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Original ArticleCocaine-induced pulmonary changes: HRCT findings*Cocaine-induced pulmonary changes: HRCT findingsRenata Rocha de Almeida1, Gláucia Zanetti1,2, Arthur Soares Souza Jr.3,Luciana Soares de Souza4, Jorge Luiz Pereira e Silva5, Dante Luiz Escuissato6,Klaus Loureiro Irion7, Alexandre Dias Mançano8, Luiz Felipe Nobre9,Bruno Hochhegger10, Edson Marchiori1,11AbstractObjective: To evaluate HRCT scans of the chest in 22 patients with cocaine-induced pulmonary disease. Methods:We included patients between 19 and 52 years of age. The HRCT scans were evaluated by two radiologistsindependently, discordant results being resolved by consensus. The inclusion criterion was an HRCT scan showingabnormalities that were temporally related to cocaine use, with no other apparent causal factors. Results: In8 patients (36.4%), the clinical and tomographic findings were consistent with “crack lung”, those cases beingstudied separately. The major HRCT findings in that subgroup of patients included ground-glass opacities, in100% of the cases; consolidations, in 50%; and the halo sign, in 25%. In 12.5% of the cases, smooth septalthickening, paraseptal emphysema, centrilobular nodules, and the tree-in-bud pattern were identified. Amongthe remaining 14 patients (63.6%), barotrauma was identified in 3 cases, presenting as pneumomediastinum,pneumothorax, and hemopneumothorax, respectively. Talcosis, characterized as perihilar conglomerate masses,architectural distortion, and emphysema, was diagnosed in 3 patients. Other patterns were found less frequently:organizing pneumonia and bullous emphysema, in 2 patients each; and pulmonary infarction, septic embolism,eosinophilic pneumonia, and cardiogenic pulmonary edema, in 1 patient each. Conclusions: Pulmonary changesinduced by cocaine use are varied and nonspecific. The diagnostic suspicion of cocaine-induced pulmonary diseasedepends, in most of the cases, on a careful drawing of correlations between clinical and radiological findings.Keywords: Cocaine, Cocaine-related disorders; Tomography, X-ray computed; Lung diseases.IntroductionCocaine is an alkaloid found in the leaves ofa bush of the Erythroxylaceae family: the cocabush (Erythroxylum coca).(1) After marijuana, it isthe second most widely consumed and traffickedillicit drug in the world.(2,3) The prevalence of“lifetime use” of cocaine in the 108 largestcities in Brazil, in 2005, was 2.9%.(3) In 2012,a survey conducted by the Fundação OswaldoCruz involving approximately 25,000 peopleestimated the number of crack users in Brazilto be 0.81%, i.e., about 370 thousand users.(4)Cocaine is the most widely consumed illicitdrug among patients treated in emergencyrooms, as well as being the leading cause ofdrug abuse-related deaths.(1,5) Several respiratoryproblems have been temporally associated withacute or chronic cocaine use.(6,7) Therefore, thediagnosis of cocaine-induced pulmonary diseasesis a challenge for clinicians and radiologists,especially in urban hospitals.Although there have been some studiesreporting cocaine-induced pulmonary changes*Study carried out at the Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil.1. Programa de Pós-Graduação em Radiologia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil.2. Faculdade de Medicina de Petrópolis, Petrópolis, Brasil.3. Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, Brasil.4. Ultra-X, São José do Rio Preto, São José do Rio Preto, Brasil.5. Departamento de Medicina e Apoio Diagnóstico, Universidade Federal da Bahia, Salvador, Brasil.6. Departamento de Clínica Médica, Universidade Federal do Paraná, Curitiba, Brasil.7. Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom.8. Radiologia Anchieta, Hospital Anchieta, Taguatinga, Brasil.9. Universidade Federal de Santa Catarina, Florianópolis, Brasil.10. Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brasil.11. Universidade Federal Fluminense, Niterói, Brasil.Correspondence to: Edson Marchiori. Rua Thomaz Cameron, 438, Valparaiso, CEP 25685-120, Petrópolis, RJ, Brasil.Tel.: 55 24 2249-2777. Fax: 55 21 2629-9017. E-mail: edmarchiori@gmail.comFinancial support: None.Submitted: 9 February 2015. Accepted, after review: 7 April 0025J Bras Pneumol. 2015;41(4):323-330
