May 2023 Medical Image of the Month: Methamphetamine Inhalation Leading to Cavitary Pneumonia and Pleural Complications

Figure 1. Two axial images from a thoracic CT angiogram with intravenous contrast upon admission demonstrates ground-glass opacities in the left upper and bilateral lower lobes.

Figure 2.  Axial images from noncontrast CT 19 days later show progression with necrosis and cavitation with areas of pleural dehiscence and loculated hydropneumothorax formation.

A 31-year-old man with a self-reported history significant for active methamphetamine and OxyContin use (last use of methamphetamine the same day with confirmation on urine drug screen) presented to the hospital with several hours of dyspnea. Having gone into cardiac arrest shortly after, he received several rounds of epinephrine and CPR and was intubated before spontaneous circulation returned. Bedside ultrasound revealed global hypokinesis with left ventricular ejection fraction of 10 to 15%, trivial pericardial effusion, and a moderate left pleural effusion. Chest CT (Figure 1) revealed segmental to subsegmental pulmonary emboli in the left lower lobe and ground-glass opacities in the left upper and bilateral lower lobes. He was treated as septic shock with Vancomycin and Cefepime, eventually speciating methicillin-sensitive Staphylococcus aureus in respiratory culture. Due to difficulty liberating the patient from the ventilator, he underwent tracheostomy tube placement. Chest x-ray on hospital day 18 showed a large left partially loculated hydropneumothorax, for which a left thoracostomy tube was placed. The next day repeat CT chest without contrast (Figure 2) showed persistent moderate left lung volume loss with tethering of the lateral and separate anterior margin of the left upper lobe to the costal pleural margin. A dense consolidation of the left lung base had progressed to developing irregular cavitary spaces with air-fluid level. There was a dehiscence of the cavitary space with the posterior left pleura.  The right upper lobe showed extensive tree-in-bud ground-glass opacities and consolidation. The right lower lobe showed necrosis with intrapulmonary cavitary spaces/air-fluid levels. There was associated focal dehiscence of the parenchyma along the posterior cavity with the pleura. Patient had developed bilateral cavitary lung lesions with persistent bilateral hydropneumothoraces.

Typical findings of amphetamine induced lung injury can include ground-glass opacities as seen here. Worldwide prevalence of amphetamine use ranged between 0.3-1.3% for those aged 15-64 in 2009 (1). Crystal meth refers to the pure form of d-methamphetamine hydrochloride that can be smoked and inhaled as heated vapor as well. It can also be administered intravenously. Other amphetamines include MDMA, methyl methcathinone (commonly referred to as bath salts), and methylenedioxyamphetamine. Neural catecholamine reuptake is blocked, and neurotransmitter is expunged into the synaptic cleft. Additionally, serotonin and dopamine reuptake blockade and increased release take place.

With inhalation, there is higher percentage uptake, faster peak time, and slower clearance in the lungs compared to other organs as evidence by data from positron emission tomography. Time to peak concentration is the same between inhalation and intravenous use. Laboratories that produce amphetamines in the United States of America reduce L-ephedrine or D-pseudoephedrine either over red phosphorous with hydrochloric acid or with liquid ammonia and lithium. Therefore, they pose risks of contamination. Red phosphorous is flammable and causes smoke inhalation injury. Other solvents used also contribute to respiratory illness including pulmonary edema and mucous membranes irritation (1).

Typical respiratory symptoms from illicit drug use, including amphetamine use, include dyspnea, cough, dark sputum, and chest pain. Mechanisms include toxic effects on the respiratory system, coronary artery constriction, and impaired coronary artery oxygen delivery leading to chest pain. Dyspnea is a primarily a result of ventilation-perfusion mismatch from vasospasm. Bronchospasm is precipitated by airway mucosal irritation. Mucosal ulceration and burns as well as subsequent diffuse alveolar capillary injury lead to hemoptysis.  Cardiogenic pulmonary edema stems from the same causes of chest pain as well as acute hypertension and myocardial ischemia. Noncardiogenic pulmonary edema is a result of alveolar epithelial and endothelial damage.

As compared to cocaine, amphetamines have lower rates of barotrauma including pneumothorax, pneumopericardium, and pneumomediastinum, however these are still significant. There have been reports of MDMA-related epidural pneumatosis and retropharyngeal emphysema (1). Air dissects along fascial planes when alveoli are injured and travels up the pulmonary vascular sheath into the mediastinum, pericardium, and between the parietal and visceral layers.  When inhaled, coughing, and performing a Valsalva maneuver predispose the patient to this complication (2). Additionally, pneumothorax is more common with exertion shortly after consumption. Attempts at intravenous administration along the chest, supraclavicular regions, and internal jugular veins increase risk of pneumothorax (3). Hemothorax and pseudoaneurysm have been documented as well (2).

