating the ability of asbestiform tremolite and tremolitic talc to cause pleural cancers in hamsters concluded that only the asbestos form of tremolite was carcinogenic (ACGIH, 1991).

Laboratory Monitoring

    A) If symptomatic, obtain baseline CBC, electrolytes, and chest x-ray.
    B) Monitor arterial blood gases regularly in those patients with severe respiratory findings.
    C) Obtain a chest radiograph in patients with pulmonary symptoms. Radiographic findings in chronic talc exposure include fibrosis, granulomas, and diffuse reticulonodular infiltrates.
    D) Subtle pulmonary abnormalities such as decreased carbon monoxide diffusing capacity are an earlier indication of pulmonary damage than clinical or radiological evidence.

Treatment Overview

    0.4.3) INHALATION EXPOSURE
    A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    1) Treatment is symptomatic and supportive. If significant amounts of talc (including talcum powder) have been inhaled it can act as a pulmonary irritant resulting in cough, dyspnea, sneezing, vomiting and cyanosis. Symptoms may not develop until several hours after aspiration. The inhalation of talc can cause drying of mucous membranes leading to possible obstruction of small airways resulting in respiratory distress. Following inhalation exposure, treat symptomatic patients with corticosteroids. Prednisone: Infant/Child: Administer 1 to 2 mg/kg/day for 3 to 5 days. Administer oxygen and monitor pulse oximetry continuously. Excessive oral (mucous) secretions should be suctioned. In one toddler, an exogenous surfactant (ie, Poractant Alfa) via aerosol was used in a toddler with talc aspiration, and was associated with an improvement in respiratory symptoms and radiological findings. Prophylactic antibiotics are not generally recommended, but antibiotics should be administered to patients with evidence of aspiration pneumonia or secondary bacterial infection. Respiratory physiotherapy may be useful in loosening thick secretions away from the bronchial wall and to stimulate muscular contractility in patients that develop lung consolidation. Bronchodilators are of limited value.
    B) MANAGEMENT OF SEVERE TOXICITY
    1) Treatment is symptomatic and supportive. Endotracheal intubation and mechanical ventilation may be necessary. Monitor ABGs and continuous pulse oximetry. Consider BRONCHIOALVEOLAR LAVAGE to remove aspirated powder. This may be of limited value and can be dangerous, but may be indicated in those patients refractory to other therapies (ie, oxygen, suctioning).
    C) DECONTAMINATION
    1) PREHOSPITAL: Do NOT induce emesis following an oral ingestion of talc.
    2) HOSPITAL: Consider bronchioalveolar lavage to remove aspirated powder. This may be of limited value and can be dangerous, but may be indicated in those patients refractory to other therapies (ie, oxygen, suctioning).
    D) AIRWAY MANAGEMENT
    1) Maintain adequate ventilation and oxygenation. Endotracheal intubation and mechanical ventilation may be necessary. Check adequacy of oxygenation and ventilation with arterial blood gases and continuous pulse oximetry as needed.
    E) PATIENT DISPOSITION
    1) HOME CRITERIA: An adult can remain at home following a minor or mild inadvertent inhalation exposure (ie, no respiratory symptoms and/or mild cough) to talc. Infants and/or a young child that has or is suspected of inhaling and/or ingesting talcum powder should be sent to a healthcare facility to rule out respiratory involvement (ie, possible aspiration, delayed symptoms (ie, dyspnea, choking, coughing)).
    2) OBSERVATION CRITERIA: Patients that develop persistent or worsening respiratory symptoms should be sent to a healthcare facility. Patients may be discharged once respiratory symptoms are resolved.
    3) ADMISSION CRITERIA: Admit patients that continue to have respiratory difficulties who require a higher level of care.
    4) CONSULT CRITERIA: Consult with a pulmonologist if the diagnosis is unclear. A hospital intensivist may be needed to treat severely ill patients requiring intubation and mechanical ventilation.
    F) PREDISPOSING CONDITIONS
    1) Obtain a complete history from the patient with minimal risk factors (ie, occupational exposure) including suspected intravenous drug use of oral agents such as methadone, methylphenidate, and pentazocine. Intravenous abuse can lead to talcosis that can lead to severe emphysema.
    G) DIFFERENTIAL DIAGNOSIS
    1) Tuberculosis, sarcoidosis, Munchausen syndrome presenting as pulmonary talcosis.

Range Of Toxicity

    A) TOXICITY: A toxic dose has not been established.
    B) ACUTE INHALATION: Only a small percentage of acute talc inhalations require hospitalization or become fatally ill.
    C) CHRONIC INHALATION: The extent and severity of lung injury (fibrosis) correlates with the length of exposure and dust concentration. Chronic talc inhalation may increase the risk of bronchogenic cancer.

Clinical Effects

Cardiovascular

    3.5.2) CLINICAL EFFECTS
    A) TACHYARRHYTHMIA
    1) WITH POISONING/EXPOSURE
    a) Tachycardia and cardiorespiratory arrest may develop following acute talc inhalation (Brouillette & Weber, 1978).
    B) EMBOLUS
    1) WITH POISONING/EXPOSURE
    a) INTRAVENOUS INJECTION of talc-containing tablets or capsules produces foreign body vascular granulomatas (microemboli) at the site of intramuscular or subcutaneous injection (Hahn et al, 1969). Intravenous talc injection produces widespread arterial wall granulomata(s) (Butch et al, 1979).

Respiratory

    3.6.2) CLINICAL EFFECTS
    A) PULMONARY ASPIRATION
    1) WITH POISONING/EXPOSURE
    a) CASE SERIES: Acute inhalation of talc, typically during diaper changing, resulted in cough (41%), dyspnea (15%), tachypnea, sneezing (15%), vomiting (18%), and cyanosis (3%) in a series of 0- to 2-year-old children (Mofenson et al, 1981).
    b) Respiratory acidosis, bronchitis, bronchiolitis, pulmonary edema, atelectasis, emphysema, and severe bronchiolar obstruction may develop (Gould & Barnardo, 1972; Motomatsu et al, 1979).
    c) Chest x-ray may show symmetrical hilar and perihilar alveolar infiltrates which are largely reversible. Delayed respiratory distress is the hallmark of a classic powder talc aspiration (Anon, 1977).
    d) ONSET: Severe respiratory distress may be delayed up to several hours following exposure (Pfenninger & D'Apuzzo, 1977).
    e) CASE REPORT: A 19-month-old toddler developed a 2 day history of cough and dyspnea requiring intubation after playing with a talc dispenser. A chest x-ray showed complete left opacity with a mediastinal shift and a chest CT scan showed left opacity with right lung hyperinflation. A bronchoscopy did not reveal any mucus plugs but bronchalveolar lavage showed large amounts of viscous, white secretions and the fluid was found to contain talc crystals. Empirically, IV antibiotics and steroids were started and the patient was successfully extubated 2 days later. The authors suggested that the large roller releasing system for the powder allowed for the large amount inhaled (Patarino et al, 2010).
    f) CASE REPORT: An 18-month-old toddler was admitted with respiratory difficulty and cough one hour after inadvertent inhalation of baby powder. Normal breath sounds were present on physical exam and the child was not cyanotic. A chest x-ray showed a consolidation in the central and middle lung zones and basal emphysema bilaterally. Empiric antibiotic and steroid therapy were started. The toddler was also started on surfactant (Poractant Alfa) aerosol treatment, along with budesonide and salbutamol. Respiratory physiotherapy was performed twice daily to loosen thick secretions. Within 5 days, the chest x-ray was improved and the toddler continued to do well. Chest x-ray at 1.5 and 6 months were normal (Matina et al, 2011).
    g) CASE REPORT: Inadvertent inhalation of baby powder in 12-week-old infant resulted in cyanosis, tachypnea, mixed acidosis and respiratory arrest necessitating endotracheal intubation. The infant recovered several days later following mechanical ventilation, supportive care, and intravenous steroids (Pairaudeau et al, 1991).
    B) PNEUMOCONIOSIS DUE TO TALC
    1) WITH POISONING/EXPOSURE
    a) CHRONIC INHALATION of industrial talc dusts or body talc produces talcosis due to talc, silica, and asbestos (talc pneumoconiosis) characterized by productive cough, dyspnea, rales, diminished breath sounds, limited chest expansion, interstitial fibrosis, and granulomas. The extent and severity of fibrosis correlates with the length of exposure and dust concentration (Kleinfeld, 1963).
    b) In a study of an Italian cohort of talc miners and millers (n=1795), no association between occupational exposure to non-asbestiform talc and risk of lung cancer or mesothelioma was observed. However, there was a significant excess mortality from non-neoplastic respiratory diseases (a standardized mortality ratio [SMR] 228.2, 95% CI 190.2-271.5), mainly due to silicosis (Coggiola et al, 2003).
    c) Pneumoconiosis associated with obstructive and restrictive lung disease following chronic intentional inhalation of talcum powder has been reported. Chest x-ray revealed a diffuse reticulonodular interstitial infiltrate with conglomerate masses in both mid-lung zones (Goldbach et al, 1982).
    C) DRUG ABUSE
    1) WITH POISONING/EXPOSURE
    a) SUMMARY
    1) CHRONIC INTRAVENOUS drug abuse resulting in pulmonary talcosis was reported in 3 patients. In one patient, CT scan revealed a ground-glass pattern with a biopsy showing vascular and perivascular granulomatous reaction secondary to talc deposition. The other 2 patients had perihilar masses with areas of high attenuation (Padley et al, 1993).
    2) PNEUMOCYSTIS, a syndrome resembling Pneumocystis carinii pneumonia has been seen following IV talc injection (O'Connor et al, 1988).
    3) Chronic abuse of cocaine by insufflation has resulted in pulmonary talc granulomatosis, with chest x-ray showing diffuse bilateral infiltrates (Oubeid et al, 1990).
    4) INTRAVENOUS INJECTION produces nonproductive cough, fever, dyspnea, and granulomatosis. Subtle x-ray changes may develop showing symmetrical hilar and perihilar interstitial infiltrations which are only minimally reversible. Open lung biopsy is diagnostic (Davis, 1983).
    b) EMPHYSEMA FOLLOWING IV ABUSE
    1) CASE REPORT: A 54-year-old woman with emphysema and a prior 4 year history of IV methylphenidate abuse 20 years earlier was admitted with dyspnea. Two years earlier her lung function had notably deteriorated and she became oxygen dependent. Upon examination, she had bilateral crackles on inspiration in the lower lobes. A chest x-ray showed bullous emphysema and fibrotic changes in the lower lobes and a perfusion scan showed reduced perfusion to the lower lung zones with almost no perfusion to the left lower lobe and to the lower third of the right lung which appeared consistent with the patient's history of talc injection. She underwent a left lung transplant. Microscopic examination of the extracted lung was consistent with talcosis as demonstrated by multinucleated giant cells with birefringent crystals. A few months after transplant she was tolerating normal activities (Shlomi et al, 2008).
    D) SQUAMOUS CELL CARCINOMA OF BRONCHUS
    1) WITH POISONING/EXPOSURE
    a) Chronic talc inhalation may increase the risk of bronchogenic carcinoma (Vallyathan & Craighead, 1981).
    E) RESPIRATORY OBSTRUCTION
    1) WITH POISONING/EXPOSURE
    a) Airway obstruction resulting in death has occurred after talc aspiration by an infant into his tracheotomy tube (Cotton & Davidson, 1985).
    b) CASE REPORT: A 61-year-old woman with a history of depression and suicidal ideation ingested and inhaled a large amount of talcum powder. She became dyspneic, could not cough, and sustained cardiorespiratory arrest due to asphyxiation. At autopsy, talcum powder was found throughout the larynx, trachea, and main bronchi, with occlusive plugs blocking large and small airways (Steele, 1990).
    F) PNEUMONITIS
    1) WITH POISONING/EXPOSURE
    a) ACUTE PNEUMONITIS with bilateral pleural effusions and interstitial infiltrates has occurred following talc pleurodesis for recurrent right pleural effusion (Bouchama et al, 1984).
    1) CASE REPORT: Acute pneumonitis developed in a 30-year-old woman with a history of breast cancer following talc pleurodesis for a malignant left pleural effusion. Findings on contrast-enhanced chest CT scan (including additional thin-section images) performed 10 days after pleurodesis included ground-glass attenuation in the entire left lung and in small areas of the right upper lobe and mixed areas of consolidation. She was treated with dexamethasone 10 mg IV every 12 hours and improved in 2 days with a oxygen saturation of 95% on room air. The steroid dose was tapered and pulmonary consolidation resolved over the course of a few months (Kim et al, 2006).
    G) STANDARD CHEST X-RAY ABNORMAL
    1) WITH POISONING/EXPOSURE
    a) PULMONARY INFILTRATES have been observed in IV drug abusers (Ben-Haim et al, 1988), and after therapeutic use for pleurodesis (Bouchama et al, 1984).

