CHEST 2016 Annual Meeting case reports: More reasons to say no to drugs

October 17, 2016

From pleasure to pain? Ecstasy and heart failure

Tuesday, October 25, 1:30 p.m., Los Angeles Convention Center Exhibit Hall, Poster 516

A medical student from Abington Jefferson Health in Abington, Pennsylvania, will present a case of methamphetamine-induced acute coronary syndrome. A 22-year-old man was brought to the emergency department (ED) for an evaluation of acute onset shortness of breath and chest pain. The patient reported he had taken "ecstasy" ("Molly", MDMA) six hours before coming to the ED. He was hypoxic, tachycardiac and hypotensive. Cardiac catheterization showed coronary artery spasm and severely reduced left ventricular function. He had persistent cardiogenic shock despite vasopressor and inotropic support, an intraaortic balloon pump, and later extracorporeal membrane oxygenation (ECMO). Despite severe cardiac failure, he survived to discharge with supportive care.

This report is unique because it describes the only case of MDMA overdose that led to extracorporeal membrane oxygenation (ECMO) and survival. MDMA is commonly abused, with similar effects to cocaine and amphetamine. These include severe and sudden constriction or narrowing of blood vessels. The direct myocardial toxicity of MDMA metabolizes and stimulates the release of noradrenaline, dopamine and serotonin from the central and autonomic nervous systems. The effects start around 20 minutes after ingestion and can last up to 48 hours, which can cause rapid heart rate, hypotension and arrhythmias as well as myocardial ischemia and infarction.

Marijuana abuse, vanishing lung and ARDS

Tuesday, October 25, 1:30 p.m., Los Angeles Convention Center Exhibit Hall, Poster 133

Researchers from Staten Island University Hospital in New York will present a case of a 47-year-old man with an unusual case of vanishing lung syndrome (VLS) complicated by pneumonia and ARDS. The patient was admitted with three days of shortness of breath, cough and fever. He admitted to smoking cigarettes and marijuana for more than 20 years. A chest radiograph of his lung showed a giant area of overinflated and destroyed lung (bulla) covering his entire right chest, left-sided apical bullae and basilar opacity. He was treated for pneumonia and later required mechanical ventilation due to septic shock and worsening hypoxia. Despite ventilatory support and extracorporeal membrane oxygenation (ECMO), he died of complications of sepsis.

VLS is a rare condition and tobacco smoking is the only known risk factor. However, marijuana use may also predispose to VLS, especially, in those who smoke both cigarettes and marijuana. Marijuana smoking involves a two-thirds larger puff volume, a one-third greater depth of inhalation and four-times longer breath-holding time than tobacco smoking, possible augmenting predisposition to bulla formation.

Black tar heroin use leads to wound botulism, vocal cord paralysis and respiratory failure

Monday, October 24, 11:15 a.m., Los Angeles Convention Center, Room 410

Researchers from the West Los Angeles VA Medical Center will present the case of a 31-year-old man with an unusual pattern of paralysis due to botulism acquired through infection at a needle site. He had a history of asthma, cocaine and amphetamine use, and presented with the feeling of a lump in his throat and breathlessness. He denied intravenous drug use. He had a high-pitched, muffled voice and laryngoscopy revealed bilateral vocal cord paralysis. CT scans of the neck and brain were negative for infection and stroke. He developed progressive weakness without fatigability of his upper extremities, pupil dilation and poor respiratory effort with impending respiratory failure, prompting intubation and tracheostomy. During his intubation, a syringe with black tar heroin was found on his stretcher and he was then treated with heptavalent antitoxin, a therapy used to treat patients showing signs of botulism following documented or suspected exposure to botulinum neurotoxin and penicillin G. The patient later underwent rehabilitation.

This patient did not present the classical cranial nerve involvement commonly associated with botulism but instead with bilateral vocal cord paralysis. Due to the timely recognition of his progressive symptoms, clinicians were able to provide quick administration of life-saving therapies.

A difficult airway: A case of S. milleri group epiglottitis in a cocaine user

Tuesday, October 25, 1:30 p.m., Los Angeles Convention Center Exhibit Hall, Poster 302

Researchers from the University of Washington will present a case of an active crack cocaine user who developed a rare abscess formation as a result. The 44-year-old man presented with worsening breathlessness. Three months prior, stridor (a high-pitched, musical breathing sound during inhalation) was noted during an admission for a small bowel obstruction. A CT scan of the head and the neck revealed a bilateral thickening of the aryepiglottic folds, the opening at the entrance of the larynx, but further work was not completed as the patient failed to attend follow-up appointments. Because of severe respiratory distress on presentation he was intubated. A repeat CT confirmed the patient's diffuse glottis edema and airway obstruction. Cultures of pus obtained from the aryepiglottic folds during operative evaluation were positive for were Streptococcus anginosus, a pathogen of the S. milleri group.

The unique presentation of epiglottis, or a flap of cartilage at the root of the tongue, caused by S. anginosus, a pathogen that is found in less that 4 percent of adults with infectious epiglottis, resulted in significant morbidity in this patient. Prompt recognition and definitive surgical management is key to clinical success when dealing with this rare disease.
CHEST 2016 is the 82nd annual meeting for the American College of Chest Physicians, held October 22-26, 2016, in Los Angeles, California. The American College of Chest Physicians, publisher of the journal CHEST, is the global leader in advancing best patient outcomes through innovative chest medicine education, clinical research and team-based care. Its mission is to champion the prevention, diagnosis and treatment of chest diseases through education, communication and research. It serves as an essential connection to clinical knowledge and resources for its 19,000 members from around the world who provide patient care in pulmonary, critical care and sleep medicine. For more information about CHEST 2016, visit, or follow CHEST meeting hashtag, #CHEST2016, on social media.

American College of Chest Physicians

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