Crack lung: a difficult differential diagnosis of ground glass opacities in the emergency setting

Abstract Background The term 'Crack lung' refers to an acute syndrome of diffuse alveolar damage and hemorrhagic alveolitis that occurs within 48 hours of smoking freebase cocaine. Crack lung induces a variety of pulmonary complications, both acute and chronic, including pulmonary edema, alveolar hemorrhage, eosinophilic pneumonia, pneumothorax, and pulmonary thromboembolism. Ischaemia of pneumocytes because of crack use is induced by the following phenomena: thermal damage to the airways, direct toxicity, inflammatory damage, barotrauma and vasospasm. Diffuse alveolar damage and alveolar hemorrhage with eosinophilic cell infiltration and IgE deposits are found in the lung tissue. Purpose We present two clinical cases of patients admitted to the emergency department of our university hospital with respiratory failure. HRCT scans showed bilaterally, subpleural, and peri-hilar lung parenchyma, extensive areas of parenchymal ground-glass hyperdensity, crazy paving aspects, and relative sparing of the apices. The temporal relationship between the appearance of the bilateral opacities, the history documenting drug use, and the onset of hypoxemia suggests the diagnosis of "Crack lung". Conclusions It is important to include drug abuse and crack lung in the differential diagnosis of acute respiratory symptoms with ground-glass opacities, as they are not uncommon in emergency departments and may rapidly progress to ARDS. CT findings are not specific, but it is important to accurately collect anamnestic data and collaborate with the clinician to achieve a diagnosis and establish proper therapy.