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) PERITONITIS
    1) WITH POISONING/EXPOSURE
    a) INTRAPERITONEAL APPLICATION may produce fever, vomiting, and painful abdomen resistant to palpation (Coder & Olander, 1972). Signs often begin 1-4 weeks after surgery. This is a transient phenomenon which peaks in several weeks, then subsides. The presence of talc may be confirmed in the paracentesis fluid.

Dermatologic

    3.14.2) CLINICAL EFFECTS
    A) GRANULOMA
    1) WITH POISONING/EXPOSURE
    a) Topical application to open wounds or surgical sites from surgical glove powder containing talc-contaminated starch produces adhesions and foreign body granulomatas (Coder & Olander, 1972).
    b) Sparrow & Hallam (1991) implicated talcum powder as the cause of numerous umbilical granulomas in pediatric patients. Histologic samples showed multinucleated giant cells, macrophages, and other inflammatory cells with varying degrees of fibrosis. The authors postulated that talc may have been introduced into the umbilical stump during dehiscence of the umbilical cord or later entrance of talc through the navel (Sparrow & Hallam, 1991).

Immunologic

    3.19.2) CLINICAL EFFECTS
    A) HISTOPLASMOSIS
    1) WITH POISONING/EXPOSURE
    a) HISTOPLASMOSIS was seen in an IV drug abuser without HIV infection or other risk factors. The authors postulated a direct toxic effect of talc on macrophage function (Racela et al, 1988).

Reproductive

    3.20.1) SUMMARY
    A) At the time of this review, no reproductive studies were found for talc in humans.
    B) Talc was classified as pregnancy category B. Talc was fetotoxic, but not teratogenic, when given orally to pregnant rabbits.
    3.20.2) TERATOGENICITY
    A) ANIMAL STUDIES
    1) Talc was fetotoxic, but not teratogenic, when given orally to pregnant rabbits (p 14). Oral administration of talc at 900 mg/kg (approximately 5-fold higher than the human dose on a mg/m(2) basis) to rabbits showed no evidence of teratogenicity (Prod Info SCLEROSOL(R) intrapleural aerosol, 2012; Prod Info sterile talc powder, 2003).
    3.20.3) EFFECTS IN PREGNANCY
    A) LACK OF INFORMATION
    1) There are no adequate and well-controlled studies of sterile talc powder in pregnant women. Therefore, it is recommended that talc be administered in pregnant women only if clearly necessary (Prod Info SCLEROSOL(R) intrapleural aerosol, 2012; Prod Info sterile talc powder, 2003).
    B) PREGNANCY CATEGORY
    1) Talc was classified as pregnancy category B (Prod Info SCLEROSOL(R) intrapleural aerosol, 2012).
    C) ABORTION
    1) Talc has been used as an inert ingredient in drugs used to induce abortions and to treat low sperm counts, but these applications were not considered in evaluating the potential reproductive hazard of talc (p 14).

Summary Of Exposure

    A) BACKGROUND: Talc is a relatively inert, insoluble crystalline powder that is a topical lubricant, absorbent, and protectant.
    B) USES: Talc is used as a dusting powder (to control rashes or in cosmetics) and as filler for paper, rubber, soap, and roofing asphalt; it is a mineral widely used as a pigment in paints, ceramics, varnishes, putty, plaster, rubber and the cosmetic industries. Talc can also be found in chewing gum, medicinal and toilet preparations, electrical insulation, insecticides, lubricants, polishing compounds, slate pencils and crayons, and vitamin supplements. When talc is isolated as a pure mineral, it is composed of 63.6% silicon dioxide, 21.89% magnesium oxide and 4.75% water, though it rarely approaches this theoretical purity as an industrial commodity. Talc is available in the following grades: crude, washed, air-floated, USP, fibrous (99.5%, 99.95%).
    C) TOXICOLOGY: Relatively inert, insoluble crystalline powder used topically as a lubricant, absorbent, and protectant. It is not a primary skin irritant and does not produce sensitization. When deposited in tissue, talc particles are physical irritants which produce intense inflammatory reactions.
    D) EPIDEMIOLOGY: Exposure to commercial talcum powder is relatively common; serious toxicity has caused fatal acute talc inhalation exposure but these events are uncommon. The incidence of accidental inhalation of talc by infants was approximately several thousand cases nationwide per year as of the early 1980s. It is unclear if the incidence has declined, but the use of creams and lotions are likely more efficacious for diaper care in infants.
    E) WITH POISONING/EXPOSURE
    1) ACUTE INHALATION: Acute aspiration of talc causes cough, dyspnea, tachycardia, tachypnea, sneezing, vomiting, cyanosis, and pulmonary edema which may be delayed up to several hours. Asphyxia and cardiorespiratory arrest may occur following severe aspiration.
    2) CHRONIC INHALATION of industrial talc dusts or body talc produces talcosis due to talc, silica, and asbestos (talc pneumoconiosis) characterized by a productive cough, dyspnea, rales, diminished breath sounds, limited chest expansion, interstitial fibrosis, and granulomas.
    3) INTRAVENOUS INJECTION of talc-containing tablets or capsules produces foreign body vascular granulomatas (microemboli) at the site of intramuscular or subcutaneous injection and widespread arterial wall granulomas.
    4) SYSTEMIC GRANULOMATOSIS has been reported in IV drug abusers. Angiothrombotic pulmonary arterial hypertension and cor pulmonale may develop. Mild retinal hemorrhage may occur following IV injection of talc or talc containing products. Pulmonary effects include nonproductive cough, fever, dyspnea, and granulomatosis. Subtle x-ray changes may develop showing symmetrical hilar and perihilar interstitial infiltrations which are only minimally reversible. As the disease progresses, typical findings on chest CT include large and irregular attenuated nodules ("ground glass") in the middle and upper part of the lung following intravenous abuse of oral drugs. These nodules can evolve into large masses or consolidations and panlobular emphysema can develop in the lower lobes likely following years of abuse.
    5) OPEN WOUNDS: When talc is applied to open wounds or contaminates wounds during surgery, it can cause a severe granulomatous reaction. Talc should not be applied to broken skin. It is a severe eye irritant and has caused symblepharon, serious enough to require surgical correction.

Heent

    3.4.1) SUMMARY
    A) WITH POISONING/EXPOSURE
    1) Mild retinal hemorrhage may occur following IV injection of talc or talc containing products.
    3.4.3) EYES
    A) WITH POISONING/EXPOSURE
    1) Following INTRAVENOUS INJECTION, talc may deposit throughout the fundi, especially about the maculas, observable on fundoscopic exam (AtLee, 1972; Tse & Ober, 1980). Retinal hemorrhage may be seen (Bluth & Hanscom, 1981). Reduced vision indicates that considerable lung damage may have already occurred (AtLee, 1972).
    2) CASE REPORT: Talc deposition was observed during a routine fundoscopic exam in a woman 10 years after intravenous drug use (Martidis et al, 1997).

