Case Report
WIENER KLINISCHE WOCHENSCHRIFT
Wien Klin Wochenschr (2008) 120/5–6: 178–180 DOI 10.1007/s00508-008-0938-0
The Middle European Journal of Medicine Printed in Austria
Eosinophilic pneumonia associated with heroin inhalation: a case report Apostolos Tsapas1, Konstantinos Paletas1, Efthymia Vlachaki1, Eleni Bekiari1, Constantine Spanos2 , and Dimitrios Economidis1* 1 Aristotle
University Thessaloniki, 2nd Department of Internal Medicine, Thessaloniki, Greece University Thessaloniki, 1st Department of Surgery, Thessaloniki, Greece
2 Aristotle
Received August 22, 2007, accepted after revision October 11, 2007 © Springer-Verlag 2008
Eosinophile Pneumonie in Verbindung mit Heroininhalation Zusammenfassung. Medikamente sind eine bekannte Ursache für eine Lungeneosinophilie. Es gibt einige Fallberichte über Patienten mit akuter eosinophiler Pneumonie in Verbindung mit Kokainkonsum. Veränderte Gewohnheiten des Heroinkonsums, mit Verschiebung vom intravenösen Gebrauch zum Heroinrauchen/Inhalation, können zu häufigerem Auftreten einer Heroin-verursachten Lungeneosinophilie führen. Berichtet wird der Fall eines Patienten, der ungefähr 10 Jahre lang Heroin inhaliert hatte. Er präsentierte sich mit Fieber, Husten, Atemnot und pleuritischem Schmerz in der Brust. Die Röntgenuntersuchung des Thorax zeigte einen einseitigen Pleuraerguß mit segmentaler Atelektase. Die Analyse des Pleuraergusses und der bronchoalveolaren Lavage zeigte eine signifikante Eosinophilie, womit die Diagnose einer eosinophilen Pneumonie gegeben war. Durch Heroinabstinenz und Kortikosteroidbehandlung konnte eine schnelle Genesung erzielt werden. Summary. Drugs are known to be a cause of pulmonary eosinophilia and several case reports of acute eosinophilic pneumonia associated with the use of cocaine have been reported. The changing pattern of heroin use, with a shift from intravenous use to smoking/inhalation of the substance, may lead to increased prevalence of heroin-induced pulmonary eosinophilia. We report on a case of a patient who had been inhaling heroin for about ten years. He presented with fever, cough, dyspnea and pleuritic chest pain. Chest radiograph showed unilateral pleural effusion with segmental atelectasis. Examination of pleuritic fluid aspirate and bronchoalveolar lavage fluid revealed significant eosinophilia. He was diagnosed with acute eosinophilic pneumonia. Rapid remission was achieved after heroin abstinence and initiation of corticosteroid treatment. Key words: Acute eosinophilic pneumonia, pulmonary eosinophilia, heroin, opiate abuse, dyspnea. * The authors declare no conflict of interest.
Introduction The AIDS epidemic and the recognition of other sequelae of intravenous drug abuse led to an upswing of inhalation of heroin in the 1990s [1]. Inhalation of heroin by a technique known as “chasing the dragon” [2] has been associated both with the indirect effects of heroin overdose and with direct pulmonary toxicity [3]; moreover, a case of heroin-induced acute eosinophilic pneumonia (AEP) has been reported [4]. We describe the second case of AEP associated with heroin inhalation.
