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A Hitherto Unreported Pulmonary Complication in an IV Heroin User* FREE TO VIEW

Ayman Bishay, MD; Alexey Amchentsev, MD; Anthony Saleh, MD, FCCP; Neelam Patel, MD; William Travis, MD, FCCP; Suhail Raoof, MD, FCCP
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*From the Department of Internal Medicine (Drs. Bishay, Amchentsev, Saleh, Patel, and Raoof), Division of Pulmonary and Critical Care Medicine, New York Methodist Hospital, New York, NY; and the Department of Pathology (Dr. Travis), Memorial Sloan Kettering Cancer Center, New York, NY.

Correspondence to: Ayman Bishay, MD, New York Methodist Hospital, Internal Medicine/Division of Pulmonary and Critical Care, 506 6th St, Brooklyn, NY 11215; e-mail: aymanbishay@yahoo.com



Chest. 2008;133(2):549-551. doi:10.1378/chest.07-0805
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IV heroin use is associated with several well-described complications, including noncardiogenic pulmonary edema, aspiration pneumonitis, ARDS, pneumonia, lung abscess, septic pulmonary emboli, and atelectasis. Foreign-body granulomatosis may develop when drug users inject solutions containing crushed oral tablets in which talc is used as filler and can be complicated by pulmonary fibrosis. The effects are distinct from pulmonary edema, which may occur acutely with heroin injection. We describe the case of a young female patient who was an IV heroin user who also smoked cigarettes, and presented with progressive dyspnea, hypoxia, and bilateral lung infiltrates. The final pathologic diagnosis in this case was one that had not been previously reported in IV heroin users.

Figures in this Article

We describe a case of an IV heroin user with progressive dyspnea, hypoxia, and bilateral lung infiltrates. Surprisingly, the final pathologic diagnosis in this case was one that has not been previously reported in IV heroin users.12

A 24-year-old female patient presented with nonproductive cough and progressive shortness of breath for 5 months with significant worsening in the last 2 weeks. She also had night sweats, nausea, and headache. The patient had been an active IV heroin user for the last 7 years and has a smoking history of 8 pack-years.

Her medical history was significant for depression and cardiac arrest in 2001 secondary to an illicit drug overdose. Her medications included fluoxetine, 80 mg daily, trazodone, 100 mg daily, and methadone, 30 mg daily.

A physical examination demonstrated a cachectic young white female in moderate respiratory distress who was normotensive and afebrile. Her arterial oxygen saturation at rest while breathing room air was 88%. She had a few scattered crackles, which were prominent at the lung bases. Laboratory results were significant for a total bilirubin concentration of 2.8 mg/dL, an aspartate aminotransferase concentration of 171 IU/L, an alanine aminotransferase concentration of 155 IU/L, and an alkaline phosphatase concentration of 2,000 IU/L. Arterial blood gas measurements, obtained with the patient breathing room air, were as follows: pH, 7.44; Paco2, 44 mm Hg; and Pao2, 52 mm Hg. The chest radiograph on day 1 showed diffuse bibasilar reticular infiltrates (Fig 1 ).

The patient was admitted to the hospital and was started on therapy with antibiotics, trimethoprim-sulfamethoxazole, and steroids. She continued to be uncooperative, frequently refusing treatment. A CT scan of the chest on day 4 demonstrated diffuse infiltrates with areas of ground-glass opacities more pronounced in the lower lobes (Fig 2, 3 ).

On day 5, the patient’s respiratory status deteriorated, requiring ICU care. At that time, her oxygen saturation was 89 to 93% while using a nonrebreather mask. The patient underwent bronchoscopy with BAL; the BAL fluid sample test was negative for acid-fast bacilli, fungi, and Pneumocystis jiroveci (carinii) pneumonia. Liver function test results improved, and the HIV test result came back negative. P jiroveci (carinii) pneumonia treatment was discontinued. An open-lung biopsy was performed on day 12, and the pathology showed patchy, temporally homogeneous, interstitial pneumonia with lymphocytic infiltration, intraluminal fibroblastic proliferation consistent with organizing pneumonia (OP), and scattered nonnecrotizing granulomata (Fig 4 ). It also showed rare multinucleated giant cells with foreign-body particles within the giant cells. The patient improved and was discharged from the hospital. A follow-up CT scan showed marked radiologic improvement.

The unique aspect of this case is the likely association of bronchiolitis obliterans OP (BOOP) with IV heroin administration. Postinfectious BOOP may have been a possibility; however, there was no evidence of infection. In addition, none of the medications that the patient was taking are known to cause BOOP.23 We hypothesized that BOOP was the result of a lung injury caused by chemical substances, such as talc or other fillers, with granuloma formation.