324Almeida RR, Zanetti G, Souza Jr AS, Souza LS, Pereira e Silva JL, Escuissato DL, et al.on chest X-ray (CXR), there have been few studiesdescribing CT findings.The objective of the present study was toevaluate, by means of an analysis of HRCT scans ofthe chest in 22 patients with pulmonary changesthat were temporally related to cocaine use, themost common HRCT findings, their morphologicalcharacteristics, and the distribution of the lesionsin the lung parenchyma. In addition, we studiedsome epidemiological aspects of those patients.MethodsThe present study was approved by theResearch Ethics Committee of the HospitalUniversitário Antonio Pedro of the UniversidadeFederal Fluminense, in the city of Niterói, Brazil.Because the study was retrospective, patientinformed consent was not required. This wasa descriptive, retrospective observational studyof HRCT scans of the chest in 22 patients withpulmonary changes induced by cocaine use, allof which were randomly gathered via personalcontacts with radiologists and pulmonologistsfrom seven different institutions, located in sixBrazilian states. Eighteen patients were male, and4 were female. Ages ranged from 19 to 52 years.Patients were assessed for route of cocaineadministration, type of cocaine used, and thepresence of AIDS. The diagnosis was based onthe association between HRCT findings and theirtemporal relationship with cocaine use, afterexcluding other possible causes.Among the cases studied, we found patientswith different types of pulmonary involvement,presenting with different clinical syndromes causedby cocaine use. In order to group patients andtheir imaging findings efficiently, we defined asubgroup of 8 patients presenting with features ofthe “crack lung” syndrome, which is characterizedby respiratory failure associated with pulmonaryopacities that are temporally related to crackuse, with no other apparent causal factors, andwhich resolves rapidly after discontinuation ofsuch use.(8-10)As multiple institutions were involved, theHRCT scans of the chest were obtained withdifferent scanners, using the high-resolutiontechnique, with images being acquired from lungapex to lung base. The scans were evaluated bytwo radiologists independently, discordant resultsbeing resolved by consensus.J Bras Pneumol. 2015;41(4):323-330All scans were analyzed for the following:ground-glass opacities, consolidations, interlobularseptal thickening, the crazy-paving pattern,nodules, small parenchymal nodules, centrilobularnodules, the tree-in-bud pattern, cavitation, thehalo sign, paraseptal emphysema, apical bullae,bullous emphysema, masses, and architecturaldistortion. The criteria for defining these findings,as well as the terminology used, were thoserecommended in the Fleischner Society Glossaryof Terms(11) and in the consensus guidelines ofthe Colégio Brasileiro de Radiologia(12) and theDepartamento de Imagem of the SociedadeBrasileira de Pneumologia e Tisiologia.(13)In addition, all scans were assessed for thepresence of pleural effusion, pneumothorax,pneumomediastinum, and any other associatedfindings.The HRCT findings were also analyzed forlaterality (bilateral, left, or right), as well as fordistribution in the axial plane (central, peripheral,or random) and in the craniocaudal plane (upper,middle, lower, or diffuse). Lesions predominatingin the inner third of the lung were defined ascentral, those predominating in the outer thirdof the lung were defined as peripheral; and thoseshowing no preferential distribution were definedas random. The craniocaudal distribution of thelesions was characterized as follows: upper, forthose located preferably above the level of theaortic arch; middle, for those located from thelevel of the aortic arch to the level of the carina;lower, for those located below the level of thecarina; and diffuse, for those with no apparentpredominance.ResultsClinical and epidemiological aspectsWe assessed 22 patients with cocaine-inducedpulmonary disease, of whom 18 (81.81%) weremale and 4 (18.18%) were female. All patientswere adults, and ages ranged from 19 to 52years (mean age of 32 years). The route ofcocaine administration was inhalation (smokersor “snorters”), in 19 cases (86.36%), and i.v.injection, in 3 cases (13.63%). Crack use alonewas reported in 9 cases, and other cocaine use,including cocaine hydrochloride and freebasecocaine, was reported in 11 cases. Two 0000025
Cocaine-induced pulmonary changes: HRCT findings325reported both crack and other cocaine use. Theprevalence of AIDS was 22.72% (n 5).Table 1 - Frequency distribution of the pulmonarycomplications induced by cocaine use (n 22).Complicationn%“Crack ing pneumonia29.09Bullous emphysema29.09Pulmonary infarction14.54Septic embolism14.54Cardiogenic edema14.54Eosinophilic pneumonia14.54Tomographic aspectsThe clinical and tomographic findings wereconsistent with the “crack lung” syndrome in 8cases. Other forms of thoracic involvement includedbarotrauma (n 3); talcosis (n 3); organizingpneumonia (n 2); bullous emphysema (n 2); and pulmonary infarction, septic embolism,cardiogenic pulmonary edema, and chroniceosinophilic pneumonia, in 1 patient each (Table1). Those changes were clinically divided intoacute (“crack lung”, barotrauma, pulmonaryinfarction, septic embolism, and cardiogenicpulmonary edema) or chronic (talcosis, organizingpneumonia, chronic eosinophilic pneumonia,and bullous emphysema).