Abstract Introduction Heroin-related lung Injury is defined as acute hypoxia (SpO2 90% on room air, RR 12) occurring within 24 hours of a heroin overdose, with diffuse pulmonary infiltrates on imaging not due to cardiogenic, infectious, thromboembolic causes, or bronchospasm, resolving clinically and radiographically within 48 hours. Case Description We present the case of a 69-year-old male with a past medical history of heroin use since age 16, who presented with two days of worsening dyspnea and productive cough. He reported intranasal use of three bags of heroin two days before presentation. On arrival, he was hypoxic to 79%, tachycardic (HR 105 bpm), and tachypneic (RR 26/min). Physical examination revealed bilateral crackles on chest auscultation. Initial arterial blood gas results showed a pH of 7.49, pCO2 of 43 mmHg, and HCO3⁻ of 33 mmol/L. Laboratory evaluation revealed WBC 10.92 x10³/µL, hemoglobin 11.5 g/dL, platelets 344 x10³/µL. Urine toxicology was positive for methadone. Microbiologic studies, including urine Legionella, Streptococcus pneumoniae antigen, and MRSA PCR, were negative. Chest radiograph showed new confluent and patchy bilateral airspace opacities. CT chest demonstrated severe centrilobular and paraseptal emphysematous changes with extensive bilateral patchy hazy opacities and alveolar septal thickening. He was admitted to the MICU for management of acute hypoxic respiratory failure, secondary to heroin induced lung injury with superimposed aspiration pneumonia. He was initiated on high-flow nasal cannula (FiO2 70% at 40L/min), intravenous methylprednisolone, and broad-spectrum antibiotics (vancomycin, cefepime, and azithromycin). One of five sputum AFB samples grew Mycobacterium fortuitum, another grew Mycobacterium chimaera, while the remaining three were negative for acid-fast bacilli. His respiratory status improved with high-flow oxygen, and he was successfully transitioned to a nasal cannula on the second hospital day. Repeat chest radiograph showed interval improvement in interstitial opacities. Discussion Due to the patient presenting with significant hypoxia and tachypnea after inhalation of a large amount of heroin, radiographic findings of diffuse pulmonary infiltrate and resolution of clinical and radiographic findings within 48 hrs, absence of a definitive infectious etiology, and quick recovery support heroin-induced lung injury. The acuity of symptoms and lack of at least two samples positive for same species of Non-Tuberculous Mycobacterium suggest likely colonization rather than active disease. A proper social history and ruling out other differential diagnosis is crucial in diagnosing heroin induced lung injury. Figure 1: CT chest with findings of severe emphysematous changes with extensive bilateral patchy hazy opacities. This abstract is funded by: none
Awale et al. (Fri,) studied this question.