European Journal of Radiology, 10 (1990) 56-58 Elsevier
56
EURRAD
00002
Spontaneous pneumothorax as a complication of septic pulmonary embolism in intravenous drug addicts A. Olazabal, J. Bartrina and R. Perez Andres Department of Radiology.Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (Received
17 August 1989; accepted 20 September
Key words: Chest, pneumothorax;
Chest, pulmonary embolism;
Introduction Patients addicted to drugs taken intravenously normally show multiple puhnonary complications. The most common are infections. The high incidence of septic pulmonary embolism is well known, as well as the increased susceptibility to ordinary pneumonia and opportunistic infections. Other pulmonary lesions reported are: reactions to the drug itself, pulmonary hypertension, foreign body granulomas, Kaposi sarcoma and pneumothorax. Recently, there have been reports of pneumothoraces occurring in these patients due to pleural lesion provoked by incorrect self-injection into the internal jugular vein. We report a case of an intravenous drug addict with septic pulmonary embolism which developed a hydropneumothorax without iatrogenic intervention or internal jugular vein self-injection.
1989)
Drug, complication
right lung. These lesions measured about l-3 cm in diameter and had fuzzy edges (Fig. 1). Treatment was initiated with cloxacillin intravenously. Four days after admission, an X-ray lihn showed a right pleural effusion (Fig. 2). Twenty-four hours later chest radiographs revealed a right hydropneumothorax without any iatrogenie intervention (Fig. 3). Chest CT performed the same day demonstrated peripheral subpleural pulmonary cavitations and a right hydropneumothorax, requiring surgical drainage (Fig. 4). The pleural effusion, being totally drained, was a sterile exudate. Doppler echocardiogram performed 24 days after admission revealed tricuspid and pulmonary insufficiency. Chest radiographs taken 3 months later showed obliteration of the right costophrenic angle and small atelectasis at the lung base.
Case report A 24-year-old intravenous male, drug addict, was admitted with a purulent sputum producing cough, right-sided pleuritic pain and fever. The white blood cell count was 11200 per cubic millimeter with a marked shift to the left side. A grade l/6 tricuspid murmur was present, the echocardiogram being normal. In three blood cultures Staphylococcus aureus was yielded. A chest radiogram showed multiple nodular cavitated lesions scattered in both lungs, predominantly in the Address for reprints: Dr. Angel Olazabal Zudaire, Servicio de Radiologia, Hospital Germans Trias i Pujol, Ctra. Canyet, s/n. Apartado. Correos 72, Badalona, Barcelona, Spain. 0720-048X/90/$03.50
0 1990 Elsevier Science Publishers
Fig. 1. Close-up of the right lung showing multiple nodular lesions with cavitation (arrow).
B.V. (Biomedical
Division)
Fig. 4. Chest CT. Hydropneumothorax and subpleural cavitated lesions in the right lung (arrowheads). Note a subpleural cavitated lesion on the posterior side of the left lung (arrow). Fig. 2. Chest radiograph. Consolidation of the air space and pleural effision in the right lung. Nodular lesions in the left lower lobe (arrow).
Discussion Pulmonary involvement in intravenous drug addicts is well known. Stern and Subbarao [5] have reported the following pulmonary complications in these patients: reactions to the drug itself producing acute pulmonary oedema. Infectious complications, including septic pulmonary embolism secondary to nonsterile
injection techniques, increased susceptibility to ordinary pneumonia and opportunistic infection. Kaposi sarcoma, in drug addicts with acquired immunodeficiency and a number of miscellaneous complications including foreign body granulomas from talcum and other injected substances, pulmonary hypertension and pleural [ 1,3,6] and mediastinal disease. Bacterial endocarditis and congestive failure are also mentioned [ 31. MacMillan et al. [4] have classified pulmonary embolism according to source. Cardiac septic emboli arising from tricuspid endocarditis is a frequent feature in these patients. Peripheral endogenous emboli can also appear in patients with thrombophlebitis near the injection site as well as peripheral exogenous emboli, which is usually secondary to nonsterile injection techniques. Septic pulmonary embolism may present as small, scattered areas of consolidation simulating bronchopneumonia and extending rapidly or as round or wedgeshaped peripheral opacities. Quickly excavating, they produce thin-walled cavities simulating pneumatoceles. Coalescence of necrotic infarcts may result in the formation of large abcesses. Lesions may extend to involve the pleura, causing empyema, bronchopleural fistula, and more infrequently pneumothorax. Following therapy, lesions may resolve completely or leave residual thickening or areas of pulmonary fibrosis
[21-
Fig. 3. Chest radiograph. Hydropneumothorax with pleural herences and subpleural consolidation in the right lung.