Carcinogenicity

    3.21.1) IARC CATEGORY
    A) IARC Carcinogenicity Ratings for CAS14807-96-6 (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004):
    1) IARC Classification
    a) Listed as: Talc, not containing asbestiform fibres
    b) Carcinogen Rating: 3
    1) The agent (mixture or exposure circumstance) is not classifiable as to its carcinogenicity to humans. This category is used most commonly for agents, mixtures and exposure circumstances for which the evidence of carcinogenicity is inadequate in humans and inadequate or limited in experimental animals. Exceptionally, agents (mixtures) for which the evidence of carcinogenicity is inadequate in humans but sufficient in experimental animals may be placed in this category when there is strong evidence that the mechanism of carcinogenicity in experimental animals does not operate in humans. Agents, mixtures and exposure circumstances that do not fall into any other group are also placed in this category.
    3.21.2) SUMMARY/HUMAN
    A) The International Agency for Research on Cancer (IARC) rates talc as having "Animal Inadequate Evidence" and "Human Inadequate Evidence." This places talc in IARC's Group 3 (not classifiable); from Monograph 42, Supplement 7; 1987. The National Toxicology Program's (NTP) Carcinogenesis Studies find "clear evidence" for the rat via inhalation, and "no evidence" for the mouse via inhalation (LOLI, 1999) (RTECS , 1999).
    B) Talc containing asbestos at greater than 1% may be a human carcinogen; when it contains asbestos fibers, it is a confirmed human carcinogen and has experimental tumorigenic data (Lewis, 1996). Earlier studies have suggested an association between talcum powder use and endometrial cancer risk; however, later studies do not suggest an association with talc use and an increased risk of endometrial cancer.
    C) Individuals investigating the ability of asbestiform tremolite and tremolitic talc to cause pleural cancers in hamsters concluded that only the asbestos form of tremolite was carcinogenic (ACGIH, 1991).
    3.21.3) HUMAN STUDIES
    A) LUNG CANCER
    1) The carcinogenicity of three poorly soluble weakly-toxic substances, carbon black, titanium dioxide and talc were evaluated by the International Agency for Research on Cancer (IARC). Although talc was carcinogenic in experimental animals, the evidence in humans is sparse and equivocal. In two large population based case-control studies of lung cancer in Montreal (study I (857 cases, 533 population controls, 1349 cancer controls), study II (1236 cases and 1512 controls), subjects with occupational exposure to industrial talc and cosmetic talc did not experience any detectable excess risk of lung cancer. The results of these studies were consistent with the recent evaluations of the International Agency for Research on Cancer (IARC) monographs (Ramanakumar et al, 2008).
    B) OVARIAN CARCINOMA
    1) LACK OF EFFECT
    a) In a population-based case-control study using data from the Australian National Endometrial Cancer Study, 1,399 with newly diagnosed histologically confirmed primary endometrial cancer and 740 control women provided risk factor information via telephone interview to assess the role of perineal talc use in the development of endometrial cancer. No significant association was found between ever use of talc in the perineal area (OR 0.88, 95% CI: 0.68 to 1.14) or upper body area (OR 0.90, 95% CI: 0.71 to 1.14) and the risk of endometrial cancer. In addition, the frequency and duration of talc use were not significantly associated with risk (either perineal use or upper body use) (Neill et al, 2012).
    b) In another study, perineal application of talc was not associated with increased risk of ovarian cancer in a group of 189 Greek women, as compared with a control group (Tzonou et al, 1993).
    1) A positive association was not found between use of perineal talcum powder use and epithelial ovarian cancer in a case-control study of 499 ovarian cancer patients and 755 matched controls. An increased risk of ovarian cancer was not observed for patients using talc for 1 to 9 years, 10 to 19 years, or greater than 20 years (Wong et al, 1999).
    c) A meta-analysis was performed to evaluate ovarian cancer risk associated with direct exposure of the female genital tract to talc via dusting of contraceptive diaphragms. All resultant summary relative risks were not statistically significant. These results did not support a causal association between the use of cosmetic talc-dusted diaphragms and ovarian cancer development (Huncharek et al, 2007).
    2) EARLIER STUDIES
    a) Epidemiological evidence suggested that epithelial ovarian cancer incidence was elevated 2- to 3-fold in women who used talc as perineum dusting powder and/or on sanitary napkins, when compared to those not using talc. Women who regularly engaged in both practices showed a 3-fold increased incidence (HSDB, 2002) (Cramer et al, 1982). Talc particles have been found in ovarian and cervical tumors (Henderson, 1971).
    b) A case-control study of 450 patients and 564 matched controls demonstrated an increased risk of invasive ovarian carcinoma in women with regular talc exposure via sanitary napkins, direct application to the perineum, or both (Odds ratio 1.42; 95% CI 1.08 to 1.86) (Chang & Risch, 1997).
    C) LUNG CARCINOMA
    1) Workers exposed to talc containing asbestos are at increased risk for lung cancer (Hathaway et al, 1991). However, talc workers were not at increased risk for lung cancer when smoking was taken into account (Gamble, 1993).
    2) Based on a review of the literature, no increase in lung cancer mortality was observed for talc millers exposed to high levels of talc not containing asbestiform fibers who had no other occupational exposures to carcinogens (Standardized Mortality Ratios {SMR} = 0.92, 42 cases). Workers exposed to both high levels of talc and to quartz and/or radon were found to have an excess of lung cancer mortality (SMR = 1.20, random effect RR=1.85, 40 cases). The authors suggest that further studies to assess the dose-response effect of talc exposure are needed (Wild, 2006).
    3) In a study of an Italian cohort of talc miners and millers (n=1795), no association between occupational exposure to non-asbestiform talc and risk of lung cancer was observed. However, there was a significant excess mortality from non-neoplastic respiratory diseases (a standardized mortality ratio [SMR] 228.2, 95% CI 190.2-271.5), mainly due to silicosis (Coggiola et al, 2003).
    D) MESOTHELIOMA
    1) Mesothelioma may result from asbestos-contaminated talc (Ng, 1984).
    2) In a study of an Italian cohort of talc miners and millers (n=1795), no association between occupational exposure to non-asbestiform talc and mesothelioma was observed. However, there was a significant excess mortality from non-neoplastic respiratory diseases (a standardized mortality ratio [SMR] 228.2, 95% CI 190.2-271.5), mainly due to silicosis (Coggiola et al, 2003).
    E) GASTRIC CARCINOMA
    1) Stomach cancer was elevated in rubber workers chronically exposed to talc, and the practice of treating rice with talc in Japan has been hypothesized to be responsible for the high incidence of stomach cancer in that country (Matsudo, 1974).
    F) ANIMAL STUDIES
    1) Pure talc has not caused cancer in laboratory animals (p 14). The purer grades of talc are generally used in cosmetics and drugs. Talcs containing silica and asbestos are used in paints, elastomers, and other commercial products.
    2) Inhalation of 18 mg/m(3) talc intermittently for 2 years induced lung tumors in rats, while 11 mg/m(3) for 1 year did not in a separate study (RTECS , 1996).

Genotoxicity

    A) Talc has been tested in a battery of short-term genetic assays, but the results were not available at the time of this review. None of the respirable talc samples tested was active for inducing sister chromatid exchanges or unscheduled DNA synthesis in cultured rat pleural mesothelial cells.

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) If symptomatic, obtain baseline CBC, electrolytes, and chest x-ray.
    B) Monitor arterial blood gases regularly in those patients with severe respiratory findings.
    C) Obtain a chest radiograph in patients with pulmonary symptoms. Radiographic findings in chronic talc exposure include fibrosis, granulomas, and diffuse reticulonodular infiltrates.
    D) Subtle pulmonary abnormalities such as decreased carbon monoxide diffusing capacity are an earlier indication of pulmonary damage than clinical or radiological evidence.

Radiographic Studies

    A) CHEST RADIOGRAPH
    1) Obtain a chest radiograph in patients with pulmonary symptoms. Radiographic findings in chronic talc exposure include fibrosis, granulomas, and diffuse reticulonodular infiltrates.
    2) Chest x-ray may show symmetrical hilar and perihilar infiltrates. Diagnosis may be established by transbronchial biopsy using scanning electromicroscopy and energy dispersive x-ray analysis to establish the presence of and identify the particles (Motomatsu et al, 1979; Cruthirds et al, 1977).
    3) TALCOSIS: The main chest x-ray findings in talcosis are diffuse micronodular pattern, large opacities, and lower-lobe emphysema (Marchiori et al, 2010).
    B) CHEST CT SCAN
    1) INHALATION EXPOSURE
    a) CT findings for talc pneumoconiosis differ from silicosis in that there is no predilection for the upper lung zones. In a recent case series including 14 patients diagnosed with pneumoconiosis and followed with CT imaging showed small nodular opacities in all lung fields, pleural plaques and lymph node enlargement not found on chest x-ray, and that the larger opacities progressed more often than smaller opacities (Akira et al, 2007).
    b) HIGH RESOLUTION CT SCAN: In 3 patients with inhalational pulmonary talcosis, the high-resolution CT revealed small centrilobular and subpleural nodules in all lobes but involved mainly the upper and middle lung zones with relative sparing of the lung bases. The subpleural nodules resembled pleural plaques (pseudoplaques). The conglomerated masses involved either all lobes or just upper or lower lobes. Soft tissue windows showed focal areas of high attenuation consistent with talc deposition within the conglomerate masses. In addition, focal ground glass opacities and a mild reticular pattern and minimal honeycombing in the subpleural regions of the lower lung zones were observed (Marchiori et al, 2004).
    2) INTRAVENOUS DRUG ABUSE
    a) CHRONIC INTRAVENOUS drug abuse resulting in pulmonary talcosis was reported in 3 patients. In one patient, CT scan revealed a ground-glass pattern with a biopsy showing vascular and perivascular granulomatous reaction secondary to talc deposition. The other 2 patients had perihilar masses with areas of high attenuation (Padley et al, 1993).
    b) Typical findings on chest CT include large and irregular attenuated nodules ("ground glass") in the middle and upper part of the lung following intravenous abuse of oral drugs (ie, methylphenidate, hydromorphone, amphetamine). These nodules can evolve into large masses or consolidations (Shlomi et al, 2008). Other findings on high-resolution CT include heterogenous conglomerate masses containing high-density amorphous areas, and panlobular emphysema in the lower lobes (Marchiori et al, 2010).

Methods

    A) OTHER
    1) Talc appears under plane polarized light as non-staining, plate-like birefringent needle-shaped crystalline bodies. Larger mean particle size (14 um) of talc is seen from injection than from inhalation (4mM).
    2) Starch particles are rounded and show characteristic Maltese cross appearance. Can also be identified by x-ray diffraction.
    B) INTRAVENOUS DRUG ABUSE
    1) FUNDOSCOPY
    a) Talc particles may be seen in the retinal vessels. Talc retinopathy can be present in up to 80% of long-term IV administration of talc in drug abusers (Marchiori et al, 2010).
    2) PATHOLOGY
    a) Characteristic histopathologic feature include the appearance of birefringent, needle-shaped particles of talc identified with the use of polarized light (Marchiori et al, 2010).

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Patient Disposition

    6.3.3) DISPOSITION/INHALATION EXPOSURE
    6.3.3.1) ADMISSION CRITERIA/INHALATION
    A) Admit patients that continue to have respiratory difficulties who require a higher level of care.
    6.3.3.2) HOME CRITERIA/INHALATION
    A) An adult can remain at home following a minor or mild inadvertent inhalation exposure (ie, no respiratory symptoms and/or mild cough) to talc. Infants and/or a young child that has or is suspected of inhaling and/or ingesting talcum powder should be sent to a healthcare facility to rule out respiratory involvement (ie, possible aspiration, delayed symptoms (ie, dyspnea, choking, coughing)).
    6.3.3.3) CONSULT CRITERIA/INHALATION
    A) Consult with a pulmonologist if the diagnosis is unclear. A hospital intensivist may be needed to treat severely ill patients requiring intubation and mechanical ventilation.
    6.3.3.5) OBSERVATION CRITERIA/INHALATION
    A) Patients that develop persistent or worsening respiratory symptoms should be sent to a healthcare facility. Patients may be discharged once respiratory symptoms are resolved.

Monitoring

    A) If symptomatic, obtain baseline CBC, electrolytes, and chest x-ray.
    B) Monitor arterial blood gases regularly in those patients with severe respiratory findings.
    C) Obtain a chest radiograph in patients with pulmonary symptoms. Radiographic findings in chronic talc exposure include fibrosis, granulomas, and diffuse reticulonodular infiltrates.
    D) Subtle pulmonary abnormalities such as decreased carbon monoxide diffusing capacity are an earlier indication of pulmonary damage than clinical or radiological evidence.

