Smoking of crack cocaine has been associated with a broad spectrum of pulmonary manifestations. We report a case of diffuse alveolar hemorrhage, a rare and potentially life threatening complication of cocaine smoking.
A 49-year-old woman presented to our ER with 1 week-history of cough, dyspnea and hemoptysis. On the day of admission she had expectorated about 500cc of bright red blood. Her medical history was significant for hypertension. On examination she was tachypneic with a room air saturation of 85%. She had diffuse crackles. The chest-X-ray showed bilateral alveolar infiltrates. She was admitted to the ICU where an urgent bronchoscopy revealed diffuse alveolar hemorrhage. Angiography of the bronchial arteries showed no local lesions and chest CT showed no masses. Toxicology screen was positive for cocaine and later she was found to have crack cocaine in her possession. Blood and respiratory cultures were negative. Initial treatment consisted mainly of supportive therapy with oxygen supplementation and fluids. By the second day the bleeding had resolved spontaneously and she was sent to the medicine floor.DISCUSSION: Cocaine use has been related to a number of pulmonary complications from asymptomatic decreased diffusing capacity to acute lung injury with respiratory failure. Although 6% to 27% of cocaine users report having episodes of blood-streaked sputum, few cases of massive hemoptysis or life threatening alveolar hemorrhage have been reported. Possible mechanisms include direct toxic epithelial cell damage, vasoconstriction of the pulmonary circulation, cocaine-induced clotting abnormalities resulting in thromboembolism, and cocaine-related pulmonary hypertension. Previously, a beneficial effect of steroids has been suggested, however, no control trials have been published. Neither steroids nor other anti-inflammatory therapies were used in this patient, who improved with supportive care only.CONCLUSSION: Diffuse alveolar hemorrhage is a serious complication of crack cocaine smoking. Its frequency is likely underreported. The value of adding steroids to the standard supportive treatment is not known.
J.E. Morales, None.