(Radiographics. 2002;22:S119-S135.)
© RSNA, 2002
Thoracic Complications of Illicit Drug Use: An Organ System Approach1
Michael B. Gotway, MD,
Shelley R. Marder, MD,
Douglas K. Hanks, MD,
Jessica W. T. Leung, MD,
Samuel K. Dawn, MD,
Alisa D. Gean, MD,
Gautham P. Reddy, MD, MPH,
Philip A. Araoz, MD and
W. Richard Webb, MD
1 From the Departments of Radiology (M.B.G., S.R.M., S.K.D., A.D.G.) and Pathology (D.K.H.), San Francisco General Hospital, 1001 Potrero Ave, Rm 1X 55A, Box 1325, San Francisco, CA 94110; the Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass (J.W.T.L.); and the Department of Radiology, University of California, San Francisco (M.B.G., S.R.M., S.K.D., A.D.G., G.P.R., P.A.A., W.R.W.). Presented as an education exhibit at the 2001 RSNA scientific assembly. Received February 6, 2001; revision requested March 18 and received April 12; accepted April 18. Address correspondence to M.B.G. (e-mail: michael.gotway@radiology.ucsf.edu).
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Abstract
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Illicit drug use constitutes a major health problem and may be associated with various thoracic complications. These complications vary depending on the specific drug used and the route of administration. Commonly abused drugs that may play a role in causing thoracic disease include cocaine, opiates, and methamphetamine derivatives. Intravenously abused oral medications may contain filler agents that may be responsible for disease. Thoracic complications may be categorized as pulmonary, pleural, mediastinal, cardiovascular, and chest wall complications. Pulmonary complications of drug abuse include pneumonia, cardiogenic edema, acute lung injury, pulmonary hemorrhage, and aspiration pneumonia. Filler agents such as talc may result in panacinar emphysema or high-attenuation upper-lobe conglomerate masses. The primary pleural complication of illicit drug use is pneumothorax. Mediastinal and cardiovascular complications of illicit drug use include pneumomediastinum, cardiomyopathy, myocardial infarction, aortic dissection, and injection-related pseudoaneurysms. Chest wall complications include diskitis and vertebral osteomyelitis, epidural abscess, necrotizing fasciitis, costochondritis, and septic arthritis. Categorization of thoracic complications of illicit drug use may facilitate understanding of these disorders and allow accurate diagnosis.
© RSNA, 2002
Index Terms: Drugs, abuse, 47.64, 50.64, 60.64 • Drugs, side effects, 47.64, 50.64, 60.64 • Lung, effects of drugs on, 60.21, 60.214, 60.64, 60.71, 60.751 • Mediastinum, diseases, 67.735 • Pericardium, abnormalities, 55.823 • Pleura, diseases, 66.73 • Talc • Thorax, CT, 60.1211 • Thorax, diseases, 47.21, 50.491, 50.761
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Introduction
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Illicit drug use is a major health problem in both urban and suburban settings. Illicit drugs that may result in thoracic complications include cocaine and its derivatives, especially crack; methamphetamine derivatives, including methylphenidate hydrochloride (Ritalin; Novartis, East Hanover, NJ); opiates such as heroin and methadone, among others; and mixtures of these agents. Furthermore, substances that are commonly mixed with an illicit drug, known as "fillers," may be primarily responsible for disease. Fillers include talc, cornstarch, and cellulose.
The complications of drug abuse are greatly dependent on the substance used. For instance, cocaine and its derivatives, such as crack, are sympathomimetic agents; the increased blood pressure resulting from their use predisposes to aortic dissection and ischemic events. Narcotic agents, such as heroin and other opiates, cause respiratory depression and thus predispose to aspiration pneumonia. In addition, the method of administration may determine the type of complication. Inhaled agents may result in direct pulmonary toxicity, whereas injected agents may cause complications related to the injection. Finally, the relative lack of sterility in the preparation may be a primary cause of complications. Although complications of drug abuse frequently affect multiple organs, thoracic complications are among the most commonly encountered. They may be divided into pulmonary, pleural, mediastinal, cardiovascular, and chest wall complications. An organized approach to the various thoracic complications of illicit drug use and a high degree of suspicion are important for early and accurate diagnosis. In this article, we discuss and illustrate a wide spectrum of thoracic complications of illicit drug use.
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Pulmonary Complications
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Pulmonary complications of illicit drug use include pneumonia, cardiogenic pulmonary edema, acute lung injury, pulmonary hemorrhage, aspiration pneumonia, septic embolization, emphysema, and talc-induced lung disease.
Pneumonia
A suggested increased frequency of infections in patients who abuse drugs, particularly intravenous drugs (1), points to pneumonia as one of the more commonly encountered thoracic complications of illicit drug use. The mechanisms that result in an increased prevalence of infection in intravenous drug users are not completely understood but may include the use of contaminated drugs and needles, skin colonization by unusual or virulent organisms from previous hospitalizations, and changes in normal bacterial flora due to self-medication with antibiotics (2,3).
Cardiogenic Pulmonary Edema
Illicit drug use, particularly that of sympathomimetic agents such as cocaine, may cause cardiogenic pulmonary edema by inducing ischemia-related transient myocardial dysfunction, severe peripheral vasoconstriction with transient left ventricular failure, cardiac arrhythmia, or frank myocardial infarction (4,5). The radiographic manifestations of cardiogenic pulmonary edema are well known and include cardiomegaly, peribronchovascular and interlobular septal thickening, pleural effusions, and, when severe, airspace areas of increased opacity that represent alveolar edema (Fig 1). At high-resolution computed tomography (CT), cardiogenic pulmonary edema manifests as smooth interlobular septal thickening, pleural effusions, and ground-glass attenuation.
