Diffuse Lung Disease |

Inhaled Heroin as a Suspected Cause of Pulmonary Langerhans Cell Histiocytosis FREE TO VIEW

Steven Kim, MD; Amee Patrawalla, MD; Andrew Berman, MD
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Rutgers New Jersey Medical School, Newark, NJ

Chest. 2014;146(4_MeetingAbstracts):378A. doi:10.1378/chest.1959396
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SESSION TITLE: Interstitial Lung Disease Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Pulmonary Langerhans Cell Histiocytosis (PLCH) is a rare disease that has been strongly correlated with tobacco use. Here, we describe a case of PLCH in a patient without a smoking history, but with a significant history of heroin inhalation.

CASE PRESENTATION: The patient is a 49 year-old African-American non-smoking female with a medical history notable for frequent nasal heroin inhalation and recurrent submandibular sialoadenitis. The patient presented to the emergency department after waking up with sharp, right-sided pleuritic chest pain and shortness of breath. A large right-sided pneumothorax was seen on chest X-ray and a chest tube was placed with successful re-expansion of the lung. A CT scan of the chest showed severe, diffuse cystic lung disease most prominent in the lower lobes. The patient subsequently underwent pleurodesis and right upper lobe biopsy, which showed pulmonary eosinophilc granulomas with subpleural emphysematous bullae and positive CD1a and S-100 immunostains, supporting the diagnosis of PLCH.

DISCUSSION: PLCH is a rare disease of unknown etiology that almost always occurs in smokers. We propose that inhaled heroin may also lead to the development of PLCH. Inhaled heroin is known to cause airway inflammation. Acute asthma following heroin inhalation has been frequently described, with severe bronchospasm occurring in both asthmatics and non-asthmatics. In addition, several case reports have described eosinophilic pneumonia in association with inhaled heroin. It is conceivable then, especially since inhaled heroin is frequently mixed with other substances, that antigens from inhaled heroin can produce the peribronchial inflammatory changes of the small airways seen in patients with PLCH. This patient also presented with other unique characteristics. PLCH is uncommon in individuals of African descent, and pneumothorax as the presenting symptom is reported in only 10% to 15% of patients. Finally, our patient had lower lobe predominant disease, rather than classic upper lobe predominance. Nonetheless, this case of diffuse cystic lung disease with positive CD1a and S-100 staining is consistent with PLCH.

CONCLUSIONS: Although tobacco smoke inhalation is most frequently cited as the instigating factor in the development of PLCH, other etiologies must also be considered.

Reference #1: Vassallo R, Ryu JH. Pulmonary Langerhans’ cell histiocytosis. Clin Chest Med 25 (2004) 561-571.

DISCLOSURE: The following authors have nothing to disclose: Steven Kim, Amee Patrawalla, Andrew Berman

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