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"Crack Lung": A Cause of Acute Hypoxic Respiratory Failure
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A6589 - ""Crack Lung"": A Cause of Acute Hypoxic Respiratory Failure
Author Block: A. A. Patel, H. Singh, P. Gill, V. R. Thakkar, M. Cheema, A. Iftikhar; New York Presbyterian/Queens, Flushing, NY, United States.
Introduction Cocaine is a heat-labile fine white powder that can be inhaled nasally or injected intravenously but cannot be smoked. However, if boiled with baking soda and water and then filtered with ether or alcohol, cocaine yields a heat-stable form that can be smoked, known as “crack.” Crack is the most potent and addictive form of cocaine. Smoking crack leads to quicker euphoric effects compared to inhaling it, making it the preferred method for many drug users. “Crack lung” is a syndrome of diffuse alveolar hemorrhage and hemorrhagic alveolitis that ensues within 48 hours of smoking crack.
Case Description 35-year-old male with no past medical history presented to emergency department for unresponsiveness. Patient was found to be unresponsive and turning blue by his family. EMS arrived, found him to be lethargic and hypoxic, saturating at 60% and place on 100% non-rebreather and got 2 doses Narcan which improve his symptoms. Patient was still hypoxic and admitted to critical care for acute hypoxic respirartory failure. Chest X-Ray showed patchy diffuse right sided infiltrate. CT of the chest showed bilateral ground glass infiltrates. Empiric antibiotics were started for possible aspiration pneumonia. Initially, he was started on BiPAP and switched to high flow nasal cannula for persistent hypoxia, leading to improved oxygen saturation. Urine toxicology was positive for marijuana, opiates, and cocaine. A bronchoscopy was performed and a bronchoalveolar lavage (BAL) was performed in the right middle and lower lobes - showed few white blood cells and rare gram-positive rods but no eosinophilia. His breathing improved and he was switched to nasal cannula. Chest X-Ray showed improvement and the patient was discharged.
Discussion Cocaine abuse can cause several cardiac and neurological complications but it can also lead to pulmonary toxicity when smoked instead of nasally inhaled. Although a thorough history of drug abuse is essential, the form of abuse is critical as it helps in earlier diagnosis of more unusual causes. BAL helps to diagnose patients with crack lung, which can include include carbonaceous debris, eosinophils, Charcot-Leyden crystals, hemosiderin-laden macrophages, and increased cell counts. Asymptomatic habitual cocaine users have an increased percentage of hemosiderin-laden macrophages compared with tobacco smokers or nonsmokers. Eosinophilia (>25 percent) is indicative of eosinophilic pneumonia. Management of crack lung is primarily supplemental oxygen via high flow nasal cannula, positive pressure ventilation, or endotracheal intubation.
Author Block: A. A. Patel, H. Singh, P. Gill, V. R. Thakkar, M. Cheema, A. Iftikhar; New York Presbyterian/Queens, Flushing, NY, United States.
Introduction Cocaine is a heat-labile fine white powder that can be inhaled nasally or injected intravenously but cannot be smoked. However, if boiled with baking soda and water and then filtered with ether or alcohol, cocaine yields a heat-stable form that can be smoked, known as “crack.” Crack is the most potent and addictive form of cocaine. Smoking crack leads to quicker euphoric effects compared to inhaling it, making it the preferred method for many drug users. “Crack lung” is a syndrome of diffuse alveolar hemorrhage and hemorrhagic alveolitis that ensues within 48 hours of smoking crack.
Case Description 35-year-old male with no past medical history presented to emergency department for unresponsiveness. Patient was found to be unresponsive and turning blue by his family. EMS arrived, found him to be lethargic and hypoxic, saturating at 60% and place on 100% non-rebreather and got 2 doses Narcan which improve his symptoms. Patient was still hypoxic and admitted to critical care for acute hypoxic respirartory failure. Chest X-Ray showed patchy diffuse right sided infiltrate. CT of the chest showed bilateral ground glass infiltrates. Empiric antibiotics were started for possible aspiration pneumonia. Initially, he was started on BiPAP and switched to high flow nasal cannula for persistent hypoxia, leading to improved oxygen saturation. Urine toxicology was positive for marijuana, opiates, and cocaine. A bronchoscopy was performed and a bronchoalveolar lavage (BAL) was performed in the right middle and lower lobes - showed few white blood cells and rare gram-positive rods but no eosinophilia. His breathing improved and he was switched to nasal cannula. Chest X-Ray showed improvement and the patient was discharged.
Discussion Cocaine abuse can cause several cardiac and neurological complications but it can also lead to pulmonary toxicity when smoked instead of nasally inhaled. Although a thorough history of drug abuse is essential, the form of abuse is critical as it helps in earlier diagnosis of more unusual causes. BAL helps to diagnose patients with crack lung, which can include include carbonaceous debris, eosinophils, Charcot-Leyden crystals, hemosiderin-laden macrophages, and increased cell counts. Asymptomatic habitual cocaine users have an increased percentage of hemosiderin-laden macrophages compared with tobacco smokers or nonsmokers. Eosinophilia (>25 percent) is indicative of eosinophilic pneumonia. Management of crack lung is primarily supplemental oxygen via high flow nasal cannula, positive pressure ventilation, or endotracheal intubation.
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