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Massive Pulmonary Hemorrhage in an Adolescent Pulmonology Massive Pulmonary Hemorrhage in an Adolescent Ibrahim Abu-kishk MD1 and Noa Rosenfeld-Yehoshua MD Pediatric Intensive Care Unit, Assaf Harofeh Medical Center, Zerifin, and Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel Key words: pulmonary hemorrhage, cocaine, crack, dyspnea, hemoptysis IMAJ 2008;10:593–594 Cocaine has become one of the most fre- He smoked 40 cigarettes a quently abused substances. More than 30 day but denied alcohol and million Americans are estimated to have drug abuse. He did not have taken cocaine at least once, and 5 million allergies, prior hospital ad- reportedly use it regularly [1]. Infants, mission or an unusual family children and adolescents are also exposed. history. It is estimated that almost 6% of high Upon arrival he looked school seniors in the United States have pale and exhausted, dysp- used cocaine and crack, a cocaine deriva- neic, with a respiratory rate tive [2]. Cocaine and crack are among the of 30/minute, blood pressure most common drugs encountered in the 110/60, tachycardia 110 beats/ pediatric emergency department. Cocaine- min, and body temperature related medical complaints continue to 38.4°C. On auscultation, his increase. The inhalation of cocaine can heart sounds were normal induce a wide variety of acute pulmonary but bilateral chest inspiratory disorders, such as alveolar hemorrhage, crackles were detected. The Chest X-ray on admission illustrates bilateral lung acute pulmonary edema, interstitial rest of the physical examina- infiltrate with normal cardiac shadow. pneumonitis and fibrosis, pulmonary tion was unremarkable. Chest hypertension, pulmonary barotraumas, X-ray revealed diffuse lung emphysema, foreign body granuloma, infiltrates with a normal cardiac shadow insertion a large amount of red blood was cocaine-related obliterative bronchiolitis, [Figure]. Laboratory tests demonstrated aspirated from the trachea. and gas exchange abnormalities [3]. erythrocyte sedimentation rate 10 mm/ A computed tomography scan with Although diffuse alveolar hemorrhage hour, hemoglobin 5.7 g/dl, leukocytes angiography of the chest revealed normal associated with dyspnea and hemoptysis 13.4 k/ul and platelets 439 k/ul. Glucose, pulmonary arteries and diffuse alveolar is a common manifestation of cocaine electrolytes, kidney and liver function tests infiltrates without any other pathology. abuse, this phenomenon is not given suf- were all normal. Prothombin time was Echocardiography excluded cardiac pathol- ficient attention in the literature. Indeed 18.9 seconds (mildly prolonged); activated ogy. Gastroduodenoscopy demonstrated one pathological study demonstrated partial thromboplastin time and fibrinogen a normal upper gastrointestinal tract. occult alveolar hemorrhage at autopsy in were normal. Larygoscopy was normal. Other laboratory 58% of crack users, suggesting that occult He was admitted to the pediatric in- tests included serology for human im- alveolar hemorrhage occurs frequently in tensive care unit. Due to hypoxemia, high munodefeciency virus and antineutrophil subjects using crack. flow oxygen was administered through cytoplasmic antibodies, both of which a facial mask with reservoir. The patient were negative; complement (C3,C4) was Patient Description required blood products transfusion, 1500 normal. Toxicology tests of urine were A 17 year old healthy adolescent was ml packed cells and a similar quantity positive for cocaine, marijuana and admitted to the pediatric intensive care of fresh frozen plasma. Cefuroxime was methamphetamine. unit. During the preceding month he administered intravenously and roxythro- Two days later, suctions through the began to experience hemoptysis while mycin orally. A few hours later he became tracheal tube were clean and a bron- coughing, accompanied by epigastric pain even more dyspneic and hypoxemic, with choscopy was normal. The patient was and sometimes blood-stained vomiting. mental deterioration manifesting as ir- extubated on the third day of admission, In the 2 days prior to his admission he ritability and confusion. He was sedated and a repeated chest X-ray demonstrated became dyspneic with general weakness, with propofol, intubated and mechanically a significant improvement. His hemoglo- and the bloody cough was exacerbated. ventilated. During laryngoscopy and tube bin level stabilized at 10 g/dl and the • Vol 10 • August-September 2008 Massive Pulmonary Hemorrhage 593 Pulmonology coagulation tests normalized. Later on, condition and the negative infection Since cocaine is one of the most the patient admitted to drug abuse in the workup, an infectious etiology was very popular drugs and its abuse is related previous 2 months. unlikely. Negative serological study, to multiple clinical effects including