Inhalation Exposure

    6.7.2) TREATMENT
    A) SUPPORT
    1) MANAGEMENT OF MILD TO MODERATE TOXICITY
    a) Treatment is symptomatic and supportive. If significant amounts of talc (including talcum powder) have been inhaled it can act as a pulmonary irritant resulting in cough, dyspnea, sneezing, vomiting and cyanosis. Symptoms may not develop until several hours after aspiration. The inhalation of talc can cause drying of mucous membranes leading to possible obstruction of small airways resulting in respiratory distress. Following inhalation exposure, treat symptomatic patients with corticosteroids. Prednisone: Infant/Child: Administer 1 to 2 mg/kg/day for 3 to 5 days. Administer oxygen and monitor pulse oximetry continuously. Excessive oral (mucous) secretions should be suctioned. In one toddler, an exogenous surfactant (ie, Poractant Alfa) via aerosol was used in a toddler with talc aspiration, and was associated with an improvement in respiratory symptoms and radiological findings. Prophylactic antibiotics are not generally recommended, but antibiotics should be administered to patients with evidence of aspiration pneumonia or secondary bacterial infection. Respiratory physiotherapy may be useful in loosening thick secretions away from the bronchial wall and to stimulate muscular contractility in patients that develop lung consolidation. Bronchodilators are of limited value.
    2) MANAGEMENT OF SEVERE TOXICITY
    a) Treatment is symptomatic and supportive. Endotracheal intubation and mechanical ventilation may be necessary. Monitor ABGs and continuous pulse oximetry. Consider BRONCHIOALVEOLAR LAVAGE to remove aspirated powder. This may be of limited value and can be dangerous, but may be indicated in those patients refractory to other therapies (ie, oxygen, suctioning).
    B) AIRWAY MANAGEMENT
    1) Maintain adequate ventilation and oxygenation. Endotracheal intubation and mechanical ventilation may be required following inhalation exposure.
    C) MONITORING OF PATIENT
    1) If symptomatic, obtain baseline CBC, electrolytes, and chest x-ray.
    2) Monitor arterial blood gases regularly in those patients with severe respiratory findings.
    3) Obtain a chest radiograph in patients with pulmonary symptoms.
    4) Radiographic findings in chronic talc exposure include fibrosis, granulomas, and diffuse reticulonodular infiltrates. Subtle pulmonary abnormalities such as decreased carbon monoxide diffusing capacity are an earlier indication of pulmonary damage than clinical or radiological evidence.
    D) ACETYLCYSTEINE
    1) Excessive mucous secretions should be suctioned. Administer oxygen and N-acetylcysteine in a mist tent as necessary to improve ventilation (Pfenninger & D'Apuzzo, 1977). Aspiration of mucous secretions following tracheal instillation of 5 mL of normal saline may be preferred to N-acetylcysteine therapy.
    E) TRACHEOBRONCHIAL LAVAGE
    1) Consider BRONCHIOALVEOLAR LAVAGE to remove aspirated powder. This will have limited value due to talc insolubility and is potentially dangerous, but may remove excessive mucous secretions refractory to N-acetylcysteine therapy (Pfenninger & D'Apuzzo, 1977; Brouillette & Weber, 1978).
    2) Bronchoalveolar lavage has been used for the diagnosis of talc-induced lung disease (Patarino et al, 2010; Redondo et al, 1988; De Vuyst et al, 1989).
    F) BIOPSY OF LUNG
    1) Open lung biopsy has been used for the diagnosis pulmonary talcosis in a woman that repeatedly inhaled large amounts of baby powder (Egan et al, 1999).
    G) CORTICOSTEROID
    1) PREDNISONE: 1 to 2 mg/kg/day for 3 to 4 days to prevent inflammation and exudation of mucous secretions.
    2) ALTERNATIVE DOSING: Prednisone 0.5 mg/kg/day was started on a patient with talc graunolomatosis of an unknown cause; the dose was gradually tapered to 0.25 mg/kg/day and the patient remained on a low-dose alternate day prednisolone 5 mg and has remained symptom free (Iqbal et al, 2008).
    3) DEXAMETHASONE: For symptomatic patients, dexamethasone 2 mg IM every 12 hours for 7 doses or 100 mg hydrocortisone IM followed by 5 mg prednisone 4 times daily has been successful in 1- to 2-year-olds (Hughes & Kalmer, 1966; Lund & Feldt-Rasmussen, 1969).
    a) In another study, parenteral dexamethasone 2 mg every 12 hours for 3 to 4 days or prednisone 3 to 5 mg/kg/day for 3 to 4 days were successful in treating pediatric patients following inadvertent aspiration of talc (Hollinger, 1990).
    H) SURFACTANT
    1) CASE REPORT: An 18-month-old toddler was admitted with respiratory difficulty and cough one hour after inadvertent inhalation of baby powder. Chest x-ray showed consolidation in the central and middle lung zones and basal emphysema bilaterally. Empiric antibiotic and steroid therapy were started. An aerosolized surfactant (Poractant Alfa), along with budesonide and salbutamol was added. Surfactant was given at a dose of 120 mg/1.5 mL and repeated after 12 hours; followed by budesonide (0.25 mg/dose) and salbutamol (2 mg/dose). The surfactant was administered by pneumatic nebulizer with a spacer to increase distal bronchial deposition. Respiratory physiotherapy was performed twice daily to loosen thick secretions. Within 5 days, the chest x-ray was improved and the toddler continued to do well. Chest x-ray at 1.5 and 6 months were normal (Matina et al, 2011).
    I) DRUG ABUSE
    1) INTRAVENOUS INJECTION OF ORAL DRUGS
    a) CHRONIC EXPOSURE: Individuals that intentionally inject oral drugs (usually psychoactive agents) by crushing or solubilizing the tablets can be repeatedly exposed to talc used in these oral agents to bind the components. If the talc is improperly or only partially removed, pulmonary talc toxicity can develop. The trapped talc can produce pulmonary angiothrombosis, foreign body granulomas and pulmonary fibrosis. If granulomas occur in the arteries it can lead to pulmonary hypertension and cor pulmonale or if the particles migrate into the adjacent interstitial tissue, granulomas can develop in the interstitium producing pulmonary interstitial fibrosis (Hollinger, 1990).
    b) Intravenous talc can also increase the risk of infection (Hollinger, 1990). Consider antibiotic therapy as necessary.
    c) Obtain a chest x-ray, CT scan of the chest, and arterial blood gas analysis to assist with the diagnosis.
    d) TALC GRANULOMATOSIS: Treatment is symptomatic and supportive. Some individuals with drug-induced talc granulomatosis have been successfully treated with oral prednisone therapy (Iqbal et al, 2008; Hollinger, 1990).
    J) TRANSPLANT OF LUNG
    1) TALCOSIS SECONDARY TO IV ABUSE
    a) SUMMARY: Talcosis secondary to talc injection by IV abuse of oral drugs requiring lung transplant is rare (Shlomi et al, 2008).
    2) CASE REPORT
    a) A 54-year-old woman with emphysema and a prior 4 year history of IV methylphenidate abuse 20 years earlier was admitted with dyspnea. Two years earlier her lung function had notably deteriorated and she became oxygen dependent. Upon examination, she had bilateral crackles on inspiration in the lower lobes. A chest x-ray showed bullous emphysema and fibrotic changes in the lower lobes and a perfusion scan showed reduced perfusion to the lower lung zones with almost no perfusion to the left lower lobe and to the lower third of the right lung which appeared consistent with the patient's history of talc injection. She underwent a left lung transplant. Microscopic examination of the extracted lung was consistent with talcosis as demonstrated by multinucleated giant cells with birefringent crystals. A few months after transplant she was tolerating normal activities (Shlomi et al, 2008).
    K) ACIDOSIS
    1) Respiratory acidosis should be treated with respiratory support by maintaining a patent airway and mechanical ventilation.
    L) BRONCHOSPASM
    1) Bronchodilators have been tried with only limited success.
    M) ANTIBIOTIC
    1) Prophylactic antibiotics are not generally recommended, but antibiotics should be administered to patients with evidence of aspiration pneumonia or secondary bacterial infection (Brouillette & Weber, 1978; Pfenninger & D'Apuzzo, 1977).
    N) CHRONIC POISONING
    1) Prednisone 40 to 60 mg/day in adults in divided doses, tapering off over prolonged period should produce improvement in x-ray, blood gases, and pulmonary function within one week (Moskowitz, 1970; Smith et al, 1978).

Abstracts

Case Reports

    A) INFANT
    1) A 4-month-old infant with a tracheotomy tube aspirated baby powder after it had been spilled and dispersed into the air. His airway became blocked, and his parents attempted ventilation by changing tracheotomy tubes and by mouth-to-tracheotomy respiration. He was in cardiopulmonary arrest upon arrival to the hospital, and died the next day despite resuscitative measures. The authors emphasized the additional hazard in this case; the tracheotomy tube is an unprotected, direct conduit to the lungs (Cotton & Davidson, 1985).
    B) CHRONIC EFFECTS
    1) CASE REPORT: A 65-year-old woman with a 25-year history of occupational talc exposure presented with hypoxemia, dyspnea, and cough. Chest X-ray was normal. Bronchoalveolar lavage revealed marked lymphocytosis. Open lung biopsy was performed, which showed numerous peribronchiolar granulomas with foreign body giant cells and birefractive, needle shaped crystals within the cells. Chest x-ray probe microanalysis confirmed talc granulomatosis. The patient was treated with oral prednisone 1 mg/kg/day, which resulted in dramatic symptomatic improvement. Discontinuance of drug therapy was attempted, but was not successful. The patient remained well on corticosteroid therapy (Redondo et al, 1988).
    C) ROUTE OF EXPOSURE
    1) INJECTION
    a) CASE REPORT: A 32-year-old IV drug abuser developed pulmonary talc granulomatosis that simulated Pneumocystis carinii pneumonia. Pneumocystis was ruled out, as were other causative agents. The patient did, however, develop P. carinii pneumonia five months later (O'Connor et al, 1988).
    D) ADULT
    1) CASE REPORT: Acute pneumonitis with bilateral pleural effusions and interstitial infiltrates developed in a 40-year-old woman following talc pleurodesis for recurrent right pleural effusion. Drainage, corticosteroids, and supportive care resulted in gradual recovery without recurrence of the effusion (Bouchama et al, 1984).

Range Of Toxicity

Summary

    A) TOXICITY: A toxic dose has not been established.
    B) ACUTE INHALATION: Only a small percentage of acute talc inhalations require hospitalization or become fatally ill.
    C) CHRONIC INHALATION: The extent and severity of lung injury (fibrosis) correlates with the length of exposure and dust concentration. Chronic talc inhalation may increase the risk of bronchogenic cancer.

Minimum Lethal Exposure

    A) A minimal lethal dose has not been established.

Maximum Tolerated Exposure

    A) SUMMARY
    1) Only a small percentage of acute talc inhalations require hospitalization or result in fatalities (Mofenson et al, 1981). Of severe cases reported in the literature, mortality was 20% (Brouillette & Weber, 1978).
    2) Toxic symptoms may be noted immediately following aspiration, or delayed for 12 to 24 hours.
    B) Occupational exposure to talc and pyrophyllite results primarily from the inhalation of dust during the processes of mining and milling. Because few of the commercial forms are pure talc, the inhaled material is generally composed of a mixture of mineral dusts. The majority of reports concerning the health effects of talc revolve around those talcs that contain appreciable amounts of amphiboles and other minerals; exposure to the nonplatiform talc crystals appears to be the major contributor to health problems (ACGIH, 1991; Clayton & Clayton, 1993).
    C) It has been reported that, while respiratory symptoms and/or simple pneumoconiosis may be related to long-term high-level exposure to relatively pure talc, severe progressive pneumoconiosis develops only as a result of concomitant exposure to additional fibrogenic dusts such as silica or asbestos (Clayton & Clayton, 1993a).

