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Bilateral pneumothorax in an intravenous drug abuser
The ~ournai
of Emergency
Medrone
Vol
2 pp
405-408
1985
Pmted
m the
USA CopyrIght E 1985Pergamor ??
Press Lld
BILATERAL PNEUMOTHORAX IN AN INTRAVENOUS DRUG ABUSER Daniel
Department
is a rare occurence.
present a case of self-induced
We
bilateral pneumo-
thorax in an intravenous
drug abuser. Causes of
bilateral
are reviewed.
0
pneumothorax
Keywords-pneumothorax;
bilateral
pneumothorax:
intravenous
Pneumothorax by emergency
is frequently encountered physicians. It occurs spon-
(IV);
drug abuse
taneously or traumatically. In the following report, we present a case of self-induced bilateral pneumothorax in an intravenous drug abuser. To our knowledge, this complication has been reported only once.’
Case Report A 43-year-old
black man arrived at the University of Cincinnati Center for Emergency Care complaining of shortness of breath. He stated that 24 hours before he had self-injected a combination of narcotics into his neck as he had done many times before. Since then, the patient had become progressively more short of breath. He believed he had “collapsed” his lung. Physical exam revealed a thin male in
=II=ZZZ
Clinical
w
Michael Tomlunovich,
RECEIVED:
C. Levy, MD
mild respiratory distress. Vital signs were: blood pressure, 170/124 mm Hg; pulse, 104 beats per min; respirations, 26. The patient was afebrile. Both sides of his neck were scarred from multiple needle entries (Figure 1). The trachea was midline, and the neck veins were flat. The left side of the chest revealed an absence of lung sounds and hyperresonance. The right chest exam was within normal limits. Upper and lower extremities revealed multiple needle scars. The remainder of the physical examination was unremarkable. A radiograph was obtained, and revealed a bilateral pneumothorax (Figure 2). The left lung was completely collapsed, while the right lung was compressed approximately 25%. Chest tubes were placed bilaterally. Both lungs reexpanded and the patient recovered uneventfully. He was discharged on the fifth hospital day. At follow-up, the patient was believed to be normal.
is a condition com-
by emergency physicians. Bi-
lateral pneumothorax
and Richard
of Emergency Medune, University of Clncinnatl Medical Center, ML #769. 234 Goodman Street, Cincinnati, OH 45267 Repnnt Address Rchard C. Levy, MD, above address
0 Abstract-Pneumothorax monly encountered
MD,
Savitt, MD, Phillip Oblinger,
Communications MD
Discussion Pneumothorax is most often unilateral. Unilateral pneumothorax secondary to internal jugular vein use in drug abusers is usually left-sided because most persons are
focusing primarily on adult emergencies is coordinated of Henry Ford Hospital in Detroit.
24 December 1984; ACCEPTED:
7
March 1985
405
by
0736-4679/85 $3.00 + .OO
Daniel Savitt, Phllllp Oblinger,
406
Figure 1. Multiple needle entries scarred the patient’s
Figure 2. Admission chest radiograph.
and Richard Levy
neck.
Arrows indicate margins of the pneumothoraces.
