UNILATERAL CRYSTAL METHAMPHETAMINE LUNG

Abstract

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Methamphetamine is a drug manufactured from ephedrine and pseudoephedrine mixed with ingredients such as ammonia, lithium, iodine, and phosphorous but adulterants such as alcohol, acetone, and energy drinks have also been used. Smoking is the most common form of abuse with complications such as eosinophilic pneumonia, alveolar hemorrhage, acute interstitial pneumonia, and pulmonary fibrosis. We present an atypical methamphetamine-induced lung injury. CASE PRESENTATION: A 57-year-old female with a 40-pack year smoking history and polysubstance abuse presented with acute onset shortness of breath. On admission, she was hypoxic requiring 25 liters of high flow oxygen. On examination, the patient was afebrile with normal blood pressure. Chest auscultation revealed wheezing, most prominent in the left lung fields, while the rest of the systemic examination was unremarkable. Laboratories showed leukocytosis, normal liver, and renal function test. Sputum culture had no bacterial growth and Covid-19 PCR negative. Urine toxicology was positive for methamphetamine. Contrast CT chest showed diffuse interstitial thickening and ground-glass opacities throughout the right lung but normal left lung parenchyma with narrowing of the distal left mainstem bronchus by an endobronchial mass. The patient's hypoxemia improved with Methylprednisolone. Bronchoscopy showed a left mainstem lesion with near-complete obstruction of the left upper and lower lobes with biopsy revealing squamous cell carcinoma. There was normal airway mucosa on the right lung segments and scant inflammation without malignant cells on biopsy. The patient underwent successful tumor debulking with follow-up PET CT demonstrating decreased but persistence of alveolar septal thickening on the right lung with FDG positive mediastinal lymph nodes. The patient was weaned off supplemental oxygen 4 weeks later. DISCUSSION: Diagnosis of Methamphetamine-induced lung injury depends on the history of recent use, ground-glass opacities on imaging, and exclusion of other infections which was fulfilled by our patient but with the question of left lung sparing. Crystalline particles range in size from less than 250 nm-10 μm, with clusters as large as 80 μm where the obstructing mass may have prevented the flow of the drug vapor. Methamphetamine has also been postulated to release early response cytokines including TNF-alpha and IL-6 leading to recruitment of neutrophils and free radicals release causing acute lung injury. The management is mainly supportive with empiric steroids with improvement via impeding this inflammatory cascade. CONCLUSIONS: Our case demonstrates multiple learning points including particle size factor in passage through an obstructed airway, response to steroids supporting in settings of acute inflammation, and the persistence of residual lung disease on imaging in contrast to clinical improvement 4 weeks post-exposure. REFERENCE #1: Javed A, Nasrullah A, Malik K (February 08, 2021) A Rare Case of Methamphetamine-Induced Lung Injury During the Ongoing COVID-19 Pandemic. Cureus 13(2): e13215. doi:10.7759/cureus.13215 REFERENCE #2: Kinner SA, Degenhardt L. Crystal methamphetamine smoking among regular ecstasy users in Australia: increases in use and associations with harm. Drug Alcohol Rev. 2008 May;27(3):292-300. doi: 10.1080/09595230801919452. PMID: 18368611. REFERENCE #3: Lin SS, Chen YC, Chang YL, Yeh DY, Lin CC. Crystal amphetamine smoking-induced acute eosinophilic pneumonia and diffuse alveolar damage: a case report and literature review. Chin J Physiol. 2014 Oct 31;57(5):295-8. doi: 10.4077/CJP.2014.BAC201. PMID: 25241990. DISCLOSURES: No relevant relationships by Uchit Thapa, source=Web Response