Pulmonary complications of cocaine abuse
- C Crawford Mechem, MD, FACEP
C Crawford Mechem, MD, FACEP
- Professor of Emergency Medicine
- Perelman School of Medicine, University of Pennsylvania
- Section Editors
- Talmadge E King, Jr, MD
Talmadge E King, Jr, MD
- Editor-in-Chief — Pulmonary, Critical Care, and Sleep Medicine
- Section Editor — Interstitial Lung Disease
- Dean, School of Medicine
- Vice Chancellor, Medical Affairs
- University of California San Francisco
- Stephen J Traub, MD
Stephen J Traub, MD
- Section Editor — Toxicology
- Associate Professor of Emergency Medicine
- Mayo Medical School
Cocaine is an alkaloid with anesthetic properties obtained from the leaves of Erythroxylon coca, a shrub native to Central and South America, the West Indies, and Indonesia. Coca’s unique chemical properties have led to its use in social, religious, and medicinal settings for centuries.
Cocaine was first isolated from coca leaves in 1859. Over the following sixty years, many over-the-counter products containing cocaine were marketed, including asthma remedies and "French Wine Cola," the predecessor of Coca-Cola. While a "pinch of coca leaves" was included in John Styth Pemberton's original 1886 recipe for Coca-Cola, the company began using decocainized leaves in 1906 when the Pure Food and Drug Act was passed. The first cocaine-related fatalities were reported in 1893, and in 1914 the Harrison Narcotic Act banned the nonprescription use of cocaine-containing products .
Cocaine is a widely abused substance around the world. Toxicity in a variety of organs has been reported, including the cardiovascular, respiratory, and central nervous systems . The pulmonary sequelae that result from cocaine abuse will be reviewed here. Other aspects of cocaine abuse are discussed separately. (See "Cocaine: Acute intoxication" and "Evaluation and management of the cardiovascular complications of cocaine abuse" and "Cocaine use disorder in adults: Epidemiology, pharmacology, clinical manifestations, medical consequences, and diagnosis".)
The local anesthetic properties of cocaine derive from its ability to stabilize cell membranes and block neuronal sodium channels. It also has potent sympathomimetic and central nervous system stimulant effects due to interference with the reuptake of catecholamines and serotonin. (See "Cocaine: Acute intoxication".)
Cocaine hydrochloride is a heat-labile fine white powder that can be inhaled nasally ("snorted") or injected intravenously but cannot be smoked. However, when boiled with baking soda and water and the resultant precipitate filtered or extracted with ether or alcohol, cocaine yields a lipid-soluble, heat-stable, free-base form that can be smoked (“free basing”). This form is commonly called "rock" (because of its gross appearance) or "crack" (because of the characteristic crackling sound it makes when heated and smoked) .
- Stolberg VB. The use of coca: prehistory, history, and ethnography. J Ethn Subst Abuse 2011; 10:126.
- Zimmerman JL. Cocaine intoxication. Crit Care Clin 2012; 28:517.
- Nadeem S, Nasir N, Israel RH. Löffler's syndrome secondary to crack cocaine. Chest 1994; 105:1599.
- Afonso L, Mohamad T, Badheka A. Drugs of Abuse and Cardiotoxicity. In: Comprehensive Toxicology, 2nd, McQueen CA, Bond JR, Lamb K, at al. (Eds), Elsevier, 2010. Vol 1-14, p.339.
- Bailey ME, Fraire AE, Greenberg SD, et al. Pulmonary histopathology in cocaine abusers. Hum Pathol 1994; 25:203.
- Ramachandaran S, Khan AU, Dadaparvar S, Sherman MS. Inhalation of crack cocaine can mimic pulmonary embolism. Clin Nucl Med 2004; 29:756.
- Kleerup EC, Koyal SN, Marques-Magallanes JA, et al. Chronic and acute effects of "crack" cocaine on diffusing capacity, membrane diffusion, and pulmonary capillary blood volume in the lung. Chest 2002; 122:629.
- Delaney K, Hoffman RS. Pulmonary infarction associated with crack cocaine use in a previously healthy 23-year-old woman. Am J Med 1991; 91:92.