Bilateral
407
Pneumothorax
right-handed.’ Direct attempts at intravenous injection are not required, as “skin popping” of the chest wall has been reported to cause pneumothorax.” Long-term drug abusers eventually sclerose their peripheral veins and then begin to use their femoral and internal jugular veins (IJV). Access to the IJV is most commonly obtained by the procedure of “pocket shooting,” whereby the patient approaches the IJV above the clavicle. This technique is similar to the “central approach” commonly described in medical literature.3 Pneumothorax occurs more often when the injection site is lower in the neck. Utilization of the subclavian vein is apparently an infrequent street technique, perhaps due to the greater technical difficulty. Spontaneous pneumothorax occurs in the presence of various pathologic conditions involving the lung. They are summarized in Table 1. Traumatic pneumothorax is often iatrogenie; but any penetrating trauma, such as a stab wound, can cause a pneumothorax if appropriately placed (Table 2). Blunt trauma may produce a pneumothorax, especially if ribs are fractured. In addition, almost every invasive procedure from colonscopy to tracheostomy is associated with the possible complication of pneumothorax. Proposed mechanisms range from direct penetration of the pleura to retroperitoneal migration of free air. Many such invasions or trauma can produce bilateral pneumothorax. While the complication of pneumothorax may be more common than is reported, part of the management problem lies with a refusal of treatment by the patient (perhaps in fear of being separated from his or
Table 1. Causes of Spontaneous Pneumothoraxs-‘6
Bilateral
Subpleural bleb Rheumatoid lung disease Sarcoldosis Marfan’s syndrome Miliary tuberculosis Metastatic carcinoma, various types Histiocytosis X Catamenial pneumothorax General anesthesia (no apparent trauma)
Table 2. Traumatic Causes of Bilateral Pneumothoraxlr-24
1. Penetrating trauma 2. Blunt trauma 3. Invasive Procedures: Attempted central vein cannulation Colonoscopy Peritoneoscopy Medlastinoscopy Tracheostomy Acupuncture 4. Foreign bodies in trachea 5. Cardiac resuscitation 6. Endotracheal intubation
her drugs.) It has been reported that in some cases pneumothorax has been neglected by the addict without significant sequelae.’ This probably represents a small pneumothorax.
Conclusions
Pneumothorax can occur spontaneously or traumatically. Bilateral pneumothorax is a rare occurence, but it has been reported under a variety of circumstances. This case represents an unusual complication of drug abuse, and should be searched for in all patients who abuse intravenous drugs.
REFERENCES I. Lewis JW. Elliott JP Jr, Obeid FN: Complications of attempted
central venous injections performed by drug abusers. Chesf 1981; 78:613-617.
2. Shih L, Sharma OP. Barnett K: Pneumothorax: A complication of “skin popping. WJ Med 1983; 138:272. 3. Wyte S, Barker W: Central venous cathetewation,
in Roberts J, Hedges J (eds): Clinical Procedures in Emergency Medicine. WB Saunders, 1985, pp
321-332. 4. Bell C, Borak J, Loeffler JR: Pneumothorax in drug abusers: A complication of internal jugular venous injections. Ann Emerg Med 1983; 12:167-170.
408
5. Tessler S, Bennett LG, Cerruti M: Metastatic sarcoma. Bilateral pneumothoraces as initial manifestation. NY .S[ J Med 1978; 78:2229-2230. DA, Davidson JT, Chandler JJ: 6. Morganstern Spontaneous bloody pneumothorax. J Med Sot NJ 1982; 79:583-584. 7. Evans WV: Bilateral pneumothoraces and pleural effusions in rheumatoid lung disease. ?%orax 1984; 39:213-214. 8. Pettersson GB, Gatzinsky P, Selin K: A case of total bilateral spontaneous pneumothorax. Scund J Thorac Cardiovasc Surg 1983; 17: 175. 9. Ross RJ, Empey DW: Bilateral spontaneous pneumothorax in sarcoidosis. Posfgrad Med J 1983; 59:106-107. 10. Ramachandran M, Dulay VC, Lobo ZA, et al: Bilateral pneumothorax with pneumomediastinum under anaesthesia in a healthy female. Can Anaesfh Sot J 1982; 29:391-394. Il. Gawkrodger DJ: Marfan’s syndrome presenting as bilateral spontaneous pneumothorax. Postgrad Med J 1981; 57:240-241. 12. Benoit Y: Bilateral pneumothorax as an early sign in a child with histiocytosis X. Acfa Puediurr Be/g 1981: 94:43-45. 13. Politis J, Varkey B: Tuberculosis presenting with multiple bilateral pulmonary nodules and a pneumothorax. Can Med Assoc J 1980; 122:1395-1397. 14. Battaglini JW, Shallal JA, Wilcox BR: Bronchogenie carcinoma presenting as spontaneous pneumothorax: Report of two cases and review of the literature. NC Med J 1980; 41:804-807. 15. Barrocas A: Catamenial pneumothorax: Case re-
Daniel
16.
