Illicit narcotic injection masquerading as acute pulmonary embolism

Abstract

A 23-year-old male presented from a nursing home with hypotension, tachycardia, diaphoresis and electrocardiographic evidence of right ventricular strain that was confirmed by echocardiography. His differential diagnosis included sepsis and pulmonary embolism. A high-resolution computed tomography scan demonstrated no pulmonary emboli but did demonstrate multiple bilateral pulmonary nodules. Upon questioning he admitted to injecting a long-acting narcotic that had been manually macerated, dissolved in saline, and injected through an indwelling intravenous line. Lung biopsy findings were consistent with cellulose-induced perivascular granulomatosis. Cellulose granulomatosis can be seen in patients who inject medications designed for oral use and should be considered in patients who present with acute pulmonary hypertension.

Cutaneous refractile foreign body microemboli with intravascular injection of oral medication

“…Case reports of other patients with chronic cutaneous ulcers or ischemia and infarction, describe histopathologically evident microemboli that originate from the hydrophilic polymer coating on catheters (which is designed to reduce friction against vessel walls) . This was a consideration in our case, but the microemboli are optically polarizing and crystalline in nature, and are morphologically similar to those found in the lungs in injection drug users . The nature of crystalline foreign body microemboli in pulmonary small vessels in such patients is well‐documented and better understood.…”

“…The nature of crystalline foreign body microemboli in pulmonary small vessels in such patients is well‐documented and better understood. Microcrystalline cellulose and talc are particulates known to cause birefringent pulmonary microemboli . The foreign material in our case most resembles microcrystalline cellulose, a material used as a binder in many pharmaceutical tablets, including various formulations of ondansetron .…”