pul- low sedimentation rate, clinical resolu- monary hemorrhage, we suggest that Comment tion without a specific therapy, normal cocaine be considered in similar cases. Cocaine abuse, and particularly crack smok- complement levels, normal urinalysis, The clinical course in cocaine-induced pul- ing, is extremely addictive. Users experience and no other organ involvement, exclude monary hemorrhage is usually benign, and pleasant sensations that are quickly replaced connective tissue or immunocomplex management is supportive. Thus, keeping by dysphoria, which may lead to self-recrim- diseases. Neither the patient nor any of in mind cocaine as a cause of pulmonary ination, agitation, anxiety, or symptoms of his relatives had a history of epistaxis or hemorrhage can save extensive workup. clinical depression. Through its release of mucosal and cutaneous hemangiomas, catechols into the blood, cocaine may cause which reduced the likelihood of arterio- References an adrenergic storm with stimulatory central venous malformations. Cardiovascular 1. National Institute of Drug Abuse. Na- nervous system, cardiovascular (acute myo- workup did not reveal pulmonary emboli tion al household survey on drug abuse. cardial infarction, dilated cardiomyopathy, or cardiac diseases. Mild prolongation of Population estimates, 1991; revised myocarditis or cardiac arrhythmias), renal prothrombin time, which normalized later, November 1992. DHHS publication 4# (ADM) 92-1887, 1992. and respiratory effects. did not explain the clinical picture. The 2. Smart RG. Crack cocaine use: a review Although hemoptysis occurs frequently prolongation could be due to consump- of prevalence and adverse effects. Am J in crack users, the pathogenesis of diffuse tion coagulopathy secondary to prolonged Drug Alcohol Abuse 1991;17:13–26. alveolar hemorrhage related to its use hemorrhage. Other entities like idiopathic 3. Terra Filho M, Yen CC, Santos Ude P, remains unclear [4]. Possible mechanisms pulmonary hemosiderosis or hemosidero- Muñoz DR. Pulmonary alterations in cocaine users. Sao Paulo Med J 2004; that induce alveolar hemorrhage are va- sis related to milk allergy are diseases 122(1):26–31. soconstriction of the pulmonary vascular of infancy and childhood and are not 4. Haim DY, Lippmann ML, Goldberg SK, bed, which may result in anoxic epithelial compatible with our patient's uneventful et al. The pulmonary complications of or endothelial cell damage producing al- medical history. cocaine: a comprehensive review. Chest veolar hemorrhage and edema, and direct Although his urine tested positive to 1995;107:233–40. 5. Tashkin DP. Airway effects of marijuana, toxic effect of the inhaled substances on both marijuana and methamphetamine, cocaine, and other inhaled illicit agents. the alveolar epithelium leading to injury we were unable to find an association Curr Opin Pulm Med 2001;7:43–61. [4]. There are some suggestions of an between the use of these substances immunological mechanism. and pulmonary hemorrhage. Tashkin [5] Correspondence: Dr. I. Abu-kishk, Pediatric In the presented case we could not described the airway effects of marijuana, Intensive Care Unit, Assaf Harofeh Medical con firm any other diagnosis apart from cocaine and other inhaled illicit agents. Of Center, Zerifin 70300, Israel. the toxicity related to cocaine. In view of all these substance, only cocaine caused Phone: (972-8) 977-9104; Fax: (972-8) 977-9109 the rapid improvement in the patient's pulmonary hemorrhage. email: [email protected] Tear man out of his outward circumstances; and what he then is; that only is he Johann Gottfried Seume (1763-1810), German author Capsule Hepatitis C vaccine Despite difficulties associated with extreme variability and provide suitable populations for assessing vaccine safety and mutability of hepatitis C virus (HCV), several vaccines that efficacy. The evaluation of prophylactic vaccines was particularly prevent initial infection or viral persistence, or that clear problematic since distribution must focus upon individuals at viremia in individuals with chronic HCV infections, are cur- high risk of exposure – for example, intravenous drug users rently in development. At least one vaccine that may prevent and health-care providers in areas with high HCV prevalence. chronic persistent infections will soon be available for testing. Although there is a huge need for therapeutic vaccines, further Strickland and team reviewed the widespread importance of immunological hurdles must be cleared before one becomes HCV infection and disease, the immune response to HCV available. and correlates of protection, prevention strategies and vac- Lancet Infect Dis 2008;8:379 cine candidates, and groups that will need the vaccine and Eitan Israeli 594 Abu-kiskh and N. Rosenfeld-Yehoshua • Vol 10 • August-September 2008.
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