Workplace Standards

    A) ACGIH TLV Values for CAS14807-96-6 (American Conference of Governmental Industrial Hygienists, 2010):
    1) Editor's Note: The listed values are recommendations or guidelines developed by ACGIH(R) to assist in the control of health hazards. They should only be used, interpreted and applied by individuals trained in industrial hygiene. Before applying these values, it is imperative to read the introduction to each section in the current TLVs(R) and BEI(R) Book and become familiar with the constraints and limitations to their use. Always consult the Documentation of the TLVs(R) and BEIs(R) before applying these recommendations and guidelines.
    a) Adopted Value
    1) Talc, containing no asbestos fibers
    a) TLV:
    1) TLV-TWA: 2 mg/m(3)
    2) TLV-STEL:
    3) TLV-Ceiling:
    b) Notations and Endnotes:
    1) Carcinogenicity Category: A4
    2) Codes: E, R
    3) Definitions:
    a) A4: Not Classifiable as a Human Carcinogen: Agents which cause concern that they could be carcinogenic for humans but which cannot be assessed conclusively because of a lack of data. In vitro or animal studies do not provide indications of carcinogenicity which are sufficient to classify the agent into one of the other categories.
    b) E: The value is for particulate matter containing no asbestos and less than 1% crystalline silica.
    c) R: Respirable fraction; see Appendix C, paragraph C (of TLV booklet).
    c) TLV Basis - Critical Effect(s): LRT irr
    d) Molecular Weight:
    1) For gases and vapors, to convert the TLV from ppm to mg/m(3):
    a) [(TLV in ppm)(gram molecular weight of substance)]/24.45
    2) For gases and vapors, to convert the TLV from mg/m(3) to ppm:
    a) [(TLV in mg/m(3))(24.45)]/gram molecular weight of substance
    e) Additional information:
    b) Adopted Value
    1) Talc, containing asbestos fibers
    a) TLV:
    1) TLV-TWA: Use asbestos TLV
    2) TLV-STEL:
    3) TLV-Ceiling:
    b) Notations and Endnotes:
    1) Carcinogenicity Category: A1
    2) Codes: K
    3) Definitions:
    a) A1: Confirmed Human Carcinogen: The agent is carcinogenic to humans based on the weight of evidence from epidemiologic studies.
    b) K: Should not exceed 2 mg/m(3) respirable dust.
    c) TLV Basis - Critical Effect(s):
    d) Molecular Weight:
    1) For gases and vapors, to convert the TLV from ppm to mg/m(3):
    a) [(TLV in ppm)(gram molecular weight of substance)]/24.45
    2) For gases and vapors, to convert the TLV from mg/m(3) to ppm:
    a) [(TLV in mg/m(3))(24.45)]/gram molecular weight of substance
    e) Additional information:
    c) Adopted Value
    1) (Soapstone)
    a) TLV:
    1) TLV-TWA: (6 mg/m(3))
    2) TLV-STEL:
    3) TLV-Ceiling:
    b) Notations and Endnotes:
    1) Carcinogenicity Category: Not Listed
    2) Codes: E
    3) Definitions:
    a) E: The value is for particulate matter containing no asbestos and less than 1% crystalline silica.
    c) TLV Basis - Critical Effect(s): (LRT irr)
    d) Molecular Weight:
    1) For gases and vapors, to convert the TLV from ppm to mg/m(3):
    a) [(TLV in ppm)(gram molecular weight of substance)]/24.45
    2) For gases and vapors, to convert the TLV from mg/m(3) to ppm:
    a) [(TLV in mg/m(3))(24.45)]/gram molecular weight of substance
    e) Additional information:
    1) See Notice of Intended Changes; Adopted values enclosed in parentheses are those for which changes are proposed in the Notice of Intended Changes.
    d) Adopted Value
    1) (Soapstone)
    a) TLV:
    1) TLV-TWA: (3 mg/m(3))
    2) TLV-STEL:
    3) TLV-Ceiling:
    b) Notations and Endnotes:
    1) Carcinogenicity Category: Not Listed
    2) Codes: E, R
    3) Definitions:
    a) E: The value is for particulate matter containing no asbestos and less than 1% crystalline silica.
    b) R: Respirable fraction; see Appendix C, paragraph C (of TLV booklet).
    c) TLV Basis - Critical Effect(s): (LRT irr)
    d) Molecular Weight:
    1) For gases and vapors, to convert the TLV from ppm to mg/m(3):
    a) [(TLV in ppm)(gram molecular weight of substance)]/24.45
    2) For gases and vapors, to convert the TLV from mg/m(3) to ppm:
    a) [(TLV in mg/m(3))(24.45)]/gram molecular weight of substance
    e) Additional information:
    1) See Notice of Intended Changes; Adopted values enclosed in parentheses are those for which changes are proposed in the Notice of Intended Changes.
    e) Notice of Intended Changes
    1) Soapstone
    a) TLV:
    1) TLV-TWA:
    2) TLV-STEL:
    3) TLV-Ceiling:
    b) Notations and Endnotes:
    1) Carcinogenicity Category: Not Listed
    2) Codes: Not Listed
    3) Definitions: Not Listed
    c) TLV Basis - Critical Effect(s):
    d) Molecular Weight:
    1) For gases and vapors, to convert the TLV from ppm to mg/m(3):
    a) [(TLV in ppm)(gram molecular weight of substance)]/24.45
    2) For gases and vapors, to convert the TLV from mg/m(3) to ppm:
    a) [(TLV in mg/m(3))(24.45)]/gram molecular weight of substance
    e) Additional information:
    1) WITHDRAW ADOPTED DOCUMENTATION AND TLV, SEE DOCUMENTATION FOR TALC

    B) NIOSH REL and IDLH Values for CAS14807-96-6 (National Institute for Occupational Safety and Health, 2007):
    1) Listed as: Talc (containing no asbestos and less than 1% quartz)
    2) REL:
    a) TWA: 2 mg/m(3) (resp)
    b) STEL:
    c) Ceiling:
    d) Carcinogen Listing: (Not Listed) Not Listed
    e) Skin Designation: Not Listed
    f) Note(s):
    3) IDLH:
    a) IDLH: 1000 mg/m3
    b) Note(s): Not Listed

    C) Carcinogenicity Ratings for CAS14807-96-6 :
    1) ACGIH (American Conference of Governmental Industrial Hygienists, 2010): A4 ; Listed as: Talc, containing no asbestos fibers
    a) A4 :Not Classifiable as a Human Carcinogen: Agents which cause concern that they could be carcinogenic for humans but which cannot be assessed conclusively because of a lack of data. In vitro or animal studies do not provide indications of carcinogenicity which are sufficient to classify the agent into one of the other categories.
    2) ACGIH (American Conference of Governmental Industrial Hygienists, 2010): A1 ; Listed as: Talc, containing asbestos fibers
    a) A1 :Confirmed Human Carcinogen: The agent is carcinogenic to humans based on the weight of evidence from epidemiologic studies.
    3) ACGIH (American Conference of Governmental Industrial Hygienists, 2010): Not Listed ; Listed as: (Soapstone)
    4) ACGIH (American Conference of Governmental Industrial Hygienists, 2010): Not Listed ; Listed as: (Soapstone)
    5) ACGIH (American Conference of Governmental Industrial Hygienists, 2010): Not Listed ; Listed as: Soapstone
    6) EPA (U.S. Environmental Protection Agency, 2011): Not Listed
    7) IARC (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004): 3 ; Listed as: Talc, not containing asbestiform fibres
    a) 3 : The agent (mixture or exposure circumstance) is not classifiable as to its carcinogenicity to humans. This category is used most commonly for agents, mixtures and exposure circumstances for which the evidence of carcinogenicity is inadequate in humans and inadequate or limited in experimental animals. Exceptionally, agents (mixtures) for which the evidence of carcinogenicity is inadequate in humans but sufficient in experimental animals may be placed in this category when there is strong evidence that the mechanism of carcinogenicity in experimental animals does not operate in humans. Agents, mixtures and exposure circumstances that do not fall into any other group are also placed in this category.
    8) NIOSH (National Institute for Occupational Safety and Health, 2007): Not Listed ; Listed as: Talc (containing no asbestos and less than 1% quartz)
    9) MAK (DFG, 2002): Not Listed
    10) NTP (U.S. Department of Health and Human Services, Public Health Service, National Toxicology Project ): Not Listed

    D) OSHA PEL Values for CAS14807-96-6 (U.S. Occupational Safety, and Health Administration (OSHA), 2010):
    1) Listed as: Silicates (less than 1% crystalline silica): Talc (containing no asbestos), respirable dust
    2) Table Z-1 for Silicates (less than 1% crystalline silica): Talc (containing no asbestos), respirable dust:
    a) 8-hour TWA:
    1) ppm:
    a) Parts of vapor or gas per million parts of contaminated air by volume at 25 degrees C and 760 torr.
    2) mg/m3:
    a) Milligrams of substances per cubic meter of air. When entry is in this column only, the value is exact; when listed with a ppm entry, it is approximate.
    3) Ceiling Value:
    4) Skin Designation: No
    5) Notation(s): Not Listed
    3) Table Z-3 for Silicates (less than 1% crystalline silica): Talc (not containing asbestos):
    a) 8-hour TWA:
    1) mppcf: 20
    a) Millions of particles per cubic foot of air, based on impinger samples counted by light-field techniques.
    2) mg/m3:
    3) Notation(s):
    a) (c): Containing less than 1% quartz; if 1% quartz or more, use quartz limit.

Toxicity Information

    7.7.1) TOXICITY VALUES
    A) For Talc containing asbestos fibers
    B) For Talc containing no asbestos fibers

Pharmacology Toxicology

Toxicologic Mechanism

    A) Relatively inert, insoluble crystalline powder used topically as a lubricant, absorbent, and protectant. It is not a primary skin irritant and does not produce sensitization. When deposited in tissue, talc particles are physical irritants which produce intense inflammatory reactions.

Physicochemical

Physical Characteristics

    A) Talc exists as a white to grayish-white or light green, finely-ground, crystalline powder consisting of natural hydrous magnesium silicate. The powder is odorless and has a pearly or greasy luster and a greasy feel. Talc shows a high resistance to acids, alkalis, and heat, and is often contaminated with asbestos (Ashford, 1994; Budavari, 1996; Lewis, 1996; Lewis, 1997; Lewis, 1998; Chemsoft , 1996).