Kia Ghiassi DO¹, Colin Jenkins MD¹, Prateek Juneja DO²

^1,2University of California Riverside, Riverside, CA USA

²Inspira Health, Vineland, NJ USA

References

1. Tseng W, Sutter ME, Albertson TE. Stimulants and the lung : review of literature. Clin Rev Allergy Immunol. 2014 Feb;46(1):82-100. [CrossRef] [PubMed]
2. Nguyen ET, Silva CI, Souza CA, Müller NL. Pulmonary complications of illicit drug use: differential diagnosis based on CT findings. J Thorac Imaging. 2007 May;22(2):199-206. [CrossRef] [PubMed]
3. Gotway MB, Marder SR, Hanks DK, et al. Thoracic complications of illicit drug use: an organ system approach. Radiographics. 2002 Oct;22 Spec No:S119-35. [CrossRef] [PubMed]

Cite as: Ghiassi K, Jenkins C, Juneja P. May 2023 Medical Image of the Month: Methamphetamine Inhalation Leading to Cavitary Pneumonia and Pleural Complications. Southwest J Pulm Crit Care Sleep. 2023;26(5):80-82. doi: https://doi.org/10.13175/swjpccs010-23 PDF

November 2018 Imaging Case of the Month: Respiratory Failure in a 36-Year-Old Woman

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Clinical History: A 36–year old woman presented with complaints of shortness of breath and worsening dyspnea on exertion. She had a reported history of central nervous system vasculitis of uncertain etiology, treated with azathioprine and prednisone currently, and cyclophosphamide in the past. Her symptoms reportedly responded well to this regimen. Her diagnosis of central nervous system vasculitis was established 6 months earlier when the patient presented with upper extremity paresthesia, headache, left arm weakness, diplopia, and a right eye visual field deficit, evidently with brain imaging showing some pathologic changes, although those records were not available at her presentation. Reportedly she responded well to her immunosuppressive therapy and her steroid and azathioprine doses had been tapered accordingly. Her past medical history was otherwise remarkable for a history of migraine headaches, depression, childhood asthma, hemorrhagic cystitis due to cyclophosphamide (which prompted discounting this drug in favor of azathioprine for the purported central nervous system vasculitis) in the past, and endometriosis.

The patient is a former smoker for a total of 5 pack-years, quitting years previously. She is the mother of a 3-year-old child. The patient denied alcohol and drug use. A history of penicillin allergy was elicited. In addition to azathioprine and prednisone, her medications included inhaled budesonide, Bactrim, escitalopram, topiramate, and sumatriptan/naproxen sodium as well as a multivitamin. There was some history of fenfluramine/phentermine (“Fen-Fen”) use years earlier.

Her physical examination was largely unremarkable. The patient complained of head pain and was visibly mildly dyspneic, but her lungs were clear and no abnormal heart sounds were detected. Her extremities appeared normal- no ecchymosis, cyanosis, or clubbing was detected. She did have some prior history suggesting the presence of erythema nodosum, now presenting as an erythematous region on the right lower extremity, which underwent biopsy, although changes characteristic of erythema nodosum were not present at her current examination. Reportedly this region had been injured when she bumped the right lower extremity on a chair, and this injury evidently became infected, requiring drainage, yielding cultures positive for Staphylococcus aureus and, about 1 month later, Actinomyces israelii. Her vital signs should normal pulse rate and blood pressure, breathing at 26 breaths / minute. Her room air oxygen saturation was 93%.

Frontal and lateral chest radiography (Figure 1) was performed.

Figure 1. Frontal (A) and lateral (B) chest radiography.

Which of the following represents the most accurate assessment of the chest radiographic findings? (Click on the correct answer to be directed to the second of twelve pages)

1. Chest radiography shows basilar fibrotic opacities
2. Chest radiography shows bilateral pleural effusions
3. Chest radiography shows cavitary pulmonary lesions
4. Chest radiography shows marked cardiomegaly
5. Chest radiography shows numerous small nodular opacities

Cite as: Gotway MB. November 2018 imaging case of the month: Respiratory failure in a 36-year-old woman. Southwest J Pulm Crit Care. 2018;17(5):119-33. doi: https://doi.org/10.13175/swjpcc114-18 PDF

Medical Image of the Week: Panlobular Emphysema

Figure 1. PA chest radiograph showing predominately lower lobe emphysematous changes.

A 60 year old female, non-smoker with a past medical history of chronic rhinosinusitis with nasal polyps presented with an eight year history of productive cough and dyspnea. Previous treatment with inhaled corticosteroids, courses of systemic corticosteroids and antibiotics provided modest improvement in her symptoms. Pulmonary function testing revealed a severe obstructive ventilatory defect without significant bronchodilator response and reduced diffusing capacity (DLCO). Chest x-ray surprisingly revealed lower lobe predominant emphysematous changes (Figure 1). Alpha-1-antitrypsin level was within normal range at 137 mg/dL.

