Heroin Pulmonary Edema

Abstract

To the Editor: In the August, 1972 Clinical Pathologic Conference concerning heroin pulmonary edema, the statement is made … “since heroin induced pulmonary edema occurs only when there has been an overdose, hypersensitivity to heroin is an unlikely explanation for the cause of this syndrome.” Although overdose is the generally accepted initiating factor for many cases of heroin pulmonary edema, not all cases can be explained on this basis. Helpern writes … “in some acute fatal cases, the rapidity and type of reaction do not suggest simple overdosage, but rather an overwhelming shock-like reaction due to hypersensitivity to the injected material. The toxicologic examination of the tissues in such fatalities … demonstrated only the presence of the alkaloid and not overdosage.” Also, “unexpected acute deaths may occur in some addicts who inject themselves with heroin mixtures even though others who take the same usual aliquot dose from the same sample at the same time may suffer no dangerous effect.”1Helpern M Yong-Myun R Deaths from narcotism in New York City.Incidence, circumstance and postmortem findings. NY J Med. 1966; (Sept 16): 2391-2408Google Scholar, 2Helpern M Fatalities from narcotic addiction in New York City.Incidence, circumstances and pathologic findings. 1972; (Human Path 3: March)Google Scholar Fulton3Cherubin CE The medical sequelae of narcotic addiction.Ann Intern Med. 1967; 67 (July)Crossref PubMed Scopus (168) Google Scholar, 4Fulton CG An analytical study of confiscated samples of narcotic drugs.Int Microfilm J Legal Med (Fall). 1965; 1Google Scholar found small amounts of narcotic in samples of seized heroin (0-5 percent) which presumably caused the acute reaction, thus arguing against overdosage in those instances. Thus, there may not be a direct correlation between the severity of the end results and the amount of heroin taken, as there is with overdosage of morphine and other alkaloids. As noted in the article, pulmonary edema is almost universally found at autopsy in patients with heroin overdose, or what Helpern calls “acute reaction” to heroin, and it seems likely that the same mechanisms may operate for the clinical syndrome of “heroin pulmonary edema.” There are currently studies in progress here to clarify whether some cases of heroin pulmonary edema at least, may be due to a hypersensitivity-like reaction, or some other mechanism not involving simple overdose.