Ph

    A) Not Applicable

Molecular Weight

    A) Varies (NIOSH , 1999)
    B) 96.49 (HSDB , 1999)

Other

    A) ODOR THRESHOLD
    1) Odorless (HSDB , 1999)

References

General Bibliography

    1) 40 CFR 372.28: Environmental Protection Agency - Toxic Chemical Release Reporting, Community Right-To-Know, Lower thresholds for chemicals of special concern. National Archives and Records Administration (NARA) and the Government Printing Office (GPO). Washington, DC. Final rules current as of Apr 3, 2006.
    2) 40 CFR 372.65: Environmental Protection Agency - Toxic Chemical Release Reporting, Community Right-To-Know, Chemicals and Chemical Categories to which this part applies. National Archives and Records Association (NARA) and the Government Printing Office (GPO), Washington, DC. Final rules current as of Apr 3, 2006.
    3) 49 CFR 172.101 - App. B: Department of Transportation - Table of Hazardous Materials, Appendix B: List of Marine Pollutants. National Archives and Records Administration (NARA) and the Government Printing Office (GPO), Washington, DC. Final rules current as of Aug 29, 2005.
    4) 49 CFR 172.101: Department of Transportation - Table of Hazardous Materials. National Archives and Records Administration (NARA) and the Government Printing Office (GPO), Washington, DC. Final rules current as of Aug 11, 2005.
    5) 62 FR 58840: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 1997.
    6) 65 FR 14186: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2000.
    7) 65 FR 39264: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2000.
    8) 65 FR 77866: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2000.
    9) 66 FR 21940: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2001.
    10) 67 FR 7164: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2002.
    11) 68 FR 42710: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2003.
    12) 69 FR 54144: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2004.
    13) ACGIH: Documentation of the Threshold Limit Values and Biological Exposure Indices, 6th ed, Am Conference of Govt Ind Hyg, Inc, Cincinnati, OH, 1991.
    14) AIHA: 2006 Emergency Response Planning Guidelines and Workplace Environmental Exposure Level Guides Handbook, American Industrial Hygiene Association, Fairfax, VA, 2006.
    15) Akira M, Kozuka T, Yamamoto S, et al: Inhalational talc pneumoconiosis: radiographic and CT findings in 14 patients. AJR Am J Roentgenol 2007; 188(2):326-333.
    16) American Conference of Governmental Industrial Hygienists : ACGIH 2010 Threshold Limit Values (TLVs(R)) for Chemical Substances and Physical Agents and Biological Exposure Indices (BEIs(R)), American Conference of Governmental Industrial Hygienists, Cincinnati, OH, 2010.
    17) Anon: A breath of talc (Editoral). Emerg Med 1977; 2:56.
    18) Anon: Fed NTIS PB-223-828, Control No FDA 71-260, p 14, 1973.
    19) Ashford R: Ashford's Dictionary of Industrial Chemicals, Wavelength Publications Ltd, London, England, 1994.
    20) AtLee We: Talc and cornstarch emboli in eyes of drug abusers. JAMA 1972; 219:49-51.
    21) Baader EW: Deut med wochenschr 1950; 75:50-51.
    22) Ben-Haim SA, Ben-Ami H, & Edoute Y: Talcosis presenting as pulmonary infiltrates in an HIV-positive heroin addict. Chest 1988; 94:656-658.
    23) Bluth LL & Hanscom TA: Retinal detachment and vitreous hemorrhage due to talc emboli. JAMA 1981; 246:980-981.
    24) Bouchama A, Chastre J, & Gaudichet A: Acute pneumonitis with bilateral pleural effusion after talc pleurodesis. Chest 1984; 86:795-797.
    25) Brouillette F & Weber ML: Massive aspiration of talcum powder by an infant. Canad Med Assoc J 1978; 119:354-355.
    26) Budavari S: The Merck Index, 12th ed, Merck & Co, Inc, Whitehouse Station, NJ, 1996.
    27) Burgess JL, Kirk M, Borron SW, et al: Emergency department hazardous materials protocol for contaminated patients. Ann Emerg Med 1999; 34(2):205-212.
    28) Butch AJ, Yokel RA, & Sigell LT: Abuse and pulmonary complications of injecting pentazocine and tripelennamine tablets. Clin Tox 1979; 14:301-306.
    29) Chang S & Risch HA: Perineal talc exposure and risk of ovarian carcinoma. Cancer 1997; 79:2396-2401.
    30) Chemsoft : Electronic EPA, NIOSH, & OSHA Methods (TM). Windowchem(TM) Software. Fairfield, CA. 1996.
    31) Clayton GD & Clayton FE: Patty's Industrial Hygiene and Toxicology, Toxicology, 3rd ed, 2A, John Wiley & Sons, New York, NY, 1993a.
    32) Clayton GD & Clayton FE: Patty's Industrial Hygiene and Toxicology, Vol 2A, Toxicology, 4th ed, John Wiley & Sons, New York, NY, 1993.
    33) Coder DM & Olander GA: Granulomatous peritonitis caused by starch glove powder. Arch Surg 1972; 105:83-86.
    34) Coggiola M, Bosio D, Pira E, et al: An update of a mortality study of talc miners and millers in Italy. Am J Ind Med 2003; 44:63-69.
    35) Cotton WH & Davidson PJ: Aspiration of baby powder (Letter). N Engl J Med 1985; 313:1662.
    36) Cramer DW, Welch WR, & Scully RE: Ovarian cancer and talc: a case-control study. Cancer 1982; 50:372-376.
    37) Cruthirds TP, Cole FH, & Paul RN: Pulmonary talcosis as a result of massive aspiration of baby powder. South Med J 1977; 70:626-628.
    38) DFG: List of MAK and BAT Values 2002, Report No. 38, Deutsche Forschungsgemeinschaft, Commission for the Investigation of Health Hazards of Chemical Compounds in the Work Area, Wiley-VCH, Weinheim, Federal Republic of Germany, 2002.
    39) Davis LL: Pulmonary "mainline" granulomatosis: talcosis secondary to intravenous heroin abuse with characteristic x-ray findings of asbestosis. J Natl Med Assoc 1983; 75:1225-1228.
    40) De Vuyst P, Dumortier P, & Leophonte P: Bronchoalveolar lavage in talc induced lung disease (Letter). Thorax 1989; 44:607.
    41) Dement JM: NIOSH Pub No 80-115, Occupational exposure to talc containing asbestos, National Institue for Occupational Safety and Health, Cincinnati, OH, 1980, pp 118.
    42) EPA: Search results for Toxic Substances Control Act (TSCA) Inventory Chemicals. US Environmental Protection Agency, Substance Registry System, U.S. EPA's Office of Pollution Prevention and Toxics. Washington, DC. 2005. Available from URL: http://www.epa.gov/srs/.
    43) ERG: Emergency Response Guidebook. A Guidebook for First Responders During the Initial Phase of a Dangerous Goods/Hazardous Materials Incident, U.S. Department of Transportation, Research and Special Programs Administration, Washington, DC, 2004.
    44) Egan AJ, Tazelaar HD, Myers JL, et al: Munchausen syndrome presenting as pulmonary talcosis. Arch Pathol Lab Med 1999; 123(8):736-738.
    45) Endocapron S, Renier A, & Janson X: In vitro response of rat pleural mesothelial cells to talc samples in genotoxicity assays (sister chromatid exchanges and DNA repair). Toxicol In Vitro 1993; 7:7-14.
    46) Feigin DS: Am J Roentgenol 1986; 146:295-301.
    47) Gamble JF: A nested case control study of lung cancer among talc workers. Internat Arch Occup Environ Health 1993; 64:449-456.
    48) Goldbach PD, Mohsenifar Z, & Abraham JL: Talcum powder pneumoconiosis: diagnosis by transbronchial biopsy using energy-dispersive x-ray analysis. West J Med 1982; 136:439-442.
    49) Gould SR & Barnardo DE: Respiratory distress after talc inhalation. Br J Dis Chest 1972; 66:230-233.
    50) Grant WM: Toxicology of the Eye, 4th ed, Charles C Thomas, Springfield, IL, 1993.
    51) HSDB : Hazardous Substances Data Bank. National Library of Medicine. Bethesda, MD (Internet Version). Edition expires 1999; provided by Truven Health Analytics Inc., Greenwood Village, CO.
    52) Hahn HH, Schweid AI, & Beaty HN: Complications of injecting dissolved methylphenidate tablets. Arch Intern Med 1969; 123:650-659.
    53) Hamilton TC: Br J Exp Pathol 1984; 65:101-106.
    54) Hathaway GJ, Proctor NH, & Hughes JP: Chemical Hazards of the Workplace, 3rd ed, Van Nostrand Reinhold Company, New York, NY, 1991, pp 527-529.
    55) Henderson WJ: J Obs Gyn Br Cmwlth 1971; 78:266-272.
    56) Hollinger MA : Pulmonary toxicity of inhaled and intravenous talc. Toxicol Lett 1990; 52(2):121-127.
    57) Hughes WT & Kalmer T: Massive talc aspiration: successful treatment with dexamethasone. Am J Dis Child 1966; 111:653-654.
    58) Huncharek M, Muscat J, Onitilo A, et al: Use of cosmetic talc on contraceptive diaphragms and risk of ovarian cancer: a meta-analysis of nine observational studies. Eur J Cancer Prev 2007; 16(5):422-429.
    59) IARC Working Group on the Evaluation of Carcinogenic Risks to Humans : IARC Monographs on the Evaluation of Carcinogenic Risks to Humans: 1,3-Butadiene, Ethylene Oxide and Vinyl Halides (Vinyl Fluoride, Vinyl Chloride and Vinyl Bromide), 97, International Agency for Research on Cancer, Lyon, France, 2008.
    60) IARC Working Group on the Evaluation of Carcinogenic Risks to Humans : IARC Monographs on the Evaluation of Carcinogenic Risks to Humans: Formaldehyde, 2-Butoxyethanol and 1-tert-Butoxypropan-2-ol, 88, International Agency for Research on Cancer, Lyon, France, 2006.
    61) IARC Working Group on the Evaluation of Carcinogenic Risks to Humans : IARC Monographs on the Evaluation of Carcinogenic Risks to Humans: Household Use of Solid Fuels and High-temperature Frying, 95, International Agency for Research on Cancer, Lyon, France, 2010a.
    62) IARC Working Group on the Evaluation of Carcinogenic Risks to Humans : IARC Monographs on the Evaluation of Carcinogenic Risks to Humans: Smokeless Tobacco and Some Tobacco-specific N-Nitrosamines, 89, International Agency for Research on Cancer, Lyon, France, 2007.
    63) IARC Working Group on the Evaluation of Carcinogenic Risks to Humans : IARC Monographs on the Evaluation of Carcinogenic Risks to Humans: Some Non-heterocyclic Polycyclic Aromatic Hydrocarbons and Some Related Exposures, 92, International Agency for Research on Cancer, Lyon, France, 2010.
    64) IARC: List of all agents, mixtures and exposures evaluated to date - IARC Monographs: Overall Evaluations of Carcinogenicity to Humans, Volumes 1-88, 1972-PRESENT. World Health Organization, International Agency for Research on Cancer. Lyon, FranceAvailable from URL: http://monographs.iarc.fr/monoeval/crthall.html. As accessed Oct 07, 2004.
    65) ICAO: Technical Instructions for the Safe Transport of Dangerous Goods by Air, 2003-2004. International Civil Aviation Organization, Montreal, Quebec, Canada, 2002.
    66) International Agency for Research on Cancer (IARC): IARC monographs on the evaluation of carcinogenic risks to humans: list of classifications, volumes 1-116. International Agency for Research on Cancer (IARC). Lyon, France. 2016. Available from URL: http://monographs.iarc.fr/ENG/Classification/latest_classif.php. As accessed 2016-08-24.
    67) International Agency for Research on Cancer: IARC Monographs on the Evaluation of Carcinogenic Risks to Humans. World Health Organization. Geneva, Switzerland. 2015. Available from URL: http://monographs.iarc.fr/ENG/Classification/. As accessed 2015-08-06.
    68) Iqbal A, Aggarwal B, Menon B, et al: Talc granulomatosis mimicking sarcoidosis. Singapore Med J 2008; 49(7):e168-e170.
    69) Kim Y, Kim YK, Choi MY, et al: A case of acute pneumonitis following talc pleurodesis: high-resolution CT findings. J Thorac Imaging 2006; 21(1):47-49.
    70) Kleinfeld M: Arch Environ Health 1963; 7:107-121-101-115.
    71) Kleinfeld M: Arch Environ Health 1965; 10:431-437.
    72) Lewis JH, Sundeen JT, & Simon GL: Disseminated talc granulomatosis: an unusual finding in a patient with acquired immunodeficiency syndrome and fatal cytomegalovirus infection. Arch Pathol Lab Med 1985; 109:147-150.
    73) Lewis RA: Lewis' Dictionary of Toxicology, Lewis Publishers, Boca Raton, FL, 1998.
    74) Lewis RJ: Dangerous Properties of Industrial Materials, 9th ed, Van Nostrand Reinhold Company, New York, NY, 1996a, pp 833.
    75) Lewis RJ: Hawley's Condensed Chemical Dictionary, 13th ed, John Wiley & Sons, Inc, New York, NY, 1997.
    76) Lewis RJ: Sax's Dangerous Properties of Industrial Materials, 9th ed, Van Nostrand Reinhold Company, New York, NY, 1996.
    77) Lund JS & Feldt-Rasmussen M: Accidental aspiration of talc: report of a case in a 2 year old child. Acta Pediatr Med Scand 1969; 58:295-296.
    78) Marchiori E, Lourenco S, Gasparetto TD, et al: Pulmonary talcosis: imaging findings. Lung 2010; 188(2):165-171.
    79) Marchiori E, Soares Souza A Jr, & Muller NL: Inhalational pulmonary talcosis. High-resolution CT findings in 3 patients. J Thorac Imaging 2004; 19(1):41-44.
    80) Martidis A, Yung CW, & Ciulla TA: Talc embolism: a static retinopathy. Am J Ophthalmol 1997; 124:841-843.
    81) Matina F, Collura M, Maggio MC, et al: Inhaled surfactant in the treatment of accidental talc powder inhalation: a new case report. Ital J Pediatr 2011; 37:47.
    82) Matsudo H: Arch Pathol 1974; 97:366-368.
    83) Mofenson HC, Greensher J, & DiTomasso A: Baby powder - a hazard. Pediatrics 1981; 68:265-266.
    84) Moskowitz RL: Talc pneumoconiosis: a treated case. Chest 1970; 58:37-41.
    85) Motomatsu K, Adachi H, & Uno T: Two infant deaths after inhaling baby powder. Chest 1979; 75:448-450.
    86) NFPA: Fire Protection Guide to Hazardous Materials, 13th ed., National Fire Protection Association, Quincy, MA, 2002.
    87) NIOSH : Pocket Guide to Chemical Hazards. National Institute for Occupational Safety and Health. Cincinnati, OH (Internet Version). Edition expires 1999; provided by Truven Health Analytics Inc., Greenwood Village, CO.
    88) NRC: Acute Exposure Guideline Levels for Selected Airborne Chemicals - Volume 1, Subcommittee on Acute Exposure Guideline Levels, Committee on Toxicology, Board on Environmental Studies and Toxicology, Commission of Life Sciences, National Research Council. National Academy Press, Washington, DC, 2001.
    89) NRC: Acute Exposure Guideline Levels for Selected Airborne Chemicals - Volume 2, Subcommittee on Acute Exposure Guideline Levels, Committee on Toxicology, Board on Environmental Studies and Toxicology, Commission of Life Sciences, National Research Council. National Academy Press, Washington, DC, 2002.
    90) NRC: Acute Exposure Guideline Levels for Selected Airborne Chemicals - Volume 3, Subcommittee on Acute Exposure Guideline Levels, Committee on Toxicology, Board on Environmental Studies and Toxicology, Commission of Life Sciences, National Research Council. National Academy Press, Washington, DC, 2003.
