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A6576 - A Rare Case of Cocaine-Induced Organizing Pneumonia
Author Block: C. Halasan1, E. Nadler2, P. Uy1, C. Monterroso3; 1Internal Medicine, University of Medicine, Farmington, CT, United States, 2Pulmonary and Critical Care, University of Connecticut, Farmington, CT, United States, 3Pulmonary and Critical Care, University of Medicine, Farmington, CT, United States.
Cocaine abuse is reaching epidemic proportions and its adverse consequences are widespread. There have been studies describing a variety of cocaine induced lung injuries. We present a case of a young female who developed severe respiratory failure secondary to organizing pneumonia (OP) related to inhaled crack cocaine use.
28-year-old female with active IV heroin abuse and crack cocaine use, and recent upper extremity abscess treated with antibiotics, who presented with fever, hypotension, dyspnea and dry cough. She was initially given fluids and broad spectrum antibiotics. She defervesce and was hemodynamically stable, however became progressively dyspneic and hypoxemic. Exam revealed tachypnea and diffuse crackles. She had an unremarkable cardiovascular exam. She subsequently required high flow oxygen and rescue non-invasive ventilation. CBC did not reveal eosinophilia. Blood, urine, throat and sputum cultures were negative. HIV was negative. Connective tissue disease was ruled out. Her chest x-ray revealed low lung volumes with diffuse reticulonodular opacities with confluent airspace disease and air bronchograms in the bilateral lower lobes. Echocardiogram was normal. Chest CT revealed widespread centrilobular ground glass opacities and tree in bud nodularity, and consolidation of the posterior right upper lobe. She was empirically started on high dose IV steroids. She was later intubated and underwent bronchoscopy with BAL. BAL was sent to rule out infectious etiologies, which was unrevealing. VATS biopsy was done and revealed extensive OP with confluent fibrosis and ongoing acute and chronic inflammation. Despite optimum ventilator settings she continued to have severe refractory hypoxemia. She was then placed on Veno-venous extracorporeal membrane oxygenation. Unfortunately, despite maximal supportive efforts the patient remained severely hypoxemic and ultimately died.
The diagnosis of cocaine-induced lung injury is based primarily on exposure to cocaine, consistent radiological findings and the exclusion of other causes. The most common complications include “crack lung”, acute eosinophilic pneumonia, pneumothorax, pneumomediastinum, pulmonary edema and hemorrhage. Organizing pneumonia has been described, however it is more rare. The first case of cocaine-induced OP was reported in 1987.Recent study evaluating cocaine-induced pulmonary changes based on HRCT findings demonstrated only 2 cases of organizing pneumonia out of the 22. One case report described a 32 year old man with biopsy demonstrated OP who showed improvement with steroids. The incidence, mechanism and treatment are not well known. Given the increasing use of cocaine especially among young adults, it should be included in the differential diagnosis in patients suspected of having cocaine induced lung injury.