Panlobular emphysema represents permanent destruction of the entire acinus distal to the respiratory bronchioles and is more likely to affect the lower lobes compared to centrilobular emphysema (1). Panlobular emphysema is associated with alpha-1-antitrypsin deficiency, intravenous drug abuse specifically with methylphenidate and methadone, Swyer-James syndrome, and obliterative bronchiolitis. Whether this pattern is seen as part of normal senescence in non-smoking individuals remains controversial (2). Panlobular emphysema may represent a phenotypically more severe disease than centrilobular emphysema and may coexist along a continuum with centrilobular emphysema (3).

Ashish Mathur MD and Tara Carr MD

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine

University of Arizona College of Medicine

Tucson, Arizona

References

1. Litmanovich D, Boiselle PM, Bankier AA. CT of pulmonary emphysema-current status, challenges, and future directions. Eur Radiol. 2009;19(3): 537-51. [CrossRef] [PubMed]
2. Takahashi M, Fukuoka J, Nitta N et al. Imaging of pulmonary emphysema: a pictorial review. Int J Chron Obstruct Pulmon Dis. 2008;3(2):193-204. [PubMed]
3. Finkelstein R, Ma HD, Ghezzo H, Whittaker K, Fraser RS, Cosio MG. Morphometry of small airways in smokers and its relationship to emphysema type and hyperresponsiveness. Am J Respir Crit Care Med. 1995;152(1):267-76. [CrossRef] [PubMed]

Reference as: Mathur A, Carr T. Medical image of the week: panloubular emphysema. Southwest J Pulm Criti Care. 2015;11(2):86-7. doi: http://dx.doi.org/10.13175/swjpcc081-15 PDF

Medical Image of the Week: Septic Emboli

Figure 1. Panels A-F: Selected static images from the thoracic CT showing numerous septic pulmonary emboli with cavitation. Lower panel: movie of selected images from thoracic CT scan.

A 46-year-old man was admitted with altered mental status. His past medical history included HIV/AIDS on HAART therapy, hepatitis B and C, non-Hodgkin's lymphoma (NHL), deep venous thrombosis with insertion of an inferior vena caval filter, and poly-substance abuse. Vitals revealed fever and tachycardia. On exam, he was lethargic and confused, and had bilateral crackles on lung auscultation. Computerized axial tomography (CT) of the head was unremarkable and chest X-ray revealed patchy nodular infiltrates in the right upper lobe and bilateral lower lobes. Work up for an infectious cause was initiated including opportunistic infections and he was started on empiric antibiotics for pneumonia. On Day 2, his roommate who came to visit him, revealed that he was recently admitted in another hospital for headache and flu-like symptoms, and discharged with a peripherally inserted central catheter (PICC) in place as he was scheduled for a positron emission tomography (PET) the next morning for evaluation of recurrence of NHL. However, he presented for the PET scan 10 days after discharge, during which period he was abusing heroin through the PICC line. A thoracic CT was also obtained which showed innumerable scattered cavitary pulmonary opacities with peripheral ground glass opacities consistent with septic pulmonary emboli in the right and left upper lobe and right middle lobe (Figure 1). Blood and urine cultures grew methicillin-resistant Staphylococcus aureus, CD4 count was 180, cryptococcus and histoplasma antigens were negative, as were urine antigens for pneumococcus and legionella. He was also found to have deep venous thrombosis of the right upper extremity. Trans-esophageal echocardiogram was negative for valvular vegetations. He was successfully treated with vancomycin and rifampin and discharged home.

Septic pulmonary emboli are embolization of infectious particles into the lungs via the pulmonary arterial system. Septic pulmonary emboli can occur from varying sources. Patients may be asymptomatic or present with sepsis. CXR shows multiple nodules in the periphery of the lower lobes. CT chest may show feeding vessel sign (a vessel coursing directly to a nodule or mass) in 50% of patients. Early diagnosis and prompt treatment can lead to a successful outcome.

Nanditha Malakkla MD and Chandramohan Meenakshisundaram MD

St. Francis Hospital

Evanston, IL

References

1. Fidan F, Acar M, Unlu M, Cetinkaya Z, Haktanir A, Sezer M. Septic pulmonary emboli following infection of peripheral intravenous cannula. Eur J Gen Med. 2006;3:132–5.
2. Kuhlman JE, Fishman EK, Teigen C. Pulmonary septic emboli: Diagnosis with CT. Radiology. 1990;174:211–3. [CrossRef] [PubMed]
3. Hind CR. Pulmonary complications of intravenous drug misuse. 1. Epidemiology and non-infective complications. Thorax 1990; 45:891-8. [CrossRef] [PubMed]

Reference as: Malakkla N, Meenakshisundaram C. Medical image of the week: septic emboli. Southwest J Pulm Crit Care. 2014;9(3):183-4. doi: http://dx.doi.org/10.13175/swjpcc120-14 PDF