- Harrell PT, Trenz RC, Scherer M, et al. Cigarette smoking, illicit drug use, and routes of administration among heroin and cocaine users. Addict Behav 2012; 37:678.
- 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.
- McCormick M, Nelson T. Cocaine-induced fatal acute eosinophilic pneumonia: a case report. WMJ 2007; 106:92.
- Devlin RJ, Henry JA. Clinical review: Major consequences of illicit drug consumption. Crit Care 2008; 12:202.
- Maybauer MO, Rehberg S, Traber DL, et al. [Pathophysiology of acute lung injury in severe burn and smoke inhalation injury]. Anaesthesist 2009; 58:805.
- Oh PI, Balter MS. Cocaine induced eosinophilic lung disease. Thorax 1992; 47:478.
- Strong DH, Westcott JY, Biller JA, et al. Eosinophilic "empyema" associated with crack cocaine use. Thorax 2003; 58:823.
- Maeder M, Ullmer E. Pneumomediastinum and bilateral pneumothorax as a complication of cocaine smoking. Respiration 2003; 70:407.
- Janes SM, Ind PW, Jackson J. Images in Thorax. Crack inhalation induced pneumomediastinum. Thorax 2004; 59:360.
- Alnas M, Altayeh A, Zaman M. Clinical course and outcome of cocaine-induced pneumomediastinum. Am J Med Sci 2010; 339:65.
- Mohammedi K, Yersin B, Staeger P, et al. [Cocaine use and pneumothorax]. Rev Med Suisse 2010; 6:1678.
- Patel RC, Dutta D, Schonfeld SA. Free-base cocaine use associated with bronchiolitis obliterans organizing pneumonia. Ann Intern Med 1987; 107:186.
- O'Donnell AE, Mappin FG, Sebo TJ, Tazelaar H. Interstitial pneumonitis associated with "crack" cocaine abuse. Chest 1991; 100:1155.
- Klinger JR, Bensadoun E, Corrao WM. Pulmonary complications from alveolar accumulation of carbonaceous material in a cocaine smoker. Chest 1992; 101:1171.
- Murray RJ, Albin RJ, Mergner W, Criner GJ. Diffuse alveolar hemorrhage temporally related to cocaine smoking. Chest 1988; 93:427.
- Janjua TM, Bohan AE, Wesselius LJ. Increased lower respiratory tract iron concentrations in alkaloidal ("crack") cocaine users. Chest 2001; 119:422.
- van der Klooster JM, Grootendorst AF. Severe bullous emphysema associated with cocaine smoking. Thorax 2001; 56:982.
- Baldwin GC, Choi R, Roth MD, et al. Evidence of chronic damage to the pulmonary microcirculation in habitual users of alkaloidal ("crack") cocaine. Chest 2002; 121:1231.
- Terra Filho M, Yen CC, Santos Ude P, Muñoz DR. Pulmonary alterations in cocaine users. Sao Paulo Med J 2004; 122:26.
- Solaini L, Gourgiotis S, Salemis NS, Koukis I. Bilateral pneumothorax, lung cavitations, and pleural empyema in a cocaine addict. Gen Thorac Cardiovasc Surg 2008; 56:610.
- Restrepo CS, Carrillo JA, Martínez S, et al. Pulmonary complications from cocaine and cocaine-based substances: imaging manifestations. Radiographics 2007; 27:941.
- Drent M, Wijnen P, Bast A. Interstitial lung damage due to cocaine abuse: pathogenesis, pharmacogenomics and therapy. Curr Med Chem 2012; 19:5607.
- Tseng W, Sutter ME, Albertson TE. Stimulants and the lung : review of literature. Clin Rev Allergy Immunol 2014; 46:82.
- de Almeida RR, de Souza LS, Mançano AD, et al. High-resolution computed tomographic findings of cocaine-induced pulmonary disease: a state of the art review. Lung 2014; 192:225.
- de Jesus Perez V, Kudelko K, Snook S, Zamanian RT. Drugs and toxins-associated pulmonary arterial hypertension: lessons learned and challenges ahead. Int J Clin Pract Suppl 2011; :8.
- Chin KM, Channick RN, Rubin LJ. Is methamphetamine use associated with idiopathic pulmonary arterial hypertension? Chest 2006; 130:1657.
