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Acute Lower Respiratory Tract Illness in Illicit Drug Users -- South Carolina, 1995
On July 31, 1995, the South Carolina Department of Health and
Environmental Control was notified of a cluster of five patients
with
acute, severe lower respiratory illnesses among previously healthy
residents of a small rural community in Berkeley County (1990
population:
128,776). All five patients were users of illicit drugs. This
report
summarizes the preliminary findings of an investigation initiated
to
describe the clinical features and epidemiology of this syndrome
and to
determine an etiology.
Based on information about the five cases obtained from
interviews
with the patients and reviews of records, a case was defined as an
unexplained acute, severe respiratory illness in a previously
healthy
person aged less than 65 years characterized by shortness of breath
and/or
pleuritic pain with onset of symptoms during July 15-31. One
additional
case was identified by contacting local physicians, intensive-care
units,
and pulmonary and infectious disease specialists. No cases of
similar acute
respiratory illness were noted in household contacts of patients.
Five of the six case-patients were male; patients ranged in
age from
30 to 37 years. Five resided in Berkeley County and one in adjacent
Charleston County. All had onset of symptoms during July 19-23 and
reportedly had recently used illicit drugs. Five had been
hospitalized.
Predominant clinical features included nonproductive cough, fever
(maximum:
103 F {39.4 C}), pleuritic chest pain, and progressively severe
shortness
of breath. Laboratory findings included a polymorphonuclear
leukocytosis
(range: 9100 mm3-23,600 mm3) in all six patients and severe hypoxia
(PO2
range: 49-81) in five. All patients had bibasilar or diffuse
pulmonary
infiltrates on chest radiographs. Of the five patients who were
hospitalized, three developed respiratory failure within 1-4 days
of
admission and within 7-10 days of onset of symptoms; two died.
Diagnostic studies included sputum gram stain and cultures,
blood
cultures, serologic tests, and pathologic examination of tissue
obtained by
open lung biopsy or postmortem. These tests were negative for
common
bacterial pathogens and for Mycoplasma sp, Chlamydia sp, Legionella
sp,
Pneumocystis carinii, Mycobacterium tuberculosis, human
immunodeficiency
virus, respiratory syncytial virus, cytomegalovirus, adenoviruses,
Epstein-Barr virus, and influenza virus. Fungal cultures of sputum
from the
two deceased patients and open lung biopsy from another were
positive for
molds believed to be contaminants; final identification is pending.
Histopathologic analysis of lung tissue from the two deceased
patients
indicated diffuse alveolar damage with microemboli and minimal
inflammatory
cell infiltrate. Tissue from the open lung biopsy of the third
patient
indicated severe organizing fibrinous pneumonia with bronchiolitis
obliterans and diffuse alveolar damage. Analyses of blood (five
patients)
and lung tissue (three patients) specimens and of samples taken
from drug
paraphernalia (i.e., homemade "pipes" of one patient) were negative
for
potential toxins.
Although interviews with patients, relatives, and
acquaintances
suggested several potential exposures (e.g., rodents and
herbicides), the
only exposure common to all patients was nonparenteral use of drugs
during
the week before onset of symptoms. Five reported use of crack
cocaine and
one reported smoking marijuana. Several of the patients were
acquainted;
however, investigation has not detected a single event attended by
all the
patients or a common source for the crack cocaine. The ongoing
investigation includes following up all possible drug-related
contacts of
the patients and continued surveillance.
Reported by: L Lettau, MD, S Miller, MD, D Handshoe, MD, J
Chambers, MD,
Trident Health District, Charleston; L Bell, MD, E Brenner, MD, J
Gibson,
MD, State Epidemiologist, South Carolina Dept of Health and
Environmental
Control. Div of Environmental Health and Hazard Effects, National
Center
for Environmental Health; Div of Field Epidemiology, Epidemiology
Program
Office, CDC. Editorial Note
Editorial Note: The clinical features of the cluster of cases of
acute
lower respiratory illness in South Carolina are similar to those
reported
previously in crack cocaine users who have sustained inhalational
injuries.
These cases have been characterized by a variety of clinical
syndromes
including pulmonary edema, interstitial pneumonitis, obliterative
bronchitis, and pulmonary hemorrhage (1-6). However, the cluster of
cases
in South Carolina is the first known outbreak of acute, severe
respiratory
tract illnesses associated with crack cocaine. Potential
explanations for
the cases in South Carolina include an idiosyncratic reaction to
crack
cocaine or the effects of a contaminant or adulterant introduced
during the
preparation or smoking of the crack.
The temporal and geographic clustering of the cases and the
similarity
of their clinical features suggest a common exposure to a unique
yet
unidentified toxin or microbiologic agent associated with
inhalational drug
abuse. Cases of similar severe illnesses should be reported to the
Division
of Disease Control, South Carolina Department of Health and
Environmental
Control, telephone (803) 737-4165.
References
Ettinger NA, Albin RJ. A review of the respiratory effects of
smoking
cocaine. Am J Med 1989;87:664-8.
Meisels IS, Like J. The pulmonary effects of free-base cocaine:
a
review. Cleve Clin J Med 1993;60:325-9.
Haim DY, Lippmann ML, Goldberg SK, Walkenstein MD. The pulmonary
complications of crack cocaine: a comprehensive review. Chest
1995;107:
233-40.
Forrester JM, Steele AW, Waldron JA, Parsons PE. Crack lung: an
acute
pulmonary syndrome with a spectrum of clinical and
histopathologic
findings. Am Rev Respir Dis 1990;142:462-7.
O'Donnell AE, Mappin FG, Sebo TJ, Tazelaar H. Interstitial
pneumonitis
associated with "crack" cocaine abuse. Chest 1991;100:1155-7.
Patel RC, Dutta D, Schonfeld SA. Free-base cocaine use
associated with
bronchiolitis obliterans organizing pneumonia. Ann Intern Med
1987;107:
186-7.
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