We suspect that these granulomas were part of an immunologic response rather than the typical foreign-body reaction seen in some IV drug users. Alternatively, other possible explanations could be a heroin-induced lung injury or idiopathic BOOP. Our patient was still using IV heroin in the hospital, and gradual improvement was noted only after the patient was taken into custody and heroin use was discontinued, which implies the association of her illness with IV heroin use. It was also observed that this improvement was seen even without steroid therapy, which is not unusual in patients with BOOP.

This case demonstrates abnormalities in lung function and histology that are related to long-term IV heroin use and OP with noncaseating granulomas.14 We had difficulty identifying the superimposed acute event. We considered noncardiogenic pulmonary edema and ARDS as a cause, since there has been a case report5 of ARDS with pulmonary granulomatosis after IV injection of heroin. Other causes of acute respiratory failure were also considered in our differential diagnosis. We did not think specifically about BOOP prior to lung biopsy because it has not been reported in association with IV heroin use.

Taken together, the clinical and biopathologic data in this case suggest that the histologic findings of BOOP with granulomas reflect the response to an initial injury by chemicals used as fillers that caused pulmonary inflammation. This process progressed to produce the characteristic buds of intraalveolar granulation tissue that are associated with fibroblasts and connective matrix.

BOOP has not been described with noncaseating granulomata in IV heroin users prior to this report. The diagnosis of BOOP should be considered in this group of patients.

Abbreviations: BOOP = bronchiolitis obliterans organizing pneumonia; OP = organizing pneumonia

The authors have reported to the ACCP that no significant conflict of interests exist with any companies/organizations whose products or services may be discussed in this article.

Figure Jump LinkFigure 1. Diffuse bilateral reticular infiltrates.Grahic Jump Location
Figure Jump LinkFigure 2. Diffuse infiltrates with areas of ground-glass opacities.Grahic Jump Location
Figure Jump LinkFigure 3. Diffuse infiltrates with areas of ground-glass opacities.Grahic Jump Location
Figure Jump LinkFigure 4. Left: interstitial pneumonia with lymphocytic infiltration associated with intraluminal proliferation. Right: scattered nonnecrotizing granulomas.Grahic Jump Location
Passarino, G, Ciccone, G, Siragusa, R, et al (2005) Histopathological findings in 851 autopsies of drug addicts, with toxicologic and virologic correlations.Am J Forensic Med Pathol26,106-116. [PubMed]
 
Camus, P, Bonniaud, P, Fanton, A, et al Drug-induced and iatrogenic infiltrative lung disease.Clin Chest Med2004;25,479-519. [PubMed] [CrossRef]
 
Epler, GR Bronchiolitis obliterans organizing pneumonia.Arch Intern Med2001;161,158-164. [PubMed]
 
Arnett, EN, Battle, WE, Russo, JV, et al Intravenous injection of talc-containing drugs intended for oral use: a cause of pulmonary granulomatosis and pulmonary hypertension.Am J Med1976;60,711-718. [PubMed]
 
Wong, LC, Chang, H, Su, JM, et al Pulmonary granulomatosis associated with insoluble fillers in a heroin addict.J Formos Med Assoc2003;102,198-201. [PubMed]
 

Figures

Figure Jump LinkFigure 1. Diffuse bilateral reticular infiltrates.Grahic Jump Location
Figure Jump LinkFigure 2. Diffuse infiltrates with areas of ground-glass opacities.Grahic Jump Location
Figure Jump LinkFigure 3. Diffuse infiltrates with areas of ground-glass opacities.Grahic Jump Location
Figure Jump LinkFigure 4. Left: interstitial pneumonia with lymphocytic infiltration associated with intraluminal proliferation. Right: scattered nonnecrotizing granulomas.Grahic Jump Location

Tables

References

Passarino, G, Ciccone, G, Siragusa, R, et al (2005) Histopathological findings in 851 autopsies of drug addicts, with toxicologic and virologic correlations.Am J Forensic Med Pathol26,106-116. [PubMed]
 
Camus, P, Bonniaud, P, Fanton, A, et al Drug-induced and iatrogenic infiltrative lung disease.Clin Chest Med2004;25,479-519. [PubMed] [CrossRef]
 
Epler, GR Bronchiolitis obliterans organizing pneumonia.Arch Intern Med2001;161,158-164. [PubMed]
 
Arnett, EN, Battle, WE, Russo, JV, et al Intravenous injection of talc-containing drugs intended for oral use: a cause of pulmonary granulomatosis and pulmonary hypertension.Am J Med1976;60,711-718. [PubMed]
 
Wong, LC, Chang, H, Su, JM, et al Pulmonary granulomatosis associated with insoluble fillers in a heroin addict.J Formos Med Assoc2003;102,198-201. [PubMed]
 
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