ad-
In the cases of pneumothorax reviewed in these patients we have found that incorrect self-injection into the jugular veins for the administration of the drug was one of the causes which initially had not been given any value in clinical history or physical examination. In our
58
case, there was no iatrogenic intervention (thoracentesis) or objective data about self-injection which explained the appearence of pneumothorax. Probably the cause of pneumothorax in our patient was the necrosis of one of the multiple septic peripheral infarcts, producing communication of the air ways with the pleural space. Due to the increase in the prevalence of intravenous drug addiction in present-day society, we think it interesting to report this case of infrequent evolution in intravenous drug addict patients with pulmonary embolism, as an increase in the number of this type of complication is foreseeable. Epidemiological studies should be conducted with a larger number of cases to establish a cause and effect relationship between pulmonary embolism and pneumothorax.
References 1 Cohen JH, Cohen SW. Spontaneous bilateral pneumothorax in drug addicts. Chest 1984; 86: 645-647. 2 JafTe RB, Koschmann EB. Septic pulmonary emboli. Radiology 1970; 96: 527-532. 3 Kurtzman RS. Complications of narcotic addiction. Radiology 1970; 96: 23-30. 4 MacMillan JC, Milstein SH, Samson PC. Clinical spectrum of pulmonary embolism and infarction. J Thorac-Cardiovasc-Surg 1978; 75: 670-679. 5 Stern WZ, Subbarao K. Pulmonary complications of drug addiction. Semin Roentgen01 1983; 18: 183-197. 6 Zorc TG, O’Donnell AE, Holt RW, Pappas LS, Slakey J. Bilateral Pyopneumothorax secondary to intravenous drug abuse. Chest 1988; 93: 645-647.
56
EURRAD
00002
Spontaneous pneumothorax as a complication of septic pulmonary embolism in intravenous drug addicts A. Olazabal, J. Bartrina and R. Perez Andres Department of Radiology.Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (Received
17 August 1989; accepted 20 September
Key words: Chest, pneumothorax;
Chest, pulmonary embolism;
Introduction Patients addicted to drugs taken intravenously normally show multiple puhnonary complications. The most common are infections. The high incidence of septic pulmonary embolism is well known, as well as the increased susceptibility to ordinary pneumonia and opportunistic infections. Other pulmonary lesions reported are: reactions to the drug itself, pulmonary hypertension, foreign body granulomas, Kaposi sarcoma and pneumothorax. Recently, there have been reports of pneumothoraces occurring in these patients due to pleural lesion provoked by incorrect self-injection into the internal jugular vein. We report a case of an intravenous drug addict with septic pulmonary embolism which developed a hydropneumothorax without iatrogenic intervention or internal jugular vein self-injection.
1989)
Drug, complication
right lung. These lesions measured about l-3 cm in diameter and had fuzzy edges (Fig. 1). Treatment was initiated with cloxacillin intravenously. Four days after admission, an X-ray lihn showed a right pleural effusion (Fig. 2). Twenty-four hours later chest radiographs revealed a right hydropneumothorax without any iatrogenie intervention (Fig. 3). Chest CT performed the same day demonstrated peripheral subpleural pulmonary cavitations and a right hydropneumothorax, requiring surgical drainage (Fig. 4). The pleural effusion, being totally drained, was a sterile exudate. Doppler echocardiogram performed 24 days after admission revealed tricuspid and pulmonary insufficiency. Chest radiographs taken 3 months later showed obliteration of the right costophrenic angle and small atelectasis at the lung base.
