Acute lung injury in a bodybuilder

Abstract

A 28-year-old man who was a bodybuilder, presented to the emergency department (ED) for sudden onset shortness of breath and non-productive cough. Upon presentation, the patient was tachycardic (heart rate: 130 beats/min) and tachypneic (respiratory rate: 28 breaths/min). The pulse oximeter reading was 93% on room air. On inspection, we noticed a diffuse erythematous macular rash mostly affecting the upper trunk. The physical examination was positive for expiratory wheezing and crackles in both pulmonary fields. The patient had no significant past medical or surgical history.The chest X-ray study showed bilateral diffuse nodular infiltrates (Fig. 1). An arterial blood gas on oxygen face mask (FiO 2 40%) showed: no acid-base disturbances (pH = 7.41; paCO 2 = 38; HCO 3 = 24.1), the Alveolararterial gradient was 132.7 (paO 2 = 105) and the calculated ratio paO 2 /FiO 2 was 262.5. The laboratory tests were negative except for a white blood cell count of 12,700 cells/ mm 3 mostly granulocytes (8,800 cells/mm 3 ), the eosinophils were 500 cells/mm 3 . The patient's symptoms slightly improved after three ipratropium nebulizer treatments and one dose of 125 mg intravenous methylprednisolone.Upon further inquiring about his symptoms, the patient reported that the shortness of breath occurred after he selfinjected intramuscularly (IM) an anabolic steroid Sustanon Ò : Twenty minutes after the injection, he felt a generalized flushing and dyspnea. He had been using this anabolic steroid for several months, and had several prior injections without any side effects. During this particular intramuscular administration, the patient failed to aspirate