17.
18.
19.
20.
21.
22.
23.
24.
Savitt,
Phlllip
Oblinger,
and
Richard
Levy
port and a review of the literature. Am Surg 1979; 45:340-343. Stevens RP, Peirce TH, Dooley PC, et al: Bilateral spontaneous pneumothorax in nongestational choriocarcinoma. Can Med Assoc J 1979; 120: 830-831. Schorlemmer CR, Khouri RK, Murray GF, et al: Bilateral pneumothoraces secondary to iatrogenic buffalo chest: An unusual complication of median sternotomy and subclavian vein catheterization. Ann Surg 1984; 199:372-374. Murray DP, Rankin RA, Lackey C: Bilateral pneumothoraces complicating peritoneoscopy (letter). Gastrointesr Endosc 1984; 30:45-46. Dudley JP: Bilateral pneumothorax resulting from the bronchoscopic removal of a puncture vine fuite. Ann Otoi Rhino1 Laryngol 1983; 92:3%-397. Saar MC: Bilateral pneumothoraces after resuscitation with esophageal airway (letter). JAMA 1980; 243:2154-2155. Thomas JH, Pierce GE, MacArthur RI: Bilateral pneumorhoraces secondary to colonic endoscopy. J Natl Med Assoc 1979; 7 1:701-702. Malloy WF, Wightman AE. O’Sullivan D, et al: Bilateral pneumothorax from suction applied to a ventilator exhaust valve. Anesrh Am/g 1979; 58:147-149. McGoon MD, Benedetto PW, Greene BM: Complications of percutaneous central venous catheterization: A report of two cases and review of the literature. Johns Hopkins Med J 1979; 145: l-6. Geelhoed GW, Joseph WL: Surgical sequelae of drug abuse. Surg Gyn and OE 1974; 139:749-755.
of Emergency
Medrone
Vol
2 pp
405-408
1985
Pmted
m the
USA CopyrIght E 1985Pergamor ??
Press Lld
BILATERAL PNEUMOTHORAX IN AN INTRAVENOUS DRUG ABUSER Daniel
Department
is a rare occurence.
present a case of self-induced
We
bilateral pneumo-
thorax in an intravenous
drug abuser. Causes of
bilateral
are reviewed.
0
pneumothorax
Keywords-pneumothorax;
bilateral
pneumothorax:
intravenous
Pneumothorax by emergency
is frequently encountered physicians. It occurs spon-
(IV);
drug abuse
taneously or traumatically. In the following report, we present a case of self-induced bilateral pneumothorax in an intravenous drug abuser. To our knowledge, this complication has been reported only once.’
Case Report A 43-year-old
black man arrived at the University of Cincinnati Center for Emergency Care complaining of shortness of breath. He stated that 24 hours before he had self-injected a combination of narcotics into his neck as he had done many times before. Since then, the patient had become progressively more short of breath. He believed he had “collapsed” his lung. Physical exam revealed a thin male in
=II=ZZZ
Clinical
w
Michael Tomlunovich,
RECEIVED:
C. Levy, MD
mild respiratory distress. Vital signs were: blood pressure, 170/124 mm Hg; pulse, 104 beats per min; respirations, 26. The patient was afebrile. Both sides of his neck were scarred from multiple needle entries (Figure 1). The trachea was midline, and the neck veins were flat. The left side of the chest revealed an absence of lung sounds and hyperresonance. The right chest exam was within normal limits. Upper and lower extremities revealed multiple needle scars. The remainder of the physical examination was unremarkable. A radiograph was obtained, and revealed a bilateral pneumothorax (Figure 2). The left lung was completely collapsed, while the right lung was compressed approximately 25%. Chest tubes were placed bilaterally. Both lungs reexpanded and the patient recovered uneventfully. He was discharged on the fifth hospital day. At follow-up, the patient was believed to be normal.
