Cocaine, particularly in its smoked form known as crack, remains a significant contributor to drug-related emergencies. This article presents a detailed case of “crack lung,” a severe pulmonary complication arising from crack cocaine smoking, aiming to enhance understanding and diagnostic approaches for this condition.
A 48-year-old male was brought to the emergency department by paramedics after being discovered unresponsive in a public park. His spouse indicated a history of crack cocaine use a few hours prior to his collapse. Upon initial assessment, the patient exhibited a Glasgow Coma Scale score of 12 (E3V4M5), a body temperature of 38°C, a heart rate of 145 beats per minute, blood pressure at 140/80 mmHg, and an alarmingly low oxygen saturation of 60% while breathing room air. Arterial blood gas analysis revealed a combination of respiratory and metabolic acidosis. An electrocardiogram confirmed sinus tachycardia. Immediate medical interventions included the administration of oxygen, naloxone, glucose, and thiamine, leading to improved mental status and an increase in oxygen saturation to 99%. Subsequent diagnostic imaging, including a chest radiograph and thoracic computed tomography, revealed widespread alveolar ground-glass infiltrates throughout both lungs. These findings were observed in the absence of pleural effusions, cardiomegaly, or any indication of pulmonary embolism. The patient was admitted for further care and commenced on intravenous ampicillin-sulbactam. Within 24 hours, both fever and hypoxemia had resolved, and a follow-up chest radiograph taken 48 hours post-admission demonstrated substantial radiological improvement. The patient was discharged in stable condition five days following hospitalization.
Understanding Crack Lung Syndrome
Smoking crack cocaine is associated with a spectrum of acute and chronic pulmonary complications. These include, but are not limited to, pulmonary edema, alveolar hemorrhage, eosinophilic pneumonia, pneumothorax, and thromboembolic events. The underlying mechanisms are multifaceted, involving thermal injury to the airways, direct cellular toxicity from cocaine, initiation of inflammatory processes, barotrauma due to smoking technique, and vasospasm leading to pulmonary ischemia. “Crack lung” specifically denotes an acute syndrome characterized by diffuse alveolar damage and hemorrhagic alveolitis. This condition typically manifests within 48 hours of crack cocaine use. Clinically, patients often present with symptoms such as dyspnea, fever, cough, and potentially hemoptysis, which in severe cases can escalate to respiratory failure.
Radiographic findings in crack lung are generally nonspecific, commonly showing diffuse alveolar infiltrates and ground-glass opacities across lung fields. If performed, bronchoalveolar lavage can be instrumental in ruling out infections and diffuse alveolar hemorrhage. Characteristic findings from lavage include carbonaceous debris and hemosiderin-laden macrophages, indicative of bleeding and inhalation of particulate matter. It’s noteworthy that the identification of more than 25% eosinophils in bronchoalveolar lavage fluid suggests acute eosinophilic pneumonia, a subtype that may benefit from corticosteroid therapy.
Crack Lung Diagnosis and Management
The diagnosis of crack lung is primarily based on clinical suspicion, particularly in patients presenting with acute respiratory symptoms in the context of recent crack cocaine use. The temporal link between cocaine consumption, the onset of hypoxemia, and corroborating chest radiography findings are crucial in establishing the diagnosis of crack lung. It is essential to consider and exclude other potential causes of acute respiratory distress, including infectious pneumonia, pulmonary edema from other etiologies, and pulmonary embolism.
Treatment for crack lung is largely supportive. Oxygen supplementation is a cornerstone of management to address hypoxemia. Conservative fluid management is also important to mitigate potential pulmonary edema. In the absence of significant complications, the prognosis for crack lung is generally favorable, with symptoms and hypoxemia typically resolving spontaneously within a few days. This case underscores the importance of prompt recognition and supportive care in managing patients presenting with crack lung.
Patient Consent
Informed consent was obtained from the patient for the publication of their clinical information and images in this article. All measures have been taken to protect patient anonymity.
Financial Disclosure
No financial support or sponsorship was received for this study.
Conflicts of Interest
The authors declare no conflicts of interest.
References
[1] Tashkin DP, Kleerup EC, Connett JE, et al. Respiratory symptoms and lung function in habitual cocaine smokers. Am Rev Respir Dis. 1992;145(1):219-26.
[2] Gondim DD, Vale DL, Pinheiro BV, et al. “Crack lung”: case report and literature review. J Bras Pneumol. 2007;33(2):231-4.