“Crack lung”The most common HRCT finding in the 8patients classified into the “crack lung” subgroupwas ground-glass opacities, in 100% of the cases.In addition, consolidations were found in 4 ofthose cases (50%; Figure 1), and the halo signwas found in 2 (25%). The crazy-paving patternwas identified in 1 case (12.5%). In another case(12.5%), concomitant centrilobular nodules,some with the tree-in-bud pattern, were found.Paraseptal emphysema in the lung apices wasidentified in 1 case (12.5%; Table 2). Althoughthe association of HRCT patterns was common,ground-glass opacities predominated in all casesanalyzed. Regarding laterality, the involvement wasbilateral in all 8 cases. The axial plane distributionwas predominantly peripheral in 5 cases andpredominantly central in the remaining 3. Innone of the cases was the distribution random.In the craniocaudal plane, lesions were foundto predominate in the upper third of the lung in2 cases and in the lower third of the lung in 2cases. In addition, diffuse involvement was seenin 4 cases. No case was found to have lesionspredominating in the middle third of the lung.Less common complicationsBarotrauma was found in 3 patients. Two ofthose patients reported using cocaine by inhalation,and the other one reported using cocaine byinhalation and injection. Pneumomediastinum(Figure 2), pneumothorax, and 5000000025Figure 1 - “Crack lung”. A 24-year-old man witha recent history of crack use. HRCT scan showingconsolidations associated with ground-glass opacities.Table 2 - Frequency distribution of the HRCT findingsin the lung parenchyma of the patients with “cracklung” (n 8).HRCT findingn%aGround-glass opacities8100.0Consolidations450.0Consolidations with the halo sign225.0Smooth septal thickening112.5Crazy-paving pattern112.5Paraseptal emphysema112.5Centrilobular nodules112.5Tree-in-bud pattern112.5The sum of the percentages is greater than 100%, giventhat some patients had associated findings.ahemopneumothorax occurred in 1 patient,respectively. Three patients developed talcosis.One of those patients reported using cocaineby inhalation, and the other 2 reported usingcocaine by injection. All patients presented withperihilar conglomerate masses associated witharchitectural distortion and emphysema (Figure3). In 1 of the injection cocaine users, increasedJ Bras Pneumol. 2015;41(4):323-330
326Almeida RR, Zanetti G, Souza Jr AS, Souza LS, Pereira e Silva JL, Escuissato DL, et al.AFigure 2 - Barotrauma. A 23-year-old man presentingwith chest pain and no history of trauma. The HRCTscan shows free air dissecting into the mediastinalstructures and the cervical soft tissues.density was noted within the masses, whereas, inthe other one, there were also small parenchymalnodules in the adjacent parenchyma.Organizing pneumonia was identified in 2patients. Both of them reported using cocaineby inhalation and had HRCT findings of centraland peripheral consolidations associated witharchitectural distortion. The diagnosis wasconfirmed by lung biopsy. Bullous emphysemawas found in 2 patients who smoked cocaine, 1 ofwhom reported both cocaine and marijuana use. Inthat patient, HRCT showed large emphysema bullaein the lung apices, associated with architecturaldistortion. One patient developed pulmonaryinfarction and reported using cocaine by inhalation.The HRCT scan of that patient showed triangularsubpleural consolidation with a pleural base. Thediagnosis of pulmonary infarction was based onthe clinical condition of the patient in combinationwith the radionuclide imaging pattern.The patient with HRCT findings consistentwith septic embolism reported using cocaineby injection. In that case, the HRCT findingsconsisted of predominantly peripheral pulmonarynodules, most of which were cavitated (Figure 4).Cardiogenic edema was identified in 1 patient,who reported using cocaine by inhalation. TheHRCT scan of that patient showed ground-glassopacities interspersed with smooth interlobularseptal thickening, resulting in a crazy-pavingpattern, associated with bilateral pleural effusionand an enlarged cardiac silhouette. The patientwith eosinophilic pneumonia reported using crackby inhalation. He presented with peripheral andpulmonary eosinophilia. His HRCT scan showedperipheral areas of ground-glass attenuation.J Bras Pneumol. 2015;41(4):323-330BFigure 3 - Talcosis. A 35-year-old male injectioncocaine user. The axial (in A) and sagittal (in B) HRCTscans show bilateral perihilar conglomerate masses,with irregular margins, associated with architecturaldistortion and hyperlucent areas corresponding toemphysema, predominantly in the upper portions.Small parenchymal nodules can also be seen.DiscussionCocaine is the second most widely used illicitdrug (second only to marijuana) in Brazil andin the world, as well as being associated withnumerous health problems, such as those related tothe respiratory system.(5,14,15) However, identifyingcocaine use in clinical practice remains difficult,representing a diagnostic challenge. For thisreason, few case series have been published onthe topic, being primarily limited to the study ofthe profile of cocaine users and their symptoms,especially those associated with psychologicaland behavioral changes.(14,16)Because of the pulmonary impairment observedin cocaine users, chest radiology plays a criticalrole in the assessment of such patients. Largeprospective studies aimed at the radiologicalinvestigation of pulmonary changes are 00025