- Kleerup EC, Wong M, Marques-Magallanes JA, et al. Acute effects of intravenous cocaine on pulmonary artery pressure and cardiac index in habitual crack smokers. Chest 1997; 111:30.
- Murray RJ, Smialek JE, Golle M, Albin RJ. Pulmonary artery medial hypertrophy in cocaine users without foreign particle microembolization. Chest 1989; 96:1050.
- Rajab R, Stearns E, Baithun S. Autopsy pathology of cocaine users from the Eastern district of London: a retrospective cohort study. J Clin Pathol 2008; 61:848.
- Dalvi P, O'Brien-Ladner A, Dhillon NK. Downregulation of bone morphogenetic protein receptor axis during HIV-1 and cocaine-mediated pulmonary smooth muscle hyperplasia: implications for HIV-related pulmonary arterial hypertension. Arterioscler Thromb Vasc Biol 2013; 33:2585.
- Leece P, Rajaram N, Woolhouse S, Millson M. Acute and chronic respiratory symptoms among primary care patients who smoke crack cocaine. J Urban Health 2013; 90:542.
- Rubin RB, Neugarten J. Cocaine-associated asthma. Am J Med 1990; 88:438.
- Rome LA, Lippmann ML, Dalsey WC, et al. Prevalence of cocaine use and its impact on asthma exacerbation in an urban population. Chest 2000; 117:1324.
- Tashkin DP. Airway effects of marijuana, cocaine, and other inhaled illicit agents. Curr Opin Pulm Med 2001; 7:43.
- Mena MJ, Rodriguez-Nieto MJ, Gómez M, et al. Melanoptysis as a complication of fibreoptic bronchoscopy. Eur Respir J 1998; 12:993.
- Gatof D, Albert RK. Bilateral thumb burns leading to the diagnosis of crack lung. Chest 2002; 121:289.
- Kabrhel C, Mark Courtney D, Camargo CA Jr, et al. Factors associated with positive D-dimer results in patients evaluated for pulmonary embolism. Acad Emerg Med 2010; 17:589.
- Tashkin DP, Khalsa ME, Gorelick D, et al. Pulmonary status of habitual cocaine smokers. Am Rev Respir Dis 1992; 145:92.
- Mançano A, Marchiori E, Zanetti G, et al. Pulmonary complications of crack cocaine use: high-resolution computed tomography of the chest. J Bras Pneumol 2008; 34:323.
- Baldwin GC, Tashkin DP, Buckley DM, et al. Marijuana and cocaine impair alveolar macrophage function and cytokine production. Am J Respir Crit Care Med 1997; 156:1606.
- Roth MD, Whittaker K, Salehi K, et al. Mechanisms for impaired effector function in alveolar macrophages from marijuana and cocaine smokers. J Neuroimmunol 2004; 147:82.
- Story A, Bothamley G, Hayward A. Crack cocaine and infectious tuberculosis. Emerg Infect Dis 2008; 14:1466.
- Barsky SH, Roth MD, Kleerup EC, et al. Histopathologic and molecular alterations in bronchial epithelium in habitual smokers of marijuana, cocaine, and/or tobacco. J Natl Cancer Inst 1998; 90:1198.
- Riezzo I, Fiore C, De Carlo D, et al. Side effects of cocaine abuse: multiorgan toxicity and pathological consequences. Curr Med Chem 2012; 19:5624.
- PATHOLOGY AND PATHOPHYSIOLOGY
- Acute pulmonary toxicity and crack lung
- Acute eosinophilic pneumonia
- Pneumothorax and pneumomediastinum
- Chronic toxicity
- Pulmonary vascular disease
- CLINICAL FEATURES
- EVALUATION AND DIAGNOSIS
- Pulmonary function testing
- Bronchoalveolar lavage
- Lung biopsy
- DIFFERENTIAL DIAGNOSIS
- Pulmonary infection
- Lung cancer
- Crack lung
- Acute eosinophilic pneumonia
- Pneumothorax, hemothorax, and pneumomediastinum
- Organizing pneumonia
- Foreign body granulomatosis
- Pulmonary hypertension
- SUMMARY AND RECOMMENDATIONS
- Pathophysiology and clinical manifestations
- Diagnosis and management