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Figure 1. Acute myocardial infarction following cocaine use in a 53-year-old man. Frontal chest radiograph shows bilateral, symmetric areas of increased opacity that represent cardiogenic pulmonary edema. The differential diagnosis of these findings must be broad and include acute lung injury due to a variety of causes, diffuse infection, and noninfectious inflammatory conditions such as pulmonary hemorrhage and acute hypersensitivity pneumonitis. Pulmonary arterial catheter measurements confirmed elevated pulmonary capillary wedge pressure.
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Acute Lung Injury and Noncardiogenic Pulmonary Edema
Both inhaled and intravenously abused drugs, including opiates and cocaine or crack, may cause acute lung injury and noncardiogenic pulmonary edema (4,6–9). The exact means by which increased pulmonary capillary permeability occurs in persons using opiates, cocaine, or crack is unclear, but reports of an increase in protein concentration in bronchoalveolar lavage fluid imply a pulmonary endothelial abnormality (9–11). The central nervous system depression that accompanies opiate use suggests that neurogenic pulmonary edema may also contribute to opiate-induced acute lung injury. Acute lung injury manifests as bilateral, perihilar areas of increased opacity or attenuation, usually without pleural effusion or cardiomegaly (Figs 2, 3). High-resolution CTmay show multifocal ground-glass attenuation associated with septal thickening (Fig 3b). In the classic case, acute lung injury that results from opiate overdose or cocaine use clears rapidly over a period of hours after cessation of use of the offending agent (Figs 2, 3), although acute lung injury related to methadone overdose may take somewhat longer to resolve than that related to overdoses of other opiates (12–14).
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Figure 2a. Heroin-induced acute lung injury following heroin ingestion in a 33-year-old man. (a) Frontal chest radiograph obtained shortly after presentation to the emergency department reveals bilateral areas of increased opacity (arrows), a finding that is consistent with acute lung injury. (b) Follow-up chest radiograph obtained 2 days later reveals complete clearing of the areas of increased opacity. Such rapid clearing is common in heroin-induced lung injury.
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Figure 2b. Heroin-induced acute lung injury following heroin ingestion in a 33-year-old man. (a) Frontal chest radiograph obtained shortly after presentation to the emergency department reveals bilateral areas of increased opacity (arrows), a finding that is consistent with acute lung injury. (b) Follow-up chest radiograph obtained 2 days later reveals complete clearing of the areas of increased opacity. Such rapid clearing is common in heroin-induced lung injury.
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Figure 3a. Acute lung injury (crack lung) in a 37-year-old man who presented with shortness of breath and cough after crack use. (a) Frontal chest radiograph reveals ground-glass areas of increased opacity in the right lower lobe (arrow), a finding that is consistent with numerous causes, including edema, infection, hemorrhage, and aspiration. (b) High-resolution CT scan (level = -700 HU, window width = 1,000 HU) reveals ground-glass attenuation (arrows) with interlobular septal thickening (arrowheads). The differential diagnosis of these findings includes infection (especially Pneumocystis carinii pneumonia), lipoid pneumonia, and alveolar proteinosis, among numerous other causes. (c) Frontal chest radiograph obtained 2 days after CT shows resolution of the increased opacity.
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Figure 3b. Acute lung injury (crack lung) in a 37-year-old man who presented with shortness of breath and cough after crack use. (a) Frontal chest radiograph reveals ground-glass areas of increased opacity in the right lower lobe (arrow), a finding that is consistent with numerous causes, including edema, infection, hemorrhage, and aspiration. (b) High-resolution CT scan (level = -700 HU, window width = 1,000 HU) reveals ground-glass attenuation (arrows) with interlobular septal thickening (arrowheads). The differential diagnosis of these findings includes infection (especially Pneumocystis carinii pneumonia), lipoid pneumonia, and alveolar proteinosis, among numerous other causes. (c) Frontal chest radiograph obtained 2 days after CT shows resolution of the increased opacity.
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Figure 3c. Acute lung injury (crack lung) in a 37-year-old man who presented with shortness of breath and cough after crack use. (a) Frontal chest radiograph reveals ground-glass areas of increased opacity in the right lower lobe (arrow), a finding that is consistent with numerous causes, including edema, infection, hemorrhage, and aspiration. (b) High-resolution CT scan (level = -700 HU, window width = 1,000 HU) reveals ground-glass attenuation (arrows) with interlobular septal thickening (arrowheads). The differential diagnosis of these findings includes infection (especially Pneumocystis carinii pneumonia), lipoid pneumonia, and alveolar proteinosis, among numerous other causes. (c) Frontal chest radiograph obtained 2 days after CT shows resolution of the increased opacity.
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Pulmonary Hemorrhage
In addition to acute lung injury and noncardiogenic pulmonary edema, pulmonary hemorrhage may result from abuse of cocaine and crack (15). At radiography, pulmonary hemorrhage manifests as multifocal bilateral areas of increased opacity with a normal heart size (Fig 4a). Effusions are usually small or absent. High-resolution CT usually reveals multifocal ground-glass attenuation that is occasionally centrilobular in distribution and associated with interlobular septal thickening (Fig 4b). Pulmonary hemorrhage clears rapidly after cessation of use of the responsible agent (Fig 4c). Because pulmonary hemorrhage and acute lung injury are radiographically indistinguishable, the development of respiratory failure with bilateral airspace areas of increased opacity that appear shortly after crack use and clear rapidly after cessation of drug use has been termed "crack lung" (8).
