Cocaine induced organizing pneumonia

ABSTRACT

Case Report Cocaine is a potent natural stimulant that is widely used and is among the most common cause of acute drug related emergency department visits in the US. All different forms of cocaine can cause a variety of neuro-psychological, cardiovascular, and pulmonary injuries. Here we present a case of respiratory failure in patient with smokes cocaine in aluminum foil. Case A35-year-old morbidly obese female with no significant medical history except for daily cannabis uses and cocaine in the past who was admitted for progressive cough, dyspnea, and fever for 10 days. She smoked a different kind of marijuana recently. Family mentioned history of smoking cocaine using aluminum foil recently. no chest pain, rash, or joint pain, no recent travels. no family history of similar condition or autoimmune disease. vital signs fever of 38 C, O2 sat of 82% Room air, BP 162/ 90 mmHg, pulse of 124, RR of 34. Patient did have bilateral rales on respiratory examination. WBC was 25,000. ESR of 68, Pro-Cal 0.11. CT angiography of the chest showed bilateral ground glass opacities and patchy consolidation. Pan cultures, viral panel including Covid test, HIV, Autoimmune diseases, and Vasculitis work-up were negative. Bronchoalveolar lavage (BAL) revealed neutrophil 38, lymphocyte 39, Eosinophile 14, Cultures were negative. Urine toxicology screen was not done. Patient was started on broad spectrum antibiotic. Patient was intubated for Video assisted thoracoscopic surgery and biopsy but could not be done due to worsening respiratory status. Based on presentation and investigation findings, diagnosis of Cocaine induced Organizing pneumonia was made. Tapered steroid therapy was added with dexamethasone initial dose of 6 mg then methyleprednisolone 125 mg. patient recovered well, extubated on day 13, switched to oral prednisone and discharged home on room air. Discussion Cocaine is an alkaloid with anesthetic properties that is administered through different routes;inhaled, IV injections, or smoked after chemical modification 'crack'. It may be smoked through different types of pipes or mixed with cigarettes or marijuana. Mechanism of cocaine induced lung injury is thought to be due to inflammatory damage, thermal injury, direct cellular toxicity, barotrauma, or vasospastic ischemia. other possibility in our patient is Smoking in aluminum foil which has food oil substances, and none stick substances can make them toxic when inhaled. Cocaine induced organizing pneumonia with respiratory failure has been reported in young cocaine smokers. Organizing pneumonia BAL cell count has increase in lymphocyte (20-40), neutrophile (5-10) and eosinophile (5-25) with the level of lymphocyte being higher than eosinophile is typical but not diagnostic for COP. Conclusion Organizing pneumonia secondary to cocaine or aluminum foil with typical presentation, radiology imaging, BAL cell count findings and excluding other causes may be diagnosed without the need of lung biopsy.