Uncovering Cocaine Induced Eosinophilic Pneumonia

Abstract

Cocaine use has a significant public health impact, causing over 1.2 million ER visits annually. Cocaine can cause a wide range of pulmonary pathology, including diffuse alveolar hemorrhage (“Crack Lung”), barotrauma, bronchiectasis, granulomatous disease, and pulmonary vascular disease. Acute eosinophilic pneumonia (AEP) is a rare and potentially life-threatening complication of cocaine use that can be successfully treated if identified. We describe a case of persistent fevers, hypoxemia, and air space opacities due to AEP related to cocaine use.A 34-year-old male with a history of polysubstance abuse was found unresponsive, apneic, and surrounded by vomitus at a party, where he had smoked marijuana and cocaine and injected heroin. Upon hospital arrival, he was hypotensive and severely hypoxic and was intubated. He had severe rhabdomyolysis, lactic acidosis, acute kidney injury, and acute liver injury. His chest radiograph demonstrated diffuse bilateral alveolar infiltrates. COVID-19 was ruled out. Sputum cultures grew Klebsiella and E. Coli;Streptococcus Pneumoniae urine antigen was positive. He received IV fluids, vasopressors, and broad spectrum antibiotics for septic shock and aspiration pneumonia in the setting of drug overdose. His septic shock and hypoxemia improved, allowing tracheostomy and gastrostomy to be performed. Despite prolonged courses of antibiotics, he had persistent fevers, worsening infiltrates on chest radiograph, and persistent hypoxemia. CT imaging demonstrated diffuse, bilateral ground glass opacities and consolidations, with reticulation and interlobular septal thickening. Viral, bacterial, and fungal cultures collected via bronchoscopy were negative, however, cell count revealed 315 WBC / mm3, with 27% eosinophils. He was started on methylprednisolone 80mg IV every eight hours and had resolution of fevers and improvement in oxygenation and infiltrates. 1 month after discharge, he was decannulated and did not require supplemental oxygen. DiscussionThis case highlights an important aspect of assessing fever in the ICU despite broad spectrum antibiotics in patient with drug overdose. In the above , bronchoscopy unmasked an eosinophilic pneumonia allowing a rapid transition to trach collar and prevention of progression to pulmonary fibrosis. (Figure Presented).