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Figure 4a. Pulmonary hemorrhage in a 29-year-old male crack smoker who presented with abrupt onset of shortness of breath and hemoptysis. (a) Frontal chest radiograph shows lower-lobe ground-glass areas of increased opacity and consolidation (arrows). (b) High-resolution CT scan (level = -700 HU, window width = 1,000 HU) reveals bilateral ground-glass attenuation (arrows), peribronchovascular thickening, and interlobular septal thickening. Bronchoscopy showed pulmonary hemorrhage. (c) High-resolution CT scan (level = -700 HU, window width = 1,000 HU) obtained 2 months later shows resolution of the previously abnormal areas.
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Figure 4b. Pulmonary hemorrhage in a 29-year-old male crack smoker who presented with abrupt onset of shortness of breath and hemoptysis. (a) Frontal chest radiograph shows lower-lobe ground-glass areas of increased opacity and consolidation (arrows). (b) High-resolution CT scan (level = -700 HU, window width = 1,000 HU) reveals bilateral ground-glass attenuation (arrows), peribronchovascular thickening, and interlobular septal thickening. Bronchoscopy showed pulmonary hemorrhage. (c) High-resolution CT scan (level = -700 HU, window width = 1,000 HU) obtained 2 months later shows resolution of the previously abnormal areas.
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Figure 4c. Pulmonary hemorrhage in a 29-year-old male crack smoker who presented with abrupt onset of shortness of breath and hemoptysis. (a) Frontal chest radiograph shows lower-lobe ground-glass areas of increased opacity and consolidation (arrows). (b) High-resolution CT scan (level = -700 HU, window width = 1,000 HU) reveals bilateral ground-glass attenuation (arrows), peribronchovascular thickening, and interlobular septal thickening. Bronchoscopy showed pulmonary hemorrhage. (c) High-resolution CT scan (level = -700 HU, window width = 1,000 HU) obtained 2 months later shows resolution of the previously abnormal areas.
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Aspiration Pneumonia
The central nervous system depression that accompanies the use of some illicit drugs, particularly opiates, impairs airway protection and renders drug users susceptible to aspiration pneumonia (4). It characteristically affects dependent regions of lung tissue, particularly the superior segments of the lower lobes (Fig 5) and the apical and posterior segments of the upper lobes, especially when the aspiration event occurs while the patient is recumbent. Because of the relatively vertical orientation of the right mainstem bronchus, the right lung is affected more than the left (Fig 5a, 5c). At radiography, consolidation, perhaps with volume loss, is seen in this distribution. This characteristic distribution may be more easily appreciated at CT (Fig 5c). Bronchiectasis, which has been reported in some heroin addicts with a history of acute lung injury related to drug use, is probably related to recurrent infection and aspiration (16,17).
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Figure 5a. Aspiration pneumonia in a 38-year-old man with obtundation following heroin overdose. (a) Frontal chest radiograph reveals bilateral areas of increased opacity, more prominent on the right side than on the left, projected over the hila (arrows). (b) Lateral chest radiograph shows that the areas of increased opacity (arrows) are somewhat masslike and are located posteriorly. (c) CT scan (7-mm collimation, level = -700 HU, window width = 1,000 HU) shows volume loss (detectable owing to the retracted position of the right major fissure) and bilateral consolidation in the superior segments of the lower lobes (arrows). Food particles were removed with bronchoscopy.
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Figure 5b. Aspiration pneumonia in a 38-year-old man with obtundation following heroin overdose. (a) Frontal chest radiograph reveals bilateral areas of increased opacity, more prominent on the right side than on the left, projected over the hila (arrows). (b) Lateral chest radiograph shows that the areas of increased opacity (arrows) are somewhat masslike and are located posteriorly. (c) CT scan (7-mm collimation, level = -700 HU, window width = 1,000 HU) shows volume loss (detectable owing to the retracted position of the right major fissure) and bilateral consolidation in the superior segments of the lower lobes (arrows). Food particles were removed with bronchoscopy.
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Figure 5c. Aspiration pneumonia in a 38-year-old man with obtundation following heroin overdose. (a) Frontal chest radiograph reveals bilateral areas of increased opacity, more prominent on the right side than on the left, projected over the hila (arrows). (b) Lateral chest radiograph shows that the areas of increased opacity (arrows) are somewhat masslike and are located posteriorly. (c) CT scan (7-mm collimation, level = -700 HU, window width = 1,000 HU) shows volume loss (detectable owing to the retracted position of the right major fissure) and bilateral consolidation in the superior segments of the lower lobes (arrows). Food particles were removed with bronchoscopy.
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Septic Embolization
Nonsterile injection techniques may cause bacteremia, which predisposes to tricuspid valve endocarditis. Once vegetations form on the tricuspid valve, recurrent septic embolization may occur (4). Nonsterile injection techniques may also result in septic thrombophlebitis, which in turn may be the source of septic embolization (4). Staphylococcus species are the most common offending organisms. Septic emboli appear at chest radiography as multifocal ill-defined lung nodules that cavitate over a period of days (Fig 6a). Foci of necrotizing pneumonia may also be encountered. CT characteristically shows multiple ill-defined, peripherally distributed lung nodules in various phases of cavitation (Fig 6b) and may reveal areas of septic infarction (Fig 7).
