SESSION TITLE: Critical Care Case Report Posters
SESSION TYPE: Case Report Poster
PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM
INTRODUCTION: Fever, hypoxia and diffuse pulmonary infiltrates are almost always considered an infectious process. However in an acute presentation, with no identifiable organism or etiology, suspicion for cocaine-induced pulmonary syndrome (crack lung) should be considered.
CASE PRESENTATION: A 28 year-old-male, diagnosed with HIV one year back, without follow-up nor treatment, presented with respiratory distress. He was seen earlier by his wife coughing excessively. He then developed mild hemoptysis and progressive dyspnea. EMS came and found him hypoxic (76% oxygen saturations on room air), improved with 100% oxygen supplementation. He was brought to the ED where he was normotensive, tachycardic, tachypneic (RR 40) and febrile (101F). His CXR showed diffuse patchy densities bilaterally concerning for ARDS. His p/f ratio was 61. Work-up showed WBC 2,700/mm3, hemoglobin 17g/dl, and platelets of 190,000/mm3. Metabolic panel was unremarkable. Toxicology screen was positive for cannabinoid and cocaine. He received vancomycin, piperacillin/tazobactam and azithromycin while noninvasive positive pressure ventilation was initiated. He deteriorated and was intubated and transferred to ICU. Empiric therapy for PCP was started. Bronchoscopy revealed scant secretions and was visually unremarkable. Lavage samples did not yield any organism, while fever work-up was unrevealing. He improved remarkably and was extubated. He admitted to recent crack abuse. CXR showed dramatic improvement in three days, now considered normal. He was transferred to the floors after four ICU days. He eloped from the hospital the next day.
DISCUSSION: Since the combustion products of crack cocaine mainly affect the lungs and airways, most crack abusers present with respiratory complaints. Cough, sputum production, wheezing and dyspnea are common symptoms. Most will have an abnormal CXR, often with diffuse patchy bilateral alveolar infiltrates. Treatment is supportive and patients often improve within 24 hours of presentation.
CONCLUSIONS: Fever, hypoxemia and diffuse pulmonary infiltrates may be manifestations of crack lung, and should be among the differentials, especially in the presence of a temporal relationship between cocaine use, onset of symptoms and CXR findings.
Reference #1: Restrepo et al. RadioGraphics 2007; 27:941-956.
Reference #2: Hui P et al. Patient With Fever, Hypoxemia, and Pulmonary Consolidations. CHEST 2012; 142( 5 ): 1348 - 1351.
Reference #3: Haim DY et al. The Pulmonary Complications of Crack Cocaine : A Comprehensive Review. Chest.1995;107(1):233-240.
DISCLOSURE: The following authors have nothing to disclose: Ma. Theresa Bautista, Ramakant sharma, Ernest DiNino
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