SESSION TITLE: Miscellaneous Student/Resident Case Report Posters II
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Cocaine use is widespread in the United States, with 5 to 8 million current abusers. The principal method of intoxication is smoked cocaine, often referred to as “crack”. It is the most commonly used illicit drug among patients seen in the emergency department, and the most frequent cause of drug-related deaths. Pulmonary sequelae include respiratory symptoms, such as persistent cough, wheeze, dyspnea and hemoptysis, deterioration in lung function, and pulmonary infiltrates or interstitial pneumonitis. We present a case of an inhaled cocaine abuser who developed respiratory compromise thought initially to be secondary to miliary mycobacterium tuberculosis based on initial work up and imaging, but was later discovered to have a grossly black lung as a result of deposition of carbonaceous material from the inhaled drug. Such findings are usually isolated to those with coal-worker pneumoconiosis.
CASE PRESENTATION: A 52 year-old black female crack addict presented with a 4-month history of dyspnea. She denied other respiratory and constitutional symptoms. She was in moderate respiratory distress with oxygen saturation of 92% on 3 L supplemental oxygen. Exam was significant for diffuse rales on auscultation, but was otherwise unremarkable. Chest x-ray and subsequent CT scan revealed a military nodular pattern. A diagnosis of TB was entertained and bronchoscopy was performed when induced sputum failed to reveal any acid-fast bacilli (AFB). The tracheobronchial tree was grossly unremarkable, but black fluid was obtained on bronchoalveolar lavage (Figure 1). Cytology revealed numerous alveolar macrophages with pigmented granules that stained negative with hemosiderin. However, neither bronchoscopy nor a bone marrow aspirate performed subsequently revealed evidence of AFB. Video-assisted thoracic surgery was performed and the entire surface of the lung was found to be black (Figure 2). On subsequent questioning, she denied exposure to coal, woodsmoke or being in a fire.
DISCUSSION: This case highlights a unique pulmonary presentation of crack cocaine abuse. The rate of adverse respiratory effects secondary to cocaine has paralleled the increased trend of smoking the drug. Cocaine abusers may typically develop pulmonary infiltrates, but it's rare to present with a diffuse, miliary infiltrative pattern, which is more common with MTB, sarcoidosis or pneumoconiosis. Furthermore, such widespread deposition of particulate matter is more often observed in those with chronic exposure to coal dust.
CONCLUSIONS: Though the impact of inhaled cocaine may be under-estimated, this report emphasizes the need to expand the differential beyond infectious etiologies when a patient presents with a miliary infiltrative pattern on imaging in the setting of cocaine abuse, especially when BAL return yields black fluid.
Reference #1: Janxes R. Klingen; Eric Bensadoun M. Pulmonary complications from alveolar accumulation of carbonaceous material in a cocaine smoker. Chest. 1992;101(4)
DISCLOSURE: The following authors have nothing to disclose: Bashar Mourad, Hammad Bhatti, James Cury, Adil Shujaat
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