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Figure 6a. Respiratory failure due to endocarditis and septic embolization in a 28-year-old man. (a) Frontal chest radiograph reveals diffuse bilateral areas of increased opacity and numerous cavities (arrows), which are consistent with septic emboli. (b) CT scan (7-mm collimation, level = -600 HU, window width = 1,500 HU) shows diffuse ground-glass attenuation, which represents diffuse alveolar damage, and multiple cavities (arrows), which are consistent with septic emboli. Left anterior pneumothorax is also present. (c) CT scan of the lower pelvis (7-mm collimation, level = 45 HU, window width = 440 HU) reveals an irregular air collection in the right side of the groin (small arrows), which indicates a recent site of self-injection by the patient, as well as a fractured needle fragment in the left side of the groin (large arrow).
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Figure 6b. Respiratory failure due to endocarditis and septic embolization in a 28-year-old man. (a) Frontal chest radiograph reveals diffuse bilateral areas of increased opacity and numerous cavities (arrows), which are consistent with septic emboli. (b) CT scan (7-mm collimation, level = -600 HU, window width = 1,500 HU) shows diffuse ground-glass attenuation, which represents diffuse alveolar damage, and multiple cavities (arrows), which are consistent with septic emboli. Left anterior pneumothorax is also present. (c) CT scan of the lower pelvis (7-mm collimation, level = 45 HU, window width = 440 HU) reveals an irregular air collection in the right side of the groin (small arrows), which indicates a recent site of self-injection by the patient, as well as a fractured needle fragment in the left side of the groin (large arrow).
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Figure 6c. Respiratory failure due to endocarditis and septic embolization in a 28-year-old man. (a) Frontal chest radiograph reveals diffuse bilateral areas of increased opacity and numerous cavities (arrows), which are consistent with septic emboli. (b) CT scan (7-mm collimation, level = -600 HU, window width = 1,500 HU) shows diffuse ground-glass attenuation, which represents diffuse alveolar damage, and multiple cavities (arrows), which are consistent with septic emboli. Left anterior pneumothorax is also present. (c) CT scan of the lower pelvis (7-mm collimation, level = 45 HU, window width = 440 HU) reveals an irregular air collection in the right side of the groin (small arrows), which indicates a recent site of self-injection by the patient, as well as a fractured needle fragment in the left side of the groin (large arrow).
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Figure 7. Endocarditis and septic embolization in a 34-year-old man. CT scan (level = -700 HU, window width = 1,000 HU) reveals a wedge-shaped area of consolidation in the periphery of the right lung (arrow), a finding that represents pulmonary infarction.
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Emphysema
The development of upper lobe–predominant bullae has also been associated with intravenous drug abuse (Fig 8) (18,19). Although coincident cigarette use may also contribute to the development of bullae in patients who use illicit drugs, the limited history of cigarette use and the young age frequently encountered in these patients suggest that the illicit drugs themselves may play a direct role (19).
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Figure 8a. Emphysema in a 34-year-old man with a history of intravenous substance abuse and cigarette smoking. (a) Frontal chest radiograph shows enormous lung volumes with large upper lobe-predominant bullae (arrows). (b) CT scan (7-mm collimation, level = -700 HU, window width = 1,000 HU) shows the extensive mass effect of the huge bullae, which are compressing the remaining pulmonary parenchyma (large arrow). Air-fluid levels in several right-sided bullae and right medial lung consolidation (small arrows) represent superinfection.
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Figure 8b. Emphysema in a 34-year-old man with a history of intravenous substance abuse and cigarette smoking. (a) Frontal chest radiograph shows enormous lung volumes with large upper lobe-predominant bullae (arrows). (b) CT scan (7-mm collimation, level = -700 HU, window width = 1,000 HU) shows the extensive mass effect of the huge bullae, which are compressing the remaining pulmonary parenchyma (large arrow). Air-fluid levels in several right-sided bullae and right medial lung consolidation (small arrows) represent superinfection.
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The intravenous injection of a number of oral medications has been associated with the development of emphysema and bulla formation. The intravenous abuse of methylphenidate in particular has been connected to the development of a specific pattern of lower-lobe emphysema that resembles panacinar emphysema due to 
1-protease inhibitor deficiency (20). Methylphenidate is one medication that is frequently mixed with talc as a filler. Although it is unclear whether the development of emphysema is related mostly to the presence of talc or is due more to methylphenidate, a panacinar pattern of emphysema is seen more often in patients who abuse that drug than in those who abuse other talc-containing drugs (21–23). At radiography, the development of emphysema associated with intravenous methylphenidate abuse results in large lung volumes with lower-lobe hyperlucency (Fig 9a). High-resolution CT reveals lower lobe–predominant simplification of the pulmonary architecture, a finding that resembles panacinar emphysema (Fig 9b) (23). Histopathologic specimens examined with polarized light reveal the refractile talc particles. Bullae and centrilobular emphysema are not features of this disease, although they may occur in association with it owing to the coincident use of tobacco.
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Figure 9a. Emphysema related to methylphenidate abuse in a 45-year-old woman with a long history of such abuse. (a) Frontal chest radiograph reveals huge lung volumes with lower lobe-predominant hyperlucency. (b) CT scan (7-mm collimation, level = -1,000 HU, window width = -700 HU) shows extensive lower-lobe hyperlucency with simplification of the pulmonary architecture, a pattern that resembles panacinar emphysema due to 1-protease inhibitor deficiency. (c) Low-power photomicrograph (original magnification, x40; hematoxylin-eosin stain) of a histologic specimen obtained with polarized light reveals multiple refractile particles consistent with talc (arrows).
