*From the Denver Health Medical Center University of Colorado Health Sciences Center, Denver, CO.
Correspondence to: Richard K. Albert, MD, FCCP, Denver Health Medical Center, 777 Bannock, MC 4000, Denver, CO 80204-4507;
Bilateral thumb burns on a young woman admitted to the hospital
with the diagnosis of community-acquired pneumonia led us to consider
the diagnosis of crack lung despite the fact that the woman denied
cocaine use. Cocaine was found on a urine toxicology study, and its use
was subsequently confirmed by history. The patient was treated for
crack lung with complete resolution of her symptoms and radiographic
findings. Inspection of the hands for burns consistent with handling
cocaine pipes should prompt a consideration of crack lung in patients
with pulmonary infiltrates.
use has increased markedly over the last 15 years, and cocaine-related
mortality has been estimated to account for 5 of every 1,000
deaths.1 We recently encountered a patient who presented
with acute respiratory failure but denied illicit drug use. An unusual
physical finding led to the suspicion of crack lung. The diagnosis was
confirmed by urine toxicology studies and by subsequent history.
A 29-year-old woman presented to the emergency department with
the acute onset of dyspnea and chest pain accompanied by a productive
cough. She had a 29-pack-year history of tobacco use and a
recent episode of acute bronchitis that had been treated with
antibiotics. She denied fever, chills, hemoptysis, and illicit drug
use. Her only current medications were conjugated estrogens and
The patient was thin, pale, and diaphoretic, and was in moderate
respiratory distress. Her temperature was 38°C, heart rate was 136
beats/min, respiratory rate was 22 breaths/min, and BP was 126/36 mm
Hg. Coarse breath sounds were heard in the lower lobes bilaterally,
along with fine crackles. Blistering lesions with black discolorations
were found on both thumbs (Fig 1
Laboratory study findings were normal, with the exception of a WBC
count of 18,900/μL; hematocrit, 35%; lactate dehydrogenase, 450 U/L.
Room air arterial blood gas measurements were as follows: pH, 7.41;
Paco2, 38 mm Hg; and
Pao2, 47 mm Hg. Her chest radiograph
showed diffuse alveolar opacities (Fig 2
The skin findings were thought to represent thermal burns from lighting
a crack cocaine pipe with a butane lighter directed downward onto the
pipe. Urine toxicology study findings were positive for cocaine; on
further questioning, the patient admitted to smoking large quantities
of free-base cocaine only a few hours before the onset of her symptoms,
and repeatedly burning her thumbs with the lighter. She was
administered IV methylprednisolone, inhaled bronchodilators, and
oxygen, resulting in complete clearing of her symptoms and radiographic
abnormalities within 72 h.
Free-base cocaine is prepared from baking soda and cocaine
hydrochloride. The combination is boiled, cooled, and extracted with
ether. The solvent is then evaporated leaving a heat-stable,
crystalline precipitant called crack (after the popping
sound made by the burning crystals). Crack is typically smoked through
a glass or brass pipe using a butane torch and can cause numerous
pulmonary toxicities (Table 1
In the proper setting, finding thermal injury on the fingertips should
suggest crack cocaine use. Because establishing a diagnosis of crack
lung has important diagnostic and therapeutic implications, this
physical finding should prompt physicians to obtain appropriate
laboratory studies and seek a more directed history.
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