An unusual case of haemoptysis in an intravenous drug user

Heroin use has been associated with multiple pulmonary complications, including foreign body aspiration. We report a case of an intravenous drug user with unintentional aspiration of a hypodermic needle into his left main bronchus.

Case

A 40-year-old man presented to the emergency department with a two-day history of frank, low volume haemoptysis. 

His background medical history was significant for intravenous drug use and a below knee deep venous thrombosis diagnosed three years previously. He was a heavy cigarette smoker and current medications included methadone 35mg once daily.

Physical examination, baseline haemoglobin and chest x-ray were normal.

A CT thorax was performed to further evaluate for cause of haemoptysis. Imaging showed a needle in the left main bronchus entering the main pulmonary vein (see Figures 1 and 2).

 (click to enlarge)

 (click to enlarge)

On further questioning, the patient denied any history of aspiration of a needle and had no recollection as to how the needle could have entered his airway. 

He was referred to cardiothoracic surgery and the needle was removed via rigid bronchoscopy. The patient was subsequently discharged and remained well without any further complications at follow up.

Discussion

Heroin use has been reported to cause multiple pulmonary complications including pneumonia, acute respiratory distress syndrome (ARDS), aspiration pneumonitis, lung abscess, foreign body granulomatosis, emphysema, pulmonary hypertension, pneumothorax and septic pulmonary emboli. 

Foreign body aspiration has also been described, including that of needles. Needles have been described as embolising from a peripheral or central injection site to the lung parenchyma.^1,2 It has also been described as a foreign body within the bronchial tree of an intravenous addict who had unintentionally inhaled a needle while inhaling illicit drugs.³

The use of plain chest radiography for the identification of foreign body is extremely limited, with up to 80% of adult chest x-rays failing to identify by this method.⁴

We are describing this case to ensure clinicians are aware of the more uncommon potential complications of foreign body aspiration in intravenous drug use and the limitations of plain chest radiography in the diagnosis of foreign body aspiration.

References

1. Shapiro S. Passage of a hollow needle into the venous blood system to the heart, through the cardiac wall, and into the thorax: report of a case. Am Heart J 1941; 22.6; 835-838
2. Lewis TD, Henry DA. Needle emboluis: a unique complication of intravenous drug abuse. Ann Emerg Med 1985; 14(9); 906-908 
3. Balu B, Andelkovic V. Foreign Body Aspiration Pneumonia in an Intravenous Drug User. Saudi Journal of Anaesthesia 6.1 (2012); 65-68. PMC Web 16 Aug 2016
4. Zissin R, Shapiro-Feinberg M, Rozenman J, Apter S, Smorjik J, Hertz M. CT findings of the chest in adults with aspirated foreign bodies. Eur Radiol 2001; 11:606-1