A CASE OF STIMULANT DESIGNER DRUG-INDUCED SARCOIDOSIS

Abstract

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Sarcoidosis, a well-recognized cause of systemic granulomatous disease, has both infectious and non-infectious etiologies. Current literature suggests industrial dust exposure can lead to granulomatous disease, particularly involving the lung. However, there is currently no report of systemic granulomatous disease caused by stimulant designer drugs, such as 4-methylcathinone (4-MEC), which have become a growing public health concern in recent years. We present a patient diagnosed with granulomatous liver disease resembling sarcoid, following exposure to 4-MEC. CASE PRESENTATION: A 30-year-old man of Peruvian descent with a history of intravenous 4-MEC use, presented with 5 months of sweats and 25-pound weight loss. He denied recent travel or occupational exposures. Physical exam revealed massive hepatosplenomegaly. Initial workup was significant for elevated liver-specific alkaline phosphatase. Imaging showed diffuse abdominal lymphadenopathy. Extensive workup was negative for infections, hematologic malignancies and autoimmune diseases. Liver biopsy revealed non-caseating granulomas and refractile material. The diagnosis of a sarcoid-like reaction to particulate matter from 4-MEC injection was made. DISCUSSION: The etiology of sarcoidosis is unclear, making it a diagnosis of exclusion. It is therefore important to have a broad differential diagnosis, ruling out the presence of infectious agents such as mycobacteria, fungi and parasites, environmental and occupational exposures such as beryllium, organic antigens, autoimmune diseases and various medications, all of which can cause a granulomatous response. Our patient’s only significant exposure was to 4-MEC, a synthetic derivative of the pharmacologically active alkaloid, cathinone, which is a stimulant similar to 3,4-Methylenedioxymethamphetamine (MDMA). In sarcoidosis, elevated alkaline phosphatase is a more common laboratory abnormality than elevated transaminases. This combined with the absence of liver lesions should prompt a workup for a systemic disease process. Non-caseating granulomas are the hallmark histologic feature of sarcoidosis. Possible pathophysiologic explanations for sarcoid-like reactions include: the formation of non-caseating granulomas with secretion of lysozyme, collagenase and angiotensin-converting enzyme (ACE) in response to foreign particles of 4-MEC; or rapid influx of neutrophils around the foreign body resulting in macrophage activation, similar to talc granulomatosis. CONCLUSIONS: The etiology of sarcoidosis remains an enigma. Our case highlights the disease pathophysiology, emphasizes the importance of maintaining a broad differential diagnosis, and encourages consideration of other factors such as stimulant designer drugs in the etiology of non-caseating granulomatous disease. Reference #1: Dubaniewicz A. [The diagnostic algorithm of practice in pulmonary and extrapulmonary sarcoidosis]. Pol Merkur Lekarski. 2018 Mar 27;44(261):101-109. Review. Polish. PubMed PMID: 29601557. Reference #2: Pereiro T, Golpe A, Lourido T, Valdés L. Extrapulmonary Tumors and Sarcoidosis. An Incidental or Real association? Arch Bronconeumol. 2018 Oct;54(10):531-533. https://doi.org/10.1016/j.arbres.2018.01.036. Epub 2018 Mar 6. English, Spanish. PubMed PMID: 29523377. Reference #3: Chopra A, Nautiyal A, Kalkanis A, Judson MA. Drug-Induced Sarcoidosis-Like Reactions. Chest. 2018 Sep;154(3):664-677. https://doi.org/10.1016/j.chest.2018.03.056. Epub 2018 Apr 24. Review. PubMed PMID: 29698718 DISCLOSURES: No relevant relationships by Thomas Botta, source=Web Response No relevant relationships by Ishwar Giri, source=Web Response No relevant relationships by Viren Kaul, source=Web Response No relevant relationships by Jishu Motta, source=Web Response No relevant relationships by Rahila Ogunnaike, source=Web Response No relevant relationships by Lauren Pischel, source=Web Response No relevant relationships by Rutvik Shah, source=Web Response No relevant relationships by Sophia Shimer, source=Web Response