    91) NRC: Acute Exposure Guideline Levels for Selected Airborne Chemicals - Volume 4, Subcommittee on Acute Exposure Guideline Levels, Committee on Toxicology, Board on Environmental Studies and Toxicology, Commission of Life Sciences, National Research Council. National Academy Press, Washington, DC, 2004.
    92) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for 1,2,3-Trimethylbenzene (Proposed). United States Environmental Protection Agency. Washington, DC. 2006k. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d68a&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    93) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for 1,2,4-Trimethylbenzene (Proposed). United States Environmental Protection Agency. Washington, DC. 2006m. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d68a&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    94) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for 1,2-Butylene Oxide (Proposed). United States Environmental Protection Agency. Washington, DC. 2008d. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648083cdbb&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    95) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for 1,2-Dibromoethane (Proposed). United States Environmental Protection Agency. Washington, DC. 2007g. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064802796db&disposition=attachment&contentType=pdf. As accessed 2010-08-18.
    96) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for 1,3,5-Trimethylbenzene (Proposed). United States Environmental Protection Agency. Washington, DC. 2006l. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d68a&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    97) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for 2-Ethylhexyl Chloroformate (Proposed). United States Environmental Protection Agency. Washington, DC. 2007b. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648037904e&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    98) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Acrylonitrile (Proposed). United States Environmental Protection Agency. Washington, DC. 2007c. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648028e6a3&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    99) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Adamsite (Proposed). United States Environmental Protection Agency. Washington, DC. 2007h. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020fd29&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    100) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Agent BZ (3-quinuclidinyl benzilate) (Proposed). United States Environmental Protection Agency. Washington, DC. 2007f. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064803ad507&disposition=attachment&contentType=pdf. As accessed 2010-08-18.
    101) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Allyl Chloride (Proposed). United States Environmental Protection Agency. Washington, DC. 2008. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648039d9ee&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    102) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Aluminum Phosphide (Proposed). United States Environmental Protection Agency. Washington, DC. 2005b. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5ed&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    103) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Arsenic Trioxide (Proposed). United States Environmental Protection Agency. Washington, DC. 2007m. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480220305&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    104) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Automotive Gasoline Unleaded (Proposed). United States Environmental Protection Agency. Washington, DC. 2009a. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7cc17&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    105) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Biphenyl (Proposed). United States Environmental Protection Agency. Washington, DC. 2005j. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064801ea1b7&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    106) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Bis-Chloromethyl Ether (BCME) (Proposed). United States Environmental Protection Agency. Washington, DC. 2006n. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648022db11&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    107) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Boron Tribromide (Proposed). United States Environmental Protection Agency. Washington, DC. 2008a. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064803ae1d3&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    108) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Bromine Chloride (Proposed). United States Environmental Protection Agency. Washington, DC. 2007d. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648039732a&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    109) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Bromoacetone (Proposed). United States Environmental Protection Agency. Washington, DC. 2008e. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064809187bf&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    110) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Calcium Phosphide (Proposed). United States Environmental Protection Agency. Washington, DC. 2005d. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5ed&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    111) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Carbonyl Fluoride (Proposed). United States Environmental Protection Agency. Washington, DC. 2008b. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064803ae328&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    112) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Carbonyl Sulfide (Proposed). United States Environmental Protection Agency. Washington, DC. 2007e. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648037ff26&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    113) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Chlorobenzene (Proposed). United States Environmental Protection Agency. Washington, DC. 2008c. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064803a52bb&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    114) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Cyanogen (Proposed). United States Environmental Protection Agency. Washington, DC. 2008f. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064809187fe&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    115) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Dimethyl Phosphite (Proposed). United States Environmental Protection Agency. Washington, DC. 2009. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7cbf3&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    116) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Diphenylchloroarsine (Proposed). United States Environmental Protection Agency. Washington, DC. 2007l. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020fd29&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    117) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Ethyl Isocyanate (Proposed). United States Environmental Protection Agency. Washington, DC. 2008h. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648091884e&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    118) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Ethyl Phosphorodichloridate (Proposed). United States Environmental Protection Agency. Washington, DC. 2008i. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480920347&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    119) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Ethylbenzene (Proposed). United States Environmental Protection Agency. Washington, DC. 2008g. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064809203e7&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    120) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Ethyldichloroarsine (Proposed). United States Environmental Protection Agency. Washington, DC. 2007j. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020fd29&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    121) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Germane (Proposed). United States Environmental Protection Agency. Washington, DC. 2008j. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480963906&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    122) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Hexafluoropropylene (Proposed). United States Environmental Protection Agency. Washington, DC. 2006. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064801ea1f5&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    123) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Ketene (Proposed). United States Environmental Protection Agency. Washington, DC. 2007. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020ee7c&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    124) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Magnesium Aluminum Phosphide (Proposed). United States Environmental Protection Agency. Washington, DC. 2005h. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5ed&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    125) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Magnesium Phosphide (Proposed). United States Environmental Protection Agency. Washington, DC. 2005g. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5ed&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    126) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Malathion (Proposed). United States Environmental Protection Agency. Washington, DC. 2009k. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064809639df&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    127) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Mercury Vapor (Proposed). United States Environmental Protection Agency. Washington, DC. 2009b. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a8a087&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    128) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Methyl Isothiocyanate (Proposed). United States Environmental Protection Agency. Washington, DC. 2008k. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480963a03&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    129) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Methyl Parathion (Proposed). United States Environmental Protection Agency. Washington, DC. 2008l. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480963a57&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    130) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Methyl tertiary-butyl ether (Proposed). United States Environmental Protection Agency. Washington, DC. 2007a. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064802a4985&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    131) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Methylchlorosilane (Proposed). United States Environmental Protection Agency. Washington, DC. 2005. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5f4&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    132) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Methyldichloroarsine (Proposed). United States Environmental Protection Agency. Washington, DC. 2007i. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020fd29&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    133) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Methyldichlorosilane (Proposed). United States Environmental Protection Agency. Washington, DC. 2005a. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c646&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    134) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Nitrogen Mustard (HN1 CAS Reg. No. 538-07-8) (Proposed). United States Environmental Protection Agency. Washington, DC. 2006a. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d6cb&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    135) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Nitrogen Mustard (HN2 CAS Reg. No. 51-75-2) (Proposed). United States Environmental Protection Agency. Washington, DC. 2006b. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d6cb&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    136) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Nitrogen Mustard (HN3 CAS Reg. No. 555-77-1) (Proposed). United States Environmental Protection Agency. Washington, DC. 2006c. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d6cb&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    137) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Nitrogen Tetroxide (Proposed). United States Environmental Protection Agency. Washington, DC. 2008n. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648091855b&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    138) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Nitrogen Trifluoride (Proposed). United States Environmental Protection Agency. Washington, DC. 2009l. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480963e0c&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    139) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Parathion (Proposed). United States Environmental Protection Agency. Washington, DC. 2008o. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480963e32&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    140) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Perchloryl Fluoride (Proposed). United States Environmental Protection Agency. Washington, DC. 2009c. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7e268&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    141) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Perfluoroisobutylene (Proposed). United States Environmental Protection Agency. Washington, DC. 2009d. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7e26a&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    142) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Phenyl Isocyanate (Proposed). United States Environmental Protection Agency. Washington, DC. 2008p. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648096dd58&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    143) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Phenyl Mercaptan (Proposed). United States Environmental Protection Agency. Washington, DC. 2006d. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020cc0c&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    144) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Phenyldichloroarsine (Proposed). United States Environmental Protection Agency. Washington, DC. 2007k. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020fd29&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    145) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Phorate (Proposed). United States Environmental Protection Agency. Washington, DC. 2008q. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648096dcc8&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    146) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Phosgene (Draft-Revised). United States Environmental Protection Agency. Washington, DC. 2009e. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a8a08a&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    147) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Phosgene Oxime (Proposed). United States Environmental Protection Agency. Washington, DC. 2009f. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7e26d&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    148) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Potassium Cyanide (Proposed). United States Environmental Protection Agency. Washington, DC. 2009g. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7cbb9&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    149) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Potassium Phosphide (Proposed). United States Environmental Protection Agency. Washington, DC. 2005c. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5ed&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    150) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Propargyl Alcohol (Proposed). United States Environmental Protection Agency. Washington, DC. 2006e. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020ec91&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    151) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Selenium Hexafluoride (Proposed). United States Environmental Protection Agency. Washington, DC. 2006f. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020ec55&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    152) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Silane (Proposed). United States Environmental Protection Agency. Washington, DC. 2006g. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d523&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    153) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Sodium Cyanide (Proposed). United States Environmental Protection Agency. Washington, DC. 2009h. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7cbb9&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    154) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Sodium Phosphide (Proposed). United States Environmental Protection Agency. Washington, DC. 2005i. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5ed&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    155) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Strontium Phosphide (Proposed). United States Environmental Protection Agency. Washington, DC. 2005f. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5ed&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    156) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Sulfuryl Chloride (Proposed). United States Environmental Protection Agency. Washington, DC. 2006h. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020ec7a&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    157) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Tear Gas (Proposed). United States Environmental Protection Agency. Washington, DC. 2008s. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648096e551&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    158) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Tellurium Hexafluoride (Proposed). United States Environmental Protection Agency. Washington, DC. 2009i. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7e2a1&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    159) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Tert-Octyl Mercaptan (Proposed). United States Environmental Protection Agency. Washington, DC. 2008r. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648096e5c7&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    160) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Tetramethoxysilane (Proposed). United States Environmental Protection Agency. Washington, DC. 2006j. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d632&disposition=attachment&contentType=pdf. As accessed 2010-08-17.
    161) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Trimethoxysilane (Proposed). United States Environmental Protection Agency. Washington, DC. 2006i. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d632&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    162) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Trimethyl Phosphite (Proposed). United States Environmental Protection Agency. Washington, DC. 2009j. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7d608&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    163) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Trimethylacetyl Chloride (Proposed). United States Environmental Protection Agency. Washington, DC. 2008t. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648096e5cc&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    164) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Zinc Phosphide (Proposed). United States Environmental Protection Agency. Washington, DC. 2005e. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5ed&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    165) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for n-Butyl Isocyanate (Proposed). United States Environmental Protection Agency. Washington, DC. 2008m. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064808f9591&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    166) National Institute for Occupational Safety and Health: NIOSH Pocket Guide to Chemical Hazards, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Cincinnati, OH, 2007.
    167) National Research Council : Acute exposure guideline levels for selected airborne chemicals, 5, National Academies Press, Washington, DC, 2007.
    168) National Research Council: Acute exposure guideline levels for selected airborne chemicals, 6, National Academies Press, Washington, DC, 2008.
    169) National Research Council: Acute exposure guideline levels for selected airborne chemicals, 7, National Academies Press, Washington, DC, 2009.
    170) National Research Council: Acute exposure guideline levels for selected airborne chemicals, 8, National Academies Press, Washington, DC, 2010.
    171) Neill AS , Nagle CM , Spurdle AB , et al: Use of talcum powder and endometrial cancer risk. Cancer Causes Control 2012; 23(3):513-519.
    172) Ng TK: Talc and mesothelioma. Med J Aust 1984; 140:452-453.
    173) OHM/TADS : Oil and Hazardous Materials/Technical Assistance Data System. US Environmental Protection Agency. Washington, DC (Internet Version). Edition expires 1999; provided by Truven Health Analytics Inc., Greenwood Village, CO.
    174) Oubeid M, Bickel JT, & Ingram EA: Pulmonary talc granulomatosis in a cocaine sniffer. Chest 1990; 98:237-239.
    175) Padley SPG, Adler BD, & Staples CA: Pulmonary talcosis: CT findings in three cases. Radiology 1993; 186:125-127.
    176) Pairaudeau PW, Wilson RG, & Hall MA: Inhalation of baby powder: an unappreciated hazard. Brit Med J 1991; 302:1200-1201.
    177) Patarino F, Norbedo S, Barbi E, et al: Acute respiratory failure in a child after talc inhalation. Respiration 2010; 79(4):340-.
    178) Pfenninger J & D'Apuzzo V: Powder aspiration in children: report of two cases. Arch Dis Child 1977; 52:157-159.
    179) Product Information: SCLEROSOL(R) intrapleural aerosol, talc intrapleural aerosol. Bryan Corporation (per FDA), Woburn, MA, 2012.
    180) Product Information: sterile talc powder, sterile talc powder. Bryan Corporation, Woburn, MA, 2003.
    181) RTECS : Registry of Toxic Effects of Chemical Substances. National Institute for Occupational Safety and Health. Cincinnati, OH (Internet Version). Edition expires 1999; provided by Truven Health Analytics Inc., Greenwood Village, CO.
    182) RTECS : Registry of Toxic Effects of Chemical Substances. National Institute for Occupational Safety and Health. Cincinnati, OH (Internet Version). Edition expires Oct/31/1996; provided by Truven Health Analytics Inc., Greenwood Village, CO.
    183) Racela LS, Papasian CJ, & Watanabe I: Systemic talc granulomatosis associated with disseminated histoplasmosis in a drug abuser. Arch Pathol Lab Med 1988; 112:557-560.
    184) Ramanakumar AV, Parent ME, Latreille B, et al: Risk of lung cancer following exposure to carbon black, titanium dioxide and talc: results from two case-control studies in Montreal. Int J Cancer 2008; 122(1):183-189.
    185) Redondo AA, Ettensohn DB, & Khan M: Bronchoalveolar lavage in talc induced lung disease. Thorax 1988; 43:1019-1021.
    186) Scancarello G, Romeo R, & Sartorelli E: Respiratory disease as a result of talc inhalation. J Occup Environ Med 1996; 38:610-614.
    187) Sherman KE, Lewey SM, & Goodman ZD: Talc in the liver of patients with chronic hepatitis C infection. Am J Gastroenterol 1995; 90:2164-2166.
    188) Shlomi D, Shitrit D, Bendayan D, et al: Successful lung transplantation for talcosis secondary to intravenous abuse of oral drug. Int J Chron Obstruct Pulmon Dis 2008; 3(2):327-330.
    189) Sittig M: Handbook of Toxic and Hazardous Chemicals and Carcinogens, 3rd ed, Noyes Publications, Park Ridge, NJ, 1991.
    190) Smith RH, Graf MS, & Silverman JF: Successful management of drug-induced talc granulomatosis with corticosteroids. Chest 1978; 73:552-554.
    191) Sparrow SA & Hallam LA: Talc granulomas (letter). Brit Med J 1991; 303:58.
    192) Steele AA: Suicidal death by aspiration of talcum powder. Am J Forensic Med Pathol 1990; 11:316-318.
    193) Tse DT & Ober RR: Talc retinopathy. Am J Ophthamol 1980; 90:624-640.
    194) Tzonou A, Polychronopoulou A, & Hsieh CC: Hair dyes, analgesics, tranquilizers and perineal talc application as risk factors for ovarian cancer. Internat J Cancer 1993; 55:408-410.
    195) U.S. Department of Energy, Office of Emergency Management: Protective Action Criteria (PAC) with AEGLs, ERPGs, & TEELs: Rev. 26 for chemicals of concern. U.S. Department of Energy, Office of Emergency Management. Washington, DC. 2010. Available from URL: http://www.hss.doe.gov/HealthSafety/WSHP/Chem_Safety/teel.html. As accessed 2011-06-27.
    196) U.S. Department of Health and Human Services, Public Health Service, National Toxicology Project : 11th Report on Carcinogens. U.S. Department of Health and Human Services, Public Health Service, National Toxicology Program. Washington, DC. 2005. Available from URL: http://ntp.niehs.nih.gov/INDEXA5E1.HTM?objectid=32BA9724-F1F6-975E-7FCE50709CB4C932. As accessed 2011-06-27.
    197) U.S. Environmental Protection Agency: Discarded commercial chemical products, off-specification species, container residues, and spill residues thereof. Environmental Protection Agency's (EPA) Resource Conservation and Recovery Act (RCRA); List of hazardous substances and reportable quantities 2010b; 40CFR(261.33, e-f):77-.
    198) U.S. Environmental Protection Agency: Integrated Risk Information System (IRIS). U.S. Environmental Protection Agency. Washington, DC. 2011. Available from URL: http://cfpub.epa.gov/ncea/iris/index.cfm?fuseaction=iris.showSubstanceList&list_type=date. As accessed 2011-06-21.
    199) U.S. Environmental Protection Agency: List of Radionuclides. U.S. Environmental Protection Agency. Washington, DC. 2010a. Available from URL: http://www.gpo.gov/fdsys/pkg/CFR-2010-title40-vol27/pdf/CFR-2010-title40-vol27-sec302-4.pdf. As accessed 2011-06-17.
    200) U.S. Environmental Protection Agency: List of hazardous substances and reportable quantities. U.S. Environmental Protection Agency. Washington, DC. 2010. Available from URL: http://www.gpo.gov/fdsys/pkg/CFR-2010-title40-vol27/pdf/CFR-2010-title40-vol27-sec302-4.pdf. As accessed 2011-06-17.
    201) U.S. Environmental Protection Agency: The list of extremely hazardous substances and their threshold planning quantities (CAS Number Order). U.S. Environmental Protection Agency. Washington, DC. 2010c. Available from URL: http://www.gpo.gov/fdsys/pkg/CFR-2010-title40-vol27/pdf/CFR-2010-title40-vol27-part355.pdf. As accessed 2011-06-17.
    202) U.S. Occupational Safety and Health Administration: Part 1910 - Occupational safety and health standards (continued) Occupational Safety, and Health Administration's (OSHA) list of highly hazardous chemicals, toxics and reactives. Subpart Z - toxic and hazardous substances. CFR 2010 2010; Vol6(SEC1910):7-.
    203) U.S. Occupational Safety, and Health Administration (OSHA): Process safety management of highly hazardous chemicals. 29 CFR 2010 2010; 29(1910.119):348-.
    204) United States Environmental Protection Agency Office of Pollution Prevention and Toxics: Acute Exposure Guideline Levels (AEGLs) for Vinyl Acetate (Proposed). United States Environmental Protection Agency. Washington, DC. 2006. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d6af&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    205) Vallyathan NV & Craighead JE: Pulmonary pathology in workers exposed to nonasbestiform talc. Human Pathol 1981; 12:28-35.
    206) Wild P: Lung cancer risk and talc not containing asbestiform fibres: a review of the epidemiological evidence. Occup Environ Med 2006; 63(1):4-9.
    207) Wong C, Hempling RE, & Piver MS: Perineal talc exposure and subsequent epithelial ovarian cancer: a case-control study. Obstet Gynecol 1999; 93:372-376.