is a condition com-
by emergency physicians. Bi-
lateral pneumothorax
and Richard
of Emergency Medune, University of Clncinnatl Medical Center, ML #769. 234 Goodman Street, Cincinnati, OH 45267 Repnnt Address Rchard C. Levy, MD, above address
0 Abstract-Pneumothorax monly encountered
MD,
Savitt, MD, Phillip Oblinger,
Communications MD
Discussion Pneumothorax is most often unilateral. Unilateral pneumothorax secondary to internal jugular vein use in drug abusers is usually left-sided because most persons are
focusing primarily on adult emergencies is coordinated of Henry Ford Hospital in Detroit.
24 December 1984; ACCEPTED:
7
March 1985
405
by
0736-4679/85 $3.00 + .OO
Daniel Savitt, Phllllp Oblinger,
406
Figure 1. Multiple needle entries scarred the patient’s
Figure 2. Admission chest radiograph.
and Richard Levy
neck.
Arrows indicate margins of the pneumothoraces.
Bilateral
407
Pneumothorax
right-handed.’ Direct attempts at intravenous injection are not required, as “skin popping” of the chest wall has been reported to cause pneumothorax.” Long-term drug abusers eventually sclerose their peripheral veins and then begin to use their femoral and internal jugular veins (IJV). Access to the IJV is most commonly obtained by the procedure of “pocket shooting,” whereby the patient approaches the IJV above the clavicle. This technique is similar to the “central approach” commonly described in medical literature.3 Pneumothorax occurs more often when the injection site is lower in the neck. Utilization of the subclavian vein is apparently an infrequent street technique, perhaps due to the greater technical difficulty. Spontaneous pneumothorax occurs in the presence of various pathologic conditions involving the lung. They are summarized in Table 1. Traumatic pneumothorax is often iatrogenie; but any penetrating trauma, such as a stab wound, can cause a pneumothorax if appropriately placed (Table 2). Blunt trauma may produce a pneumothorax, especially if ribs are fractured. In addition, almost every invasive procedure from colonscopy to tracheostomy is associated with the possible complication of pneumothorax. Proposed mechanisms range from direct penetration of the pleura to retroperitoneal migration of free air. Many such invasions or trauma can produce bilateral pneumothorax. While the complication of pneumothorax may be more common than is reported, part of the management problem lies with a refusal of treatment by the patient (perhaps in fear of being separated from his or
Table 1. Causes of Spontaneous Pneumothoraxs-‘6
Bilateral
Subpleural bleb Rheumatoid lung disease Sarcoldosis Marfan’s syndrome Miliary tuberculosis Metastatic carcinoma, various types Histiocytosis X Catamenial pneumothorax General anesthesia (no apparent trauma)
Table 2. Traumatic Causes of Bilateral Pneumothoraxlr-24
1. Penetrating trauma 2. Blunt trauma 3. Invasive Procedures: Attempted central vein cannulation Colonoscopy Peritoneoscopy Medlastinoscopy Tracheostomy Acupuncture 4. Foreign bodies in trachea 5. Cardiac resuscitation 6. Endotracheal intubation
her drugs.) It has been reported that in some cases pneumothorax has been neglected by the addict without significant sequelae.’ This probably represents a small pneumothorax.
Conclusions
Pneumothorax can occur spontaneously or traumatically. Bilateral pneumothorax is a rare occurence, but it has been reported under a variety of circumstances. This case represents an unusual complication of drug abuse, and should be searched for in all patients who abuse intravenous drugs.
REFERENCES I. Lewis JW. Elliott JP Jr, Obeid FN: Complications of attempted
central venous injections performed by drug abusers. Chesf 1981; 78:613-617.
