RECURRENT ARDS IN THE SETTING OF POLYSUBSTANCE ABUSE

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Drug abuse remains a significant social problem in many countries. Adverse pulmonary complications of substance abuse are well documented, including diffuse alveolar haemorrhage, aspiration pneumonitis, and opportunistic infections related to HIV and hepatitis. Acute lung injury and acute respiratory distress syndrome are well known complications of narcotic overdose, but ARDS from drug use without overdose is a much rarer entity. [1] CASE PRESENTATION: We report a case of a 39 year old female, current 10 pack-year smoker, with a history of polysubstance abuse including heroin, cocaine and alcohol, who was admitted 5 times in 8 months with recurrent episodes of dyspnea, fever, myalgias and fatigue. Each time she presented with hypoxic respiratory failure and bilateral infiltrates on chest imaging, and required high flow oxygen and BIPAP. She was treated with IV antibiotics, steroids and diuresis with good response. An extensive workup was performed including negative cultures, negative connective tissue disease serologies, and negative HIV testing. Echocardiogram showed a normal ejection fraction and negative bubble study. CT scan during the first hospitalization showed diffuse bilateral ground-glass opacities with bilateral lower lobe predominance and subpleural sparing without bronchiectasis or subpleural honeycombing. Outpatient PFTs showed only a moderately decreased diffusing capacity; methacholine challenge test showed mild bronchial hyperresponsiveness. Patient underwent bronchoscopy during one hospitalization that showed grossly normal airways, neutrophil predominant BAL and no eosinophilia; endobronchial biopsy showed atypical bronchial epithelium favoring reactive process. Surgical lung biopsy revealed rare intracapillary granulomas with exogenous polarizable material – microcrystalline cellulose consistent with IV drug injection. DISCUSSION: Pulmonary foreign body granulomatosis is described in patients who inject oral drugs intravenously. [2-3]. This would not account for the fulminant respiratory failure with ARDS in this patient. A case series of 6 patients using narcotics, gabapentin, and other psychoactive drugs, with presentation similar to our patient, with recurrent ARDS and diffuse alveolar damage on lung biopsy, has been reported [4]. DAD was not identified on this patient’s surgical lung biopsy, perhaps because the patient was biopsied in between recurrences. Management of this condition is unclear with some reports indicating a potential benefit from systemic glucocorticoids [5]. Some patients with recurrent ARDS progress to worsening fibrosis and may eventually need lung transplant. Our patient has been managed with recurrent prolonged prednisone taper, but further treatment is complicated by her social issues and medication noncompliance. CONCLUSIONS: DAD is pathologic manifestation of severe acute lung injury, recurrence can be attributed to polysubstance abuse. Reference #1: [1] Benson MK, Bentley AM. Lung disease induced by drug addiction. Thorax. 1995; 50(11): 1125–1127. Reference #2: [2]Bishay A, Amchentsev A, Saleh A, Patel N, Travis W, Raoof S. A hitherto unreported pulmonary complication in an IV heroin user. Chest 2008;133(2)549-51. Reference #3: [3] Radow SK, Nachamkin I, Morrow C, et al. Foreign body granulomatosis. Clinical and immunologic findings. Am Rev Respir Dis 1983;127:575. [4] Savici D, Katzenstein A-LA. Diffuse alveolar damage and recurrent respiratory failure: report of 6 cases. Human Pathology 2001;32(12):1398-402. [5] Chau CH, Yew WW, Lee J. Inhaled budesonide in the treatment of talc-induced pulmonary granulomatosis. Respiration. 2003;70(4):439. DISCLOSURES: No relevant relationships by Moayad Al Sona, source=Web Response No relevant relationships by Sandrine Hanna, source=Web Response No relevant relationships by Margaret Zambon, source=Web Response