From Relief to Risk: Menace of Injecting Crushed Antihistamine Pills: A Case Report

Document Type

Conference Proceeding

Publication Date

5-21-2024

Publication Title

Am J Respir Crit Care Med

Abstract

Pulmonary foreign body granulomatosis (PFBG) is a rare disorder characterized by the development of granulomatous inflammation secondary to foreign bodies lodged in the pulmonary capillaries. It can be caused by intravenous injection of grounded oral medications, typically methylphenidate, opiates, antihistamines, and meperidine. We present a case of PFBG induced by injecting crushed antihistamine pills. 31-year-old male, daily marijuana smoker, with a history of a small bowel resection followed by a small bowel transplant complicated by transplant failure, ultimately leading to transplant enterectomy requiring long-term total parenteral nutrition via a peripherally inserted central catheter (PICC) was hospitalized for abdominal pain with staph epidermidis bacteremia. He was asymptomatic from a pulmonary standpoint. Computed tomography (CT) abdomen and pelvis showed new bibasilar diffuse micronodular pulmonary opacities. Confirmatory CT chest showed diffuse bilateral tree-in-bud nodular opacities with centrilobular groundglass opacities. Comprehensive autoimmune review of systems and autoimmune workup was negative and there was no clinical suspicion for chronic aspiration. No other occupational or environmental exposures were identified. Non-invasive work-up for fungal infections and bronchoalveolar lavage cultures ruled out fungal, bacterial, atypical bacterial and mycobacterial infections. Transbronchial biopsy showed perivascular, intra-alveolar and interstitial, irregular, and birefringent (under polarized light) foreign particulates associated with granulomatous inflammation. On H&E stains particulates with coral-like morphology and deep basophilic staining were seen and Elastin van Gieson stain showed fragmentation of elastic laminae of vessels. The histopathological diagnosis was consistent with PFBG. Later, upon questioning, the patient admitted to injecting crushed Benadryl pills into his PICC line. The patient was recommended to discontinue this practice and despite abstinence he had progression of his disease. Unfortunately, our patient died shortly after due a non-pulmonary cause. The clinical manifestations of PFBG range from being asymptomatic to fulminant respiratory failure, pulmonary hypertension and progressive pulmonary fibrosis. Our patient had asymptomatic PFBG with no previous history of substance use making it a challenging diagnosis. Centrilobular micronodules are caused by bronchiolar disorders including endobronchial infections and tumors, hypersensitivity pneumonitis, respiratory bronchiolitis, follicular bronchiolitis, chronic aspiration, and pulmonary vascular disease. Definitive diagnosis requires tissue diagnosis with transbronchial biopsy or open lung biopsy and stopping the use of offending agent is the mainstay of treatment. Periodic reassessment for disease progression is recommended in asymptomatic patients due to the risk of progressive pulmonary fibrosis despite cessation of IV drug use. (Figure Presented).

Volume

209

Issue

9

First Page

A2022

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