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Figure 9b. Emphysema related to methylphenidate abuse in a 45-year-old woman with a long history of such abuse. (a) Frontal chest radiograph reveals huge lung volumes with lower lobe-predominant hyperlucency. (b) CT scan (7-mm collimation, level = -1,000 HU, window width = -700 HU) shows extensive lower-lobe hyperlucency with simplification of the pulmonary architecture, a pattern that resembles panacinar emphysema due to 1-protease inhibitor deficiency. (c) Low-power photomicrograph (original magnification, x40; hematoxylin-eosin stain) of a histologic specimen obtained with polarized light reveals multiple refractile particles consistent with talc (arrows).
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Figure 9c. Emphysema related to methylphenidate abuse in a 45-year-old woman with a long history of such abuse. (a) Frontal chest radiograph reveals huge lung volumes with lower lobe-predominant hyperlucency. (b) CT scan (7-mm collimation, level = -1,000 HU, window width = -700 HU) shows extensive lower-lobe hyperlucency with simplification of the pulmonary architecture, a pattern that resembles panacinar emphysema due to 1-protease inhibitor deficiency. (c) Low-power photomicrograph (original magnification, x40; hematoxylin-eosin stain) of a histologic specimen obtained with polarized light reveals multiple refractile particles consistent with talc (arrows).
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Pulmonary Disease Related to Filler Agents
Talc (magnesium silicate) is an insoluble filler used in several oral medications to bind the active medicinal agent within the individual tablets. When oral medications are crushed, dissolved, and injected intravenously, talc particles embolize small pulmonary vessels, resulting in occlusion and, possibly, pulmonary hypertension. The talc particles may then migrate into the pulmonary interstitium, where they induce a foreign-body reaction and fibrosis (22).
Nodules Related to Intravenous Injection of Talc
At chest radiography, injection talcosis may appear as irregular nodular areas of increased opacity in the middle and upper areas of the lungs that may coalesce to form conglomerate masses (24). Diffuse small nodules may be the first manifestation of talc-induced lung disease, with enlargement of the nodules being observed as the disease progresses (20). On occasion, lymphadenopathy is present (24). In the later stages of talc-induced pulmonary disease, upper-lobe conglomerate masses that resemble progressive massive fibrosis may develop (Fig 10a) (20). These areas of increased opacity are often superimposed on a background of numerous small nodules and lower lobe–predominant emphysema.
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Figure 10a. Talc-induced lung disease in a 34-year-old man with acquired immunodeficiency syndrome and a long history of intravenous drug abuse, including the use of methylphenidate. (a) Frontal chest radiograph reveals irregular nodular areas of increased opacity in the upper lobes associated with architectural distortion (arrows). (b) High-resolution CT scan (level = 40 HU, window width = 440 HU) reveals that the upper-lobe process in a has high attenuation (arrows). The location and appearance of this finding, particularly the increased attenuation, are suggestive of talc-induced lung disease.
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Figure 10b. Talc-induced lung disease in a 34-year-old man with acquired immunodeficiency syndrome and a long history of intravenous drug abuse, including the use of methylphenidate. (a) Frontal chest radiograph reveals irregular nodular areas of increased opacity in the upper lobes associated with architectural distortion (arrows). (b) High-resolution CT scan (level = 40 HU, window width = 440 HU) reveals that the upper-lobe process in a has high attenuation (arrows). The location and appearance of this finding, particularly the increased attenuation, are suggestive of talc-induced lung disease.
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Several patterns of talcosis have been described at high-resolution CT. They include numerous small nodules with or without lower lobe–predominant panacinar emphysema, ground-glass attenuation, and multiple small nodules accompanied by conglomerate masses (21,22,25). The conglomerate masses may have high attenuation (Fig 10b). These patterns are often seen in combination (22).
Other fillers used in oral medications may cause pulmonary disease when they are crushed and injected intravenously, particularly cellulose. The trapping of cellulose particles within pulmonary arterioles results in inflammation and eventually causes a granulomatous foreign-body reaction much like talcosis (26). At CT, cellulose granulomatosis appears as numerous small nodules, often in a centrilobular distribution. A tree-in-bud appearance related to cellulose granulomatosis has recently been described at high-resolution CT (26).
Nodular pulmonary parenchymal amyloidosis has recently been reported in association with intravenous abuse of medications intended for oral use (27). Amyloidosis represents a heterogeneous group of disorders that result from the deposition of fibrillar, proteinaceous material within various tissues. Systemic amyloidosis may be associated with chronic infections and illnesses, particularly rheumatic diseases, and drug abuse. Pulmonary parenchymal amyloidosis may take several forms, including tracheobronchial amyloidosis, nodular parenchymal amyloidosis, and alveolar septal amyloidosis. A recent report identified a nodular pulmonary parenchymal form of amyloidosis that may be associated with intravenous drug abuse (27). Most often, this disease manifests as small, well-defined nodules, although single nodules may also occur (Fig 11).
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Figure 11a. Surgically proved pulmonary amyloidosis in a 44-year-old woman with a history of intravenous drug abuse. (a) Frontal chest radiograph reveals a nodule projected over the right hilum (arrows). (b) CT scan (10-mm collimation, level = 40 HU, window width = 440 HU) shows irregular calcification within the central portion of the nodule (arrows). The presence of calcification within a solitary pulmonary nodule suggests that the lesion is benign, possibly an infectious granuloma. Nevertheless, a significant portion of the mass is not calcified, which raises the possibility of malignancy; bronchogenic carcinoma and carcinoid tumor should be considered. Amyloidosis was proved at surgery. (c) Low-power photomicrograph (original magnification, x10; Congo red stain) shows multiple apple-green birefringent particles (arrows), a finding that is consistent with amyloidosis. Talc (not shown) was also present within the biopsy specimen.