Case report A 41-year-old man with a history of cigarette smoking (32 pack/years) and daily heroin inhalation for the last ten years, presented to the emergency department with fever, cough, dyspnea and pleuritic chest pain. The patient had no history of asthma and had an unremarkable travel history. He had been well until 15 days ago, when he had first presented with fever, cough, dyspnea and pleuritic chest pain, and diffuse infiltrations on a chest radiograph (Fig. 1). These findings were thought to be consistent with a respiratory tract infection, and treatment with roxithromycin and NSAIDs was initiated. However, after discharge the patient continued to inhale heroin and showed no improvement. He was re-admitted. On his second admission, the patient was febrile (37.8 ºC) and again complained of persistent cough, dyspnea and pleuritic chest pain. His pulse was 98 beats/min, blood pressure 110/80 mmHg and respiratory rate 20 breaths/min. Auscultation revealed impaired breath sounds and late crackles on the left lung base. The rest of the physical examination was normal. Arterial blood gas measurement on room air demonstrated a pH of 7.45, PaO2 72 mmHg and PaCO2 30 mmHg. The patient’s WBC count was 15,200 cells/μl, with 60% neutrophils, 11% lymphocytes and 11% eosinophils. A chest radiograph revealed unilateral pleural effusion with segmental atelectasis. The patient was started on clarithromycin. Bronchoscopy was performed the following day. The leucocytes in the bronchoalveolar lavage fluid (BALF) were 26% eosinophils. We proceeded with thoracentesis and aspiration of pleuritic fluid. This revealed leucocytosis with eosinophilia (49%) in the aspirated fluid. Samples of blood, BALF and stool
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were cultured to check for common bacteria, fungi, ova and parasites, and were all negative. Viral antibody tests were negative. The total serum IgE was 57 IU/ml. The diffusing capacity of the lung for carbon monoxide (DLCO) was within the expected range (DLCOcorr = 23.82 ml/min/mmHg), pulmonary function tests were normal, and a pulmonary provocation test with methacholine was negative. A CT scan of the lungs revealed unilateral pleural effusion and diffuse bilateral pulmonary infiltrates (Fig. 2). The patient was seronegative for human immunodeficiency virus (HIV). The patient was diagnosed with AEP. Rapid remission was obtained after heroin abstinence and initiation of corticosteroid treatment (methylprednisolone 32 mg daily). Findings on the chest radiograph and the pleural effusion improved remarkably starting on the fifth hospital day and the patient was discharged. A chest radiograph and clinical examination both proved normal at follow-up ten days after discharge. The patient was referred to a drug abuse treatment program.
Discussion Drugs are known to be a cause of pulmonary eosinophilia [5]. Smoking of cocaine has been associated with diffuse alveolar infiltrates, eosinophilia and fever, a syndrome termed “crack lung” [6]. AEP has been defined as pulmonary infiltration by eosinophils [7] and several cases associated with the use of cocaine have been reported [8]. However, there has been only one case report of AEP associated with heroin inhalation [4], despite the fact that heroin is known to cause mast cell degranulation and release of histamine and other preformed mediators of inflammation [9]. This may be related to the fact that the vast majority of people addicted to heroin used to be injectors. According to the Office of Applied Studies, Substance Abuse and Mental Health Services Administration (SAMHSA) in the USA [1], heroin is among the three most frequently reported drugs that result in emergency department visits, and there are similar results from studies con-
Fig. 2. CT scan of the lungs on the second day after admission
ducted in Europe [10]. Reports in the 1990s indicated that inhalation as a means of substance abuse had increased among primary heroin admissions. Recent reports seem to verify this finding, and support the conclusion that heroin inhalation is a growing problem, especially in young adults. Among primary heroin admissions in the USA, the proportion of those who injected the drug declined from 69% in 1995 to 63% in 2005, whereas the proportion who inhaled the drug increased from 27% to 33%. In Europe, “chasing the dragon” has become an established route of heroin self-administration in the Netherlands, the UK, Spain and Ireland: 75–85% of Dutch heroin users predominantly or exclusively inhale their heroin [11]. Heroin inhalation is known to cause leucoencephalopathy [12], bronchospasm, asthma attacks [13] despite a negative asthma history, and AEP. In our patient, peripheral and BALF eosinophilia, as well as the rapid clinical recovery after initiation of corticosteroid treatment, were suggestive of AEP. The patient had no history of asthma, parasitic infections were ruled out, and there were no data supporting the presence of systemic vasculitis.
Conclusion This is the second case report of AEP after heroin inhalation. The increasing prevalence of heroin inhalers among people addicted to heroin could possibly lead to increased prevalence of heroin-related AEP cases, similarly to crack cocaine.
References
Fig. 1. Chest radiograph fifteen days before admission
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