2. Shih L, Sharma OP. Barnett K: Pneumothorax: A complication of “skin popping. WJ Med 1983; 138:272. 3. Wyte S, Barker W: Central venous cathetewation,
in Roberts J, Hedges J (eds): Clinical Procedures in Emergency Medicine. WB Saunders, 1985, pp
321-332. 4. Bell C, Borak J, Loeffler JR: Pneumothorax in drug abusers: A complication of internal jugular venous injections. Ann Emerg Med 1983; 12:167-170.
408
5. Tessler S, Bennett LG, Cerruti M: Metastatic sarcoma. Bilateral pneumothoraces as initial manifestation. NY .S[ J Med 1978; 78:2229-2230. DA, Davidson JT, Chandler JJ: 6. Morganstern Spontaneous bloody pneumothorax. J Med Sot NJ 1982; 79:583-584. 7. Evans WV: Bilateral pneumothoraces and pleural effusions in rheumatoid lung disease. ?%orax 1984; 39:213-214. 8. Pettersson GB, Gatzinsky P, Selin K: A case of total bilateral spontaneous pneumothorax. Scund J Thorac Cardiovasc Surg 1983; 17: 175. 9. Ross RJ, Empey DW: Bilateral spontaneous pneumothorax in sarcoidosis. Posfgrad Med J 1983; 59:106-107. 10. Ramachandran M, Dulay VC, Lobo ZA, et al: Bilateral pneumothorax with pneumomediastinum under anaesthesia in a healthy female. Can Anaesfh Sot J 1982; 29:391-394. Il. Gawkrodger DJ: Marfan’s syndrome presenting as bilateral spontaneous pneumothorax. Postgrad Med J 1981; 57:240-241. 12. Benoit Y: Bilateral pneumothorax as an early sign in a child with histiocytosis X. Acfa Puediurr Be/g 1981: 94:43-45. 13. Politis J, Varkey B: Tuberculosis presenting with multiple bilateral pulmonary nodules and a pneumothorax. Can Med Assoc J 1980; 122:1395-1397. 14. Battaglini JW, Shallal JA, Wilcox BR: Bronchogenie carcinoma presenting as spontaneous pneumothorax: Report of two cases and review of the literature. NC Med J 1980; 41:804-807. 15. Barrocas A: Catamenial pneumothorax: Case re-
Daniel
16.
17.
18.
19.
20.
21.
22.
23.
24.
Savitt,
Phlllip
Oblinger,
and
Richard
Levy
port and a review of the literature. Am Surg 1979; 45:340-343. Stevens RP, Peirce TH, Dooley PC, et al: Bilateral spontaneous pneumothorax in nongestational choriocarcinoma. Can Med Assoc J 1979; 120: 830-831. Schorlemmer CR, Khouri RK, Murray GF, et al: Bilateral pneumothoraces secondary to iatrogenic buffalo chest: An unusual complication of median sternotomy and subclavian vein catheterization. Ann Surg 1984; 199:372-374. Murray DP, Rankin RA, Lackey C: Bilateral pneumothoraces complicating peritoneoscopy (letter). Gastrointesr Endosc 1984; 30:45-46. Dudley JP: Bilateral pneumothorax resulting from the bronchoscopic removal of a puncture vine fuite. Ann Otoi Rhino1 Laryngol 1983; 92:3%-397. Saar MC: Bilateral pneumothoraces after resuscitation with esophageal airway (letter). JAMA 1980; 243:2154-2155. Thomas JH, Pierce GE, MacArthur RI: Bilateral pneumorhoraces secondary to colonic endoscopy. J Natl Med Assoc 1979; 7 1:701-702. Malloy WF, Wightman AE. O’Sullivan D, et al: Bilateral pneumothorax from suction applied to a ventilator exhaust valve. Anesrh Am/g 1979; 58:147-149. McGoon MD, Benedetto PW, Greene BM: Complications of percutaneous central venous catheterization: A report of two cases and review of the literature. Johns Hopkins Med J 1979; 145: l-6. Geelhoed GW, Joseph WL: Surgical sequelae of drug abuse. Surg Gyn and OE 1974; 139:749-755.