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Figure 11b. Surgically proved pulmonary amyloidosis in a 44-year-old woman with a history of intravenous drug abuse. (a) Frontal chest radiograph reveals a nodule projected over the right hilum (arrows). (b) CT scan (10-mm collimation, level = 40 HU, window width = 440 HU) shows irregular calcification within the central portion of the nodule (arrows). The presence of calcification within a solitary pulmonary nodule suggests that the lesion is benign, possibly an infectious granuloma. Nevertheless, a significant portion of the mass is not calcified, which raises the possibility of malignancy; bronchogenic carcinoma and carcinoid tumor should be considered. Amyloidosis was proved at surgery. (c) Low-power photomicrograph (original magnification, x10; Congo red stain) shows multiple apple-green birefringent particles (arrows), a finding that is consistent with amyloidosis. Talc (not shown) was also present within the biopsy specimen.
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Figure 11c. Surgically proved pulmonary amyloidosis in a 44-year-old woman with a history of intravenous drug abuse. (a) Frontal chest radiograph reveals a nodule projected over the right hilum (arrows). (b) CT scan (10-mm collimation, level = 40 HU, window width = 440 HU) shows irregular calcification within the central portion of the nodule (arrows). The presence of calcification within a solitary pulmonary nodule suggests that the lesion is benign, possibly an infectious granuloma. Nevertheless, a significant portion of the mass is not calcified, which raises the possibility of malignancy; bronchogenic carcinoma and carcinoid tumor should be considered. Amyloidosis was proved at surgery. (c) Low-power photomicrograph (original magnification, x10; Congo red stain) shows multiple apple-green birefringent particles (arrows), a finding that is consistent with amyloidosis. Talc (not shown) was also present within the biopsy specimen.
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Pleural Complications
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Pleural complications of illicit drug use are primarily related to pneumothorax. Pneumothorax is commonly due to attempted intravenous injections in the supraclavicular fossa, the so-called "pocket shot" (4). On occasion, it may be related to inhalational drugs, particularly crack (4,28,29). Deep inhalation of the drug may be followed by a Valsalva maneuver and coughing, which may lead to alveolar rupture and subsequent dissection of air into the pleural space (4). Pneumothorax is usually unilateral but may, in rare cases, be bilateral. If adjacent vasculature is damaged, hydropneumothorax may result. Pyopneumothorax occasionally may result from the use of contaminated needles.
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Mediastinal Complications
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Mediastinal complications of illicit drug use primarily include pneumomediastinum (30–32) and pneumopericardium (32,33). Pneumomediastinum results from the deep inhalation of a drug, followed by coughing, which causes increased alveolar pressure and subsequent dissection of air into the pulmonary interstitium. Air may then enter the mediastinum or, rarely, the pericardial space (4).
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Cardiovascular Complications
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Cardiovascular complications of illicit drug use include myocardial infarction, aortic dissection, cardiomyopathy (34), and arterial damage from injections (5).
Acute Myocardial Infarction
Acute myocardial infarction may occur following the use of sympathomimetic agents, particularly cocaine and its derivatives. These agents cause intense vasoconstriction, predispose to arrhythmias, and may also promote thrombogenesis, all of which may cause myocardial ischemia and infarction (35).
Aortic Dissection
Cocaine-induced vasoconstriction results in arterial hypertension, which, combined with the increase in myocardial contractility and tachycardia that also occur with the ingestion of sympathomimetic agents, creates the proper environment for the development and propagation of aortic dissections (4,35–37). The radiographic appearance of aortic dissection related to drug abuse is similar to that of other causes of aortic dissection (38). Typical manifestations include a widened mediastinum with an indistinct aortic contour, displaced intimal calcifications, and an undulating contour of the descending thoracic portion of the aorta. Cross-sectional imaging modalities commonly used to evaluate suspected dissection include transesophageal echocardiography, magnetic resonance (MR) imaging, and helical CT. Each has excellent sensitivity and specificity for the detection of aortic dissection (39), although helical CT, particularly multidetector-row helical CT, is generally preferred because of its accuracy, speed, and availability. CT findings in aortic dissection include an intimal flap (Fig 12a), intramural hematoma, displaced intimal calcifications, and an abnormal vascular contour. Helical CT also clearly depicts complications of dissection, including aneurysm formation, pericardial and pleural effusions, and high-attenuation fluid in the mediastinum, which is suggestive of aortic rupture (Fig 12b).
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Figure 12a. Cocaine-induced aortic dissection and aortic rupture in a 35-year-old man with acute onset of chest pain following the inhalation of crack. (a) Contrast material-enhanced CT scan (5-mm collimation, level = 40 HU, window width = 440 HU) through the lower portion of the chest reveals an intimal flap (arrows). The patient left the intensive care unit against medical advice. (b) Contrast-enhanced CT scan (5-mm collimation, level = 40 HU, window width = 440 HU) obtained 3 days later and after the patient had smoked cocaine again once more shows the intimal flap (small arrows). The material with soft-tissue attenuation within the mediastinum and surrounding the aorta (large arrows) represents mediastinal blood, a finding that indicates the presence of aortic rupture.