Cocaine-induced pulmonary changes: HRCT findingsFigure 4 - Septic embolism. A 20-year-old maleinjection cocaine user presenting with fever, cough,and purulent sputum. The HRCT scan shows multiplenodules, some cavitated, in the peripheral lung regions.and limited to CXR series.(17,18) Taking only theliterature related to CT into consideration, studiesare even scarcer, consisting of case reports andreview studies.Regarding the profile of cocaine users inBrazil and in South America, the incidence ofuse is higher in males in the 25- to 35-year agegroup.(19,20) The data found in our sample arecomparable to those from the literature, withthe incidence being higher in males (80.95%),especially in young adults (mean age of 32 years).Currently, the most widely used form ofcocaine is crack, mainly because of its intenseeuphoric effects, which are obtained within afew minutes, and its lower cost.(15,16,21) In ourstudy, crack also was the most widely used typeof cocaine, in 11 cases (50%), and, in 2 of thosecases, the patients reported both crack and othercocaine use.Cocaine can be administered by inhalation(smokers or “snorters”) and/or by i.v. injection. (5)Currently, the most widely used route ofadministration is inhalation, especially crack orfreebase cocaine smoking.(15) The preference forinhalation over i.v. injection that has occurredin recent decades is mainly due to the increasein HIV transmission via injection drug use.(22) Inour study, 86.36% of the patients reported usingcocaine by inhalation, and only 13.63% reportedusing i.v. cocaine, which is consistent with datafrom the national and international literature.In Brazil, at least two other varieties offreebase cocaine, designated “merla” and “oxi”,are administered by inhalation (smoked). (23)“Merla” contains acids obtained from 25327batteries, sometimes combined with differentorganic solvents. “Oxi”, or oxidized cocaine, issynthesized by mixing leftovers of cocaine pastewith gasoline or kerosene and raw (virgem) lime(CaO). “Oxi” has become popular as an alternativesubstance that can be sold at a very low price,and its use is spread across Brazil.(23)There is a relationship between cocaine useand the presence of HIV infection and AIDS(5);this is due to increased exposure to risky sexualbehavior and to transmission via injection druguse.(19) The prevalence of AIDS in our samplewas 22.7%.The diagnosis of cocaine-induced pulmonaryimpairment is based primarily on a history ofexposure to cocaine, consistent radiologicalfindings, and the exclusion of other apparentcauses for those findings.(24) Although knowledgeof whether patients have a history of cocaineuse is extremely important for establishing acausal relationship, rarely is this informationspontaneously provided by patients or theirguardians, which makes the diagnosis difficult.Often, this information is only obtainedretrospectively, after direct history taking,and, although 25-60% of crack users exhibitrespiratory symptoms after smoking the drug,few seek medical attention.(18,24) In most of thecases analyzed in our study, cocaine use wasmentioned by patients only at a late stage ofthe investigation.Certain physical examination findings, suchas burned fingertips, resulting from handlingthe glass pipes typically used to smoke the drug,or the presence of black sputum, characteristicof crack use and attributed to the inhalation ofcarbon residues from butane or from the alcoholsoaked cotton used for the purpose of cookingthe cocaine, can suggest the diagnosis.(5,24)The frequency of cocaine-induced pulmonarycomplications is unknown; however, a widespectrum of changes have been described inliterature reviews.(5,8,24-28) Those changes include“crack lung”, pulmonary edema, alveolarhemorrhage, interstitial disease, pulmonaryhypertension, organizing pneumonia, emphysema,barotrauma, infection, lung cancer, pulmonaryinfarction, eosinophilic disease, aspirationpneumonia, lipoid pneumonia, etc.(5,8,24-28)In our study, the HRCT scans of 22 patientswere evaluated, and the most common finding was“crack lung”, in 8 cases, followed by barotraumaJ Bras Pneumol. 2015;41(4):323-330
328Almeida RR, Zanetti G, Souza Jr AS, Souza LS, Pereira e Silva JL, Escuissato DL, et al.and talcosis, in 3 cases each. Other findingsincluded organizing pneumonia and bullousemphysema, in 2 cases each. In addition, pulmonaryinfarction, septic embolism, cardiogenic edema,and eosinophilic pneumonia were identified inone
acute (“crack lung”, barotrauma, pulmonary infarction, septic embolism, and cardiogenic pulmonary edema) or chronic (talcosis, organizing pneumonia, chronic eosinophilic pneumonia, and bullous emphysema). “Crack lung” The most common HRCT finding in the 8 patients classified into the “crack lung” subgroup
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