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

1. Ettinger NA, Albin RJ. A review of the respiratory effects of smoking cocaine. Am J Med 1989;87:664-8.

2. Meisels IS, Like J. The pulmonary effects of free-base cocaine: a review. Cleve Clin J Med 1993;60:325-9.

3. Haim DY, Lippmann ML, Goldberg SK, Walkenstein MD. The pulmonary complications of crack cocaine: a comprehensive review. Chest 1995;107: 233-40.

4. 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.

5. O'Donnell AE, Mappin FG, Sebo TJ, Tazelaar H. Interstitial pneumonitis associated with "crack" cocaine abuse. Chest 1991;100:1155-7.

6. 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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