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Figure 12b. Cocaine-induced aortic dissection and aortic rupture in a 35-year-old man with acute onset of chest pain following the inhalation of crack. (a) Contrast material-enhanced CT scan (5-mm collimation, level = 40 HU, window width = 440 HU) through the lower portion of the chest reveals an intimal flap (arrows). The patient left the intensive care unit against medical advice. (b) Contrast-enhanced CT scan (5-mm collimation, level = 40 HU, window width = 440 HU) obtained 3 days later and after the patient had smoked cocaine again once more shows the intimal flap (small arrows). The material with soft-tissue attenuation within the mediastinum and surrounding the aorta (large arrows) represents mediastinal blood, a finding that indicates the presence of aortic rupture.
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Pseudoaneurysm Formation
The formation of a pseudoaneurysm may result from direct vascular laceration or from bacteremia and subsequent microbiologic damage (40). In the latter circumstance, the pseudoaneurysm is mycotic in origin (4).
Traumatic pseudoaneurysm may be a complication of the pocket shot, which usually affects the subclavian and common carotid arteries (4). Traumatic (Fig 13) or mycotic (Fig 14) pseudoaneurysms appear on chest radiographs as rounded masses projected over the medial portion of the lung apex (Figs 13a, 14a). These masses have a distinct inferior margin where they contact the lung; the superior margin of the mass always blends imperceptibly into the soft tissues of the neck. CT, MR imaging, and ultrasound are all valuable for demonstrating the vascular nature of the mass (Figs 13b, 14b, 14c). CT is particularly useful for revealing air within a mycotic pseudoaneurysm, a rare finding that is diagnostic for infection (Fig 14b). Angiography is usually diagnostic (Figs 13c, 14d).
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Figure 13a. Right subclavian arterial pseudoaneurysm that resulted from a right supraclavicular pocket shot in a 28-year-old man with a long history of intravenous drug abuse. (a) Frontal chest radiograph reveals a rounded mass projected over the right lung apex (arrows). (b) Contrast-enhanced CT scan (10-mm collimation, level = 40 HU, window width = 440 HU) shows a rounded low-attenuation mass (large arrows) surrounding an irregular collection of intravenous contrast material (small arrows). The latter finding represents a pseudoaneurysm of the right subclavian artery. (c) Right subclavian angiogram shows the pseudoaneurysm (arrow).
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Figure 13b. Right subclavian arterial pseudoaneurysm that resulted from a right supraclavicular pocket shot in a 28-year-old man with a long history of intravenous drug abuse. (a) Frontal chest radiograph reveals a rounded mass projected over the right lung apex (arrows). (b) Contrast-enhanced CT scan (10-mm collimation, level = 40 HU, window width = 440 HU) shows a rounded low-attenuation mass (large arrows) surrounding an irregular collection of intravenous contrast material (small arrows). The latter finding represents a pseudoaneurysm of the right subclavian artery. (c) Right subclavian angiogram shows the pseudoaneurysm (arrow).
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Figure 13c. Right subclavian arterial pseudoaneurysm that resulted from a right supraclavicular pocket shot in a 28-year-old man with a long history of intravenous drug abuse. (a) Frontal chest radiograph reveals a rounded mass projected over the right lung apex (arrows). (b) Contrast-enhanced CT scan (10-mm collimation, level = 40 HU, window width = 440 HU) shows a rounded low-attenuation mass (large arrows) surrounding an irregular collection of intravenous contrast material (small arrows). The latter finding represents a pseudoaneurysm of the right subclavian artery. (c) Right subclavian angiogram shows the pseudoaneurysm (arrow).
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Figure 14a. Right subclavian arterial mycotic pseudoaneurysm in a 27-year-old man with a long history of intravenous drug abuse. (a) Frontal chest radiograph shows an ill-defined mass projected over the right lung apex (arrows). (b) Contrast-enhanced CT scan (10-mm collimation, level = 40 HU, window width = 440 HU) reveals a low-attenuation mass in the right supraclavicular fossa with extension into the soft tissues of the right axillary fossa (large arrows). A small focus of gas within the center of the mass (small arrow) is suggestive of superinfection. (c) Sagittal gadolinium-enhanced three-dimensional MR angiogram (repetition time msec/echo time msec = 9.8/2.4) shows a markedly enhanced extraparenchymal mass (large arrows) that is spatially separated from the right subclavian artery (small arrow). (d) Right subclavian arterial angiogram reveals extravasation of contrast material into a large mycotic pseudoaneurysm (arrows).
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Figure 14b. Right subclavian arterial mycotic pseudoaneurysm in a 27-year-old man with a long history of intravenous drug abuse. (a) Frontal chest radiograph shows an ill-defined mass projected over the right lung apex (arrows). (b) Contrast-enhanced CT scan (10-mm collimation, level = 40 HU, window width = 440 HU) reveals a low-attenuation mass in the right supraclavicular fossa with extension into the soft tissues of the right axillary fossa (large arrows). A small focus of gas within the center of the mass (small arrow) is suggestive of superinfection. (c) Sagittal gadolinium-enhanced three-dimensional MR angiogram (repetition time msec/echo time msec = 9.8/2.4) shows a markedly enhanced extraparenchymal mass (large arrows) that is spatially separated from the right subclavian artery (small arrow). (d) Right subclavian arterial angiogram reveals extravasation of contrast material into a large mycotic pseudoaneurysm (arrows).
