A Rare Etiology of Diffuse Pulmonary Hemorrhage

Abstract

A 36-year-old drug addict presented to the emergency room after intravenously injecting 20 milliliters of pure gasoline. At the initial evaluation, he had complained of severe "freezing" chest pain and raging thirst. He provided a remote history of intravenously injecting low doses of gasoline. The admission examination was notable for a pronounced scent of gasoline on his breath, hypotension, and respiratory distress with diffuse rhonchi throughout the lungs. The laboratory workup showed severe metabolic acidosis, leukocytosis with neutrophilia, and markedly elevated serum myoglobin. The patient was treated with corticosteroids and maximum supportive care but there was no improvement. A chest radiograph was not performed given the patient's rapid decline. He soon developed large-volume hemoptysis and died without a definitive diagnosis 4 hours after presentation to the hospital. Postmortem examination was significant for diffusely enlarged and blood-filled lungs (Figure 1A, B). The left lung weighed 1780 g and the right lung weighed 1890 g (a normal lung weighs ~ 300-400 g). Microscopically, all lung sections demonstrated diffuse areas of fresh hemorrhage (Figure 1C). Thickened alveolar septa contained many neutrophils with dilated capillaries consistent with capillaritis (Figure 1D). There were also prominent hemosiderin-filled alveolar macrophages that showed evidence of previous alveolar hemorrhage (Figure 1E). Targeted toxicology confirmed a high concentration of hydrocarbons in the postmortem blood.