Case report A 24-year-old intravenous male, drug addict, was admitted with a purulent sputum producing cough, right-sided pleuritic pain and fever. The white blood cell count was 11200 per cubic millimeter with a marked shift to the left side. A grade l/6 tricuspid murmur was present, the echocardiogram being normal. In three blood cultures Staphylococcus aureus was yielded. A chest radiogram showed multiple nodular cavitated lesions scattered in both lungs, predominantly in the Address for reprints: Dr. Angel Olazabal Zudaire, Servicio de Radiologia, Hospital Germans Trias i Pujol, Ctra. Canyet, s/n. Apartado. Correos 72, Badalona, Barcelona, Spain. 0720-048X/90/$03.50
0 1990 Elsevier Science Publishers
Fig. 1. Close-up of the right lung showing multiple nodular lesions with cavitation (arrow).
B.V. (Biomedical
Division)
Fig. 4. Chest CT. Hydropneumothorax and subpleural cavitated lesions in the right lung (arrowheads). Note a subpleural cavitated lesion on the posterior side of the left lung (arrow). Fig. 2. Chest radiograph. Consolidation of the air space and pleural effision in the right lung. Nodular lesions in the left lower lobe (arrow).
Discussion Pulmonary involvement in intravenous drug addicts is well known. Stern and Subbarao [5] have reported the following pulmonary complications in these patients: reactions to the drug itself producing acute pulmonary oedema. Infectious complications, including septic pulmonary embolism secondary to nonsterile
injection techniques, increased susceptibility to ordinary pneumonia and opportunistic infection. Kaposi sarcoma, in drug addicts with acquired immunodeficiency and a number of miscellaneous complications including foreign body granulomas from talcum and other injected substances, pulmonary hypertension and pleural [ 1,3,6] and mediastinal disease. Bacterial endocarditis and congestive failure are also mentioned [ 31. MacMillan et al. [4] have classified pulmonary embolism according to source. Cardiac septic emboli arising from tricuspid endocarditis is a frequent feature in these patients. Peripheral endogenous emboli can also appear in patients with thrombophlebitis near the injection site as well as peripheral exogenous emboli, which is usually secondary to nonsterile injection techniques. Septic pulmonary embolism may present as small, scattered areas of consolidation simulating bronchopneumonia and extending rapidly or as round or wedgeshaped peripheral opacities. Quickly excavating, they produce thin-walled cavities simulating pneumatoceles. Coalescence of necrotic infarcts may result in the formation of large abcesses. Lesions may extend to involve the pleura, causing empyema, bronchopleural fistula, and more infrequently pneumothorax. Following therapy, lesions may resolve completely or leave residual thickening or areas of pulmonary fibrosis
[21-
Fig. 3. Chest radiograph. Hydropneumothorax with pleural herences and subpleural consolidation in the right lung.
ad-
In the cases of pneumothorax reviewed in these patients we have found that incorrect self-injection into the jugular veins for the administration of the drug was one of the causes which initially had not been given any value in clinical history or physical examination. In our
58
case, there was no iatrogenic intervention (thoracentesis) or objective data about self-injection which explained the appearence of pneumothorax. Probably the cause of pneumothorax in our patient was the necrosis of one of the multiple septic peripheral infarcts, producing communication of the air ways with the pleural space. Due to the increase in the prevalence of intravenous drug addiction in present-day society, we think it interesting to report this case of infrequent evolution in intravenous drug addict patients with pulmonary embolism, as an increase in the number of this type of complication is foreseeable. Epidemiological studies should be conducted with a larger number of cases to establish a cause and effect relationship between pulmonary embolism and pneumothorax.
References 1 Cohen JH, Cohen SW. Spontaneous bilateral pneumothorax in drug addicts. Chest 1984; 86: 645-647. 2 JafTe RB, Koschmann EB. Septic pulmonary emboli. Radiology 1970; 96: 527-532. 3 Kurtzman RS. Complications of narcotic addiction. Radiology 1970; 96: 23-30. 4 MacMillan JC, Milstein SH, Samson PC. Clinical spectrum of pulmonary embolism and infarction. J Thorac-Cardiovasc-Surg 1978; 75: 670-679. 5 Stern WZ, Subbarao K. Pulmonary complications of drug addiction. Semin Roentgen01 1983; 18: 183-197. 6 Zorc TG, O’Donnell AE, Holt RW, Pappas LS, Slakey J. Bilateral Pyopneumothorax secondary to intravenous drug abuse. Chest 1988; 93: 645-647.