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Figure 14c. Right subclavian arterial mycotic pseudoaneurysm in a 27-year-old man with a long history of intravenous drug abuse. (a) Frontal chest radiograph shows an ill-defined mass projected over the right lung apex (arrows). (b) Contrast-enhanced CT scan (10-mm collimation, level = 40 HU, window width = 440 HU) reveals a low-attenuation mass in the right supraclavicular fossa with extension into the soft tissues of the right axillary fossa (large arrows). A small focus of gas within the center of the mass (small arrow) is suggestive of superinfection. (c) Sagittal gadolinium-enhanced three-dimensional MR angiogram (repetition time msec/echo time msec = 9.8/2.4) shows a markedly enhanced extraparenchymal mass (large arrows) that is spatially separated from the right subclavian artery (small arrow). (d) Right subclavian arterial angiogram reveals extravasation of contrast material into a large mycotic pseudoaneurysm (arrows).
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Figure 14d. Right subclavian arterial mycotic pseudoaneurysm in a 27-year-old man with a long history of intravenous drug abuse. (a) Frontal chest radiograph shows an ill-defined mass projected over the right lung apex (arrows). (b) Contrast-enhanced CT scan (10-mm collimation, level = 40 HU, window width = 440 HU) reveals a low-attenuation mass in the right supraclavicular fossa with extension into the soft tissues of the right axillary fossa (large arrows). A small focus of gas within the center of the mass (small arrow) is suggestive of superinfection. (c) Sagittal gadolinium-enhanced three-dimensional MR angiogram (repetition time msec/echo time msec = 9.8/2.4) shows a markedly enhanced extraparenchymal mass (large arrows) that is spatially separated from the right subclavian artery (small arrow). (d) Right subclavian arterial angiogram reveals extravasation of contrast material into a large mycotic pseudoaneurysm (arrows).
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Chest Wall Complications
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Chest wall complications of illicit drug use include vertebral body osteomyelitis with epidural abscess, necrotizing fasciitis, costochondritis (41,42), and septic arthritis.
Osteomyelitis and Epidural Abscess
Vertebral body osteomyelitis begins as bacteremic seeding of the end plates or, less commonly, of the facet joints after nonsterile intravenous drug injections. The infection is often related to skin flora, such as staphylococcal organisms, although gram-negative bacteria and fungi can occasionally be responsible. The infection usually involves adjacent end plates and rapidly destroys the intervertebral disk, resulting in collapse of one vertebral body into its neighbor (Fig 15). The infection may extend beyond the vertebrae, resulting in an epidural abscess. Although radiography may depict diskitis, it is relatively insensitive compared with MR imaging and cannot demonstrate the presence of an epidural abscess. MR imaging readily demonstrates an epidural abscess and shows the extent of spinal canal stenosis, as well as any signal intensity abnormalities of the spinal cord that may be suggestive of myelitis.
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Figure 15a. Vertebral body osteomyelitis in a 36-year-old man with a long history of intravenous drug abuse who presented with fever and back pain. (a) Lateral radiograph of the thoracic spine shows collapse of one thoracic vertebral body (arrow) into its neighbor. (b) CT scan reveals destruction of the vertebral body (small arrow) and an associated soft-tissue mass (large arrows). (c) Sagittal contrast-enhanced T1-weighted MR image (500/40) shows collapse of one vertebral body into another (large arrow), as well as intense enhancement around the intervertebral disk space, a finding that is consistent with infection. Effacement of the ventral thecal sac by abnormal soft tissue (small arrows) represents the development of an epidural abscess.
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Figure 15b. Vertebral body osteomyelitis in a 36-year-old man with a long history of intravenous drug abuse who presented with fever and back pain. (a) Lateral radiograph of the thoracic spine shows collapse of one thoracic vertebral body (arrow) into its neighbor. (b) CT scan reveals destruction of the vertebral body (small arrow) and an associated soft-tissue mass (large arrows). (c) Sagittal contrast-enhanced T1-weighted MR image (500/40) shows collapse of one vertebral body into another (large arrow), as well as intense enhancement around the intervertebral disk space, a finding that is consistent with infection. Effacement of the ventral thecal sac by abnormal soft tissue (small arrows) represents the development of an epidural abscess.
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Figure 15c. Vertebral body osteomyelitis in a 36-year-old man with a long history of intravenous drug abuse who presented with fever and back pain. (a) Lateral radiograph of the thoracic spine shows collapse of one thoracic vertebral body (arrow) into its neighbor. (b) CT scan reveals destruction of the vertebral body (small arrow) and an associated soft-tissue mass (large arrows). (c) Sagittal contrast-enhanced T1-weighted MR image (500/40) shows collapse of one vertebral body into another (large arrow), as well as intense enhancement around the intervertebral disk space, a finding that is consistent with infection. Effacement of the ventral thecal sac by abnormal soft tissue (small arrows) represents the development of an epidural abscess.
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Necrotizing Fasciitis
Necrotizing fasciitis represents an infection of the intermuscular fascial layers, often the result of direct inoculation from contaminated needles. This infection is more commonly encountered in patients whose peripheral veins are so sclerotic that peripheral intravenous access is no longer possible. Such patients often inject drugs into the subcutaneous tissues, an activity called "skin popping." Radiographs are usually unrevealing in cases of necrotizing fasciitis. Occasionally, CT can be helpful, but the superior contrast resolution of MR imaging allows a more definitive determination of the severity and extent of disease (Fig 16) and more readily shows complicating soft-tissue abscesses. MR imaging characteristically shows extensive T2 prolongation in affected
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Abstract
Introduction
