A CRACK LUNG WITH CRACK COCAINE

Abstract

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Crack lung is an acute pulmonary syndrome with a spectrum of clinical and histopathologic findings occurring within 48 hours of smoking crack cocaine.1 Patients may present with clinical features of pneumonia. As such, it is important to differentiate the two clinical entities as the management approach differs. Here we present a case of acute pulmonary cocaine toxicity mimicking possible pneumonia. CASE PRESENTATION: A 40 year old man with a history of depression was brought in by paramedics after being found unconscious.He was given naloxone en route with improved consciousness but was tachypneic and hypoxic, requiring oxygen. On arrival to the Emergency Department, he admitted to having smoked crack cocaine which was impure.He reported having hemoptysis and rhinorrhea but denied any chest pain, fever or any gastrointestinal symptoms.There was no personal or family history of lung or autoimmune disease. On presentation he was afebrile, tachycardic, tachypneic and persistently hypoxic requiring high flow nasal cannula (HFNC). Pertinent findings were diminished breath sounds with diffuse rales, with an otherwise unremarkable exam. Laboratory results were notable for cocaine on urine toxicology, leukocytosis with neutrophilia, elevated procalcitonin with normal CRP, BNP, serial troponins, lactic acid, COVID-19 test and HIV. Initial CXR showed bilateral extensive nodular interstitial lung pattern. He was admitted for acute hypoxic respiratory failure (AHRF) secondary to crack lung syndrome with superimposed pneumonia on HFNC and started on empiric antibiotics as well as methylprednisolone. Unfortunately, he remained persistently tachypneic and required non-invasive ventilation (NIV) and transfer to the intensive care unit. On day 2, his respiratory status markedly improved and he was weaned from NIV to room air. Final blood cultures and mycoplasma antibody were negative and the rest of his hospital stay was uneventful. DISCUSSION: In 2018, approximately 5.5 million persons aged ≥ 12 years reported cocaine use within the past year of which 757,000 used crack cocaine.2,3 With likely underreported usage, the deleterious pulmonary complications related to cocaine use including pulmonary edema, alveolar hemorrhage, eosinophilic pneumonia, pneumothorax, thromboembolic disease and AHRF,4 are clinically relevant. However, the diagnosis of cocaine-induced pulmonary diseases remains challenging for clinicians given that the clinical features and chest images are non specific and can mimic several other processes e.g. pneumonia.5 This distinction is important as mortality for pneumonia requiring ICU admission approaches 30%,6 while acute eosinophilic pneumonia portends an excellent prognosis with rapid clinical recovery. CONCLUSIONS: This case highlights that "Crack Lung" should be considered as a differential diagnosis in patients with AHRF and diffuse bilateral pulmonary infiltrates. REFERENCE #1: Forrester, J. M., Steele, A. W., Waldron, J. A., & Parsons, P. E. (1990). Crack lung: an acute pulmonary syndrome with a spectrum of clinical and histopathologic findings. The American review of respiratory disease, 142(2), 462–467. https://doi.org/10.1164/ajrccm/142.2.462 REFERENCE #2: National Institute on Drug Abuse.(2020) What is the scope of cocaine use in the United States? Available from:https://www.drugabuse.gov/publications/research-reports/cocaine/what-scope-cocaine-use-in-united-states REFERENCE #3: 3.Center for Disease Control and Prevention. (2019). Annual surveillance report of drug-related risks and outcome. Available from:https://www.cdc.gov/drugoverdose/pdf/pubs/2019-cdc-drug-surveillance-report.pdf DISCLOSURES: No relevant relationships by Sahai Donaldson, source=Web Response No relevant relationships by Lorenzo Leys, source=Web Response No relevant relationships by Alicia Thomas, source=Web Response No relevant relationships by Felix Wireko, source=Web Response