Pleurisy secondary to nonthrombotic pulmonary emboli in a patient with intravenous drug use

Abstract

Patients with injection drug use can have nonthrombotic pulmonary emboli (NTPE) of foreign insoluble particles that are either parts of the equipment used or mixed with the drug as an additive. These foreign particles can become a nidus for infection and inflammation. We present a case of a 31-year-old man with active intravenous drug use who initially presented with signs and symptoms of pleurisy and was found to have NTPE of septic refractile crystalline material as seen on bronchial wash and brush biopsy. We believe our patient likely had embolism of either crack particles, needle fragments or cotton-wool fragments that led to a localized inflammatory reaction and infection. This highlights the importance of obtaining detailed history and diagnostic workup. Once the diagnoses of bacterial endocarditis and thrombophlebitis are ruled out with blood cultures, transthoracic echocardiogram, trans-esophageal echocardiogram and/or CT scan (depending on the suspicion), NTPE should be considered and bronchoscopy with bronchoalveolar lavage with biopsy should be performed.

Keywords: NTPE; Nonthrombotic pulmonary emboli; PWID; Patients with injection drug use; Septic emboli.

Fig. 1

Chest X-ray showing patchy increased density in the left lower lobe, lingula, and right middle and lower lobes.

Fig. 2

CT angiography of the chest showing multiple, fluffy, nodules of varying size and ill-defined margins throughout both lungs.

Fig. 3

High resolution CT of the chest remonstrating the nodules with feeding vessel sign.

Fig. 4

Crystalline refractile foreign body fragments (arrow and arrowhead) with surrounding dense neutrophilic infiltration.

Fig. 5

Higher magnification demonstrated the crystalline foreign body fragment (arrow) with surrounding mononuclear cells (arrowheads).