The patient in this question presents with acute pulmonary toxicity due to diffuse alveolar damage and hemorrhage from crack cocaine smoking. People who smoke crack can acutely develop nonspecific respiratory symptoms that sometimes cannot be diagnosed until other pulmonary diseases have been excluded. Other clinical features associated with crack lung include fever, chest pain, back pain, carbonaceous sputum production, and hemoptysis. Clinicians must obtain detailed health and social histories to diagnose this problem. Specific exam features can also suggest drug use. Thermal burns on the fingers or thumbs result from handling crack pipes and should raise the clinician’s suspicion for crack cocaine use. Laboratory and radiographic findings are nonspecific in cocaine-induced pulmonary toxicity. The differential diagnosis includes infection, heart failure, and pulmonary embolism. Treatment includes supportive care and eventual referral to a drug use disorder treatment program. Since crack lung leads to acute respiratory distress syndrome, the mainstay of treatment is supportive with oxygen supplementation and conservative fluid management. Clinicians should begin with noninvasive positive pressure ventilation, but endotracheal intubation may be required.
Anticoagulation with heparin (A) is indicated for a patient diagnosed with a pulmonary embolism. This diagnosis is made after obtaining computed tomography imaging. Although pulmonary embolism is on the differential for this patient’s acute dyspnea, the physical exam finding of black discoloration on the left thumb suggests crack cocaine use. It is not uncommon for these patients to initially receive broad-spectrum antibiotics (B) while awaiting culture results. However, broad-spectrum antibiotics are not indicated as definitive management for pulmonary damage related to crack cocaine use. Finally, the differential for this clinical presentation also includes cardiogenic pulmonary edema, treated with nitroglycerin and furosemide (C). But this patient does not have any previous medical problems to suggest underlying cardiac disease, and her other exam findings suggest cocaine use.