A 71-year-old man was admitted from a nursing home to the medical service with a one-week history of fever, deteriorating level of consciousness, and inability to take adequate fluid. Two months previously he had suffered a stroke and since that time had required nursing care due to inability to communicate anddifficulty swallowing. His medications at the nursing home included cimetidine (Tagamet), 300 mg daily, and multivitamins, one tablet daily.
On examination, he was a thin, pale, elderly gentleman who was completely unresponsive to command. His temperature was 39.2°C; blood pressure, 140/100 mm Hg; respirations, 26 per minute; and pulse rate, 120 beats per minute. Examination of the chest revealed a Cheyne-Stokes pattern of respiration and coarse wheezes in the left base. The patient was clinically dehydrated. Neurologic examination revealed a rightsided upper motor neiiron deficit. The hemoglobin value was 12.1 g/dl, and the leukocyte count was 11,300/ cu mm. Arterial blood gas levels on room air showed a pH of 7.52, Pco of 25 mm/Hg, and Poa of 66 mm Hg. Sputum and blood cultures failed to show any pathogenic organisms. A chest x-ray film was obtained (Fig 1) which showed scattered left perihilar densities.
Diagnosis: Aspiration of crushed cimetidine tablets
The initial chest x-ray film demonstrated scattered opacifications in the region of the left main stem bronchus which were of metallic density. A roentgenogram taken two months previously did not show these opacities (Fig 2). It was therefore surmised that they most likely represented aspirated material.
On further investigation, it was discovered that the nursing home had been crushing the patients medications to facilitate administration. Roentgenograms of cimetidine and the vitamin tablets supported the theory that a tablet component of the cimetidine could be radiopaque, resulting in a picture similar to calcification if the crushed tablet was aspirated.
Smith Kline and French Canada Limited supplied cimetidine (Tagamet) film coated tablets, tablet cores, placebo-coated tablets, and sample materials of all components of the cores for study. These were examined by x-ray and the cimetidine tablet, tablet core, placebo, and one of the sample materials were found to be radiopaque. Figure 3 shows the tablets and some of the components. Figure 4 illustrates the radiopacity of the tablets; the sample material which is radiopaque can be clearly distinguished from the other two sam-pies shown.
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The sample material in question was discovered to be cosmetic ochre, a synthetic, purified yellow iron oxide, used in combination with a blue dye to obtain the pale green color of the tablet. It is present in the core and the coating of cimetidine tablets. Since iron oxides are approved coloring agents, and are a safe alternative to dyes such as tartrazine, they are common ingredients in many colored tablets in Canada and the United States. Tartrazine (FD & C Yellow No. 5) is now widely recognized as a potential cause of asthmatic attacks in sensitive patients.
In this patient, the aspiration of tablet material was likely reponsible for the roentgenographic appearance of scattered opacities, due to the density of the yellow iron oxide used in tablet manufacturing. As the use of iron oxides in tablet formulation is widespread, aspiration of crushed medication should be considered if a similar chest roentgenogram is obtained in a patient experiencing difficulty swallowing.
Figure 3. lop row (left to right): cimetidine film coated tablet, placebo-coated tablet, cimetidine 300 mg tablet core, and crushed cimetidine 300 mg tablet. Bottom row (left to right): three of the samples of raw material components of the cores.
Figure 4. Roentgenogram of Figure 3. The sample material in the middle of the bottom row was identified as a yellow iron oxide.