Pulmonary complications from cocaine and cocaine-based substances: imaging manifestations

A quantitative LC-MS/MS method for investigation of polysubstance use involving heroin and cocaine

Concurrent use of heroin and cocaine (known as the "speedball") prevails among substance use disorder populations, especially in opioid-dependent individuals, with severe consequences and a high fatality rate. Little is known about the patterns and correlations of the concurrent use of heroin and cocaine. It is vital to investigate such a polydrug use in both humans and animals to uncover concomitant toxicity and the cause of fatal overdose (death). In this study, we aimed to shed some light on the role of cocaine in the etiology of heroin-related deaths in the context of molecular pharmacokinetics (PK). For the purpose, a high-performance liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS) method for simultaneous determination of heroin, cocaine, and their metabolites in whole blood was developed and fully validated in accordance with the US Food and Drug Administration (FDA) and European Medicines Agency (EMA) guidelines. Then, this method was used to analyze heroin, cocaine, and their metabolites in blood from the rats intraperitoneally administered non-lethal 10 mg/kg heroin or 20 mg/kg cocaine alone, or their combination that is lethal with a proximal mortality of 33 %. The obtained results from the rats that experienced the lethal toxicity revealed that the concurrent use of heroin and cocaine significantly increased the risk of fatality from overdose. Heroin significantly slowed down the elimination of cocaine and its main metabolites in blood, while cocaine significantly enhanced heroin metabolism from 6-monoacetylmorphine (6-MAM) to morphine. Similar elimination half-lives for other heroin metabolites were observed. These findings are reported for the first time in this study, facilitating our understanding of the polysubstance metabolism and severe consequences produced by the polydrug use.

Cardiovascular and pulmonary complications of recreational drugs: A pictorial review

Recreational drug abuse constitutes a serious health problem worldwide. Consumption of cocaine, amphetamine-type stimulants, opioids and cannabis can lead to multiple acute and chronic cardiopulmonary complications, resulting in high morbidity and mortality. These complications may be first detected at imaging, since clinical presentation is usually non-specific. Cardiovascular complications include myocardial infarction, endocarditis, aortic dissection, infectious pseudoaneurysm, retained needle fragments, cardiomyopathy and pulmonary arterial hypertension. Pulmonary complications encompass pulmonary oedema, crack lung, pneumonia, septic emboli, barotrauma, airway disease, emphysema and excipient lung disease. Knowledge of the cardiopulmonary imaging manifestations of illicit drug use in conjunction with clinical history and a high grade of suspicion enable an accurate diagnosis and appropriate management plan. In this article we aim to provide a pictorial review of the most frequent cardiopulmonary manifestations of recreational drugs, emphasizing the underlying pathophysiologic mechanisms and the various imaging appearances.

[Substance use disorder: Epidemiology, medical consequences and treatment]

Substance use is a common health problem, and substance use disorder, which is its most severe presentation, is associated with multiple medical consequences and a negative impact on individual and on population health. Substance use disorder needs to be addressed as any chronic medical condition; therefore, it has to be detected at the early stages and has to be properly treated to prevent drug-related harm. Internists should be able to recognize and treat intoxication and abstinence. Internists should also be able to refer the patient to state of the art long term treatment, aimed to detoxification and treatment induction to promote abstinence and prevent relapse. In this narrative review we will discuss substance use epidemiology, its main medical consequences and its treatment, with a focus on alcohol, opiates, cocaine and other stimulants, cannabis and benzodiazepines.

Spectrum of Thoracic Imaging Findings in the Setting of Substance Abuse

ABSTRACT

Substance abuse continues to be prevalent nationwide and can lead to a myriad of chest pathologies. Imaging findings are vast and can include nodules, masses, ground-glass opacities, airspace disease, and cysts. Radiologists with awareness of these manifestations can assist in early identification of disease in situations where information is unable to be obtained from the patient. This review focuses on thoracic imaging findings associated with various forms of substance abuse, which are organized by portal of entry into the thorax: inhalation, ingestion, and injection.

Crack lung with toxic cerebral vasculitis: Case report

Crack is the most potent form of cocaine. It directly affects lungs if inhaled and the damage may include barotrauma, acute pulmonary edema, alveolar hemorrhage, bronchiolitis obliterans with organizing pneumonia, or vasculitis. The diagnosis of cocaine-related lung damage is based on clinical symptoms and radiological findings. When young individuals develop respiratory symptoms, investigation into cocaine use is necessary. We report the case of a young man with a history of cocaine use who presented for respiratory and neurological symptoms revealing crack lung and toxic cerebral vasculitis.

Cocaine-use disorder and childhood maltreatment are associated with the activation of neutrophils and increased inflammation

BACKGROUND

Cocaine-use disorder (CUD) has been associated with early life adversity and activated cellular immune responses. Women are most vulnerable to complications from chronic substance disorders, generally presenting an intense feeling of abstinence and consuming significant drug amounts. Here, we investigated neutrophil functional activities in CUD, including the formation of neutrophil extracellular traps (NETs) and related intracellular signalling. We also investigated the role of early life stress in inflammatory profiles.

METHODS

Blood samples, clinical data, and history of childhood abuse or neglect were collected at the onset of detoxification treatment of 41 female individuals with CUD and 31 healthy controls (HCs). Plasma cytokines, neutrophil phagocytosis, NETs, intracellular reactive oxygen species (ROS) generation, and phosphorylated protein kinase B (Akt) and mitogen-activated protein kinases (MAPK)s were assessed by flow cytometry.

RESULTS

CUD subjects had higher scores of childhood trauma than controls. Increased plasma cytokines (TNF-α, IL-1β, IL-6, IL-8, IL-12, and IL-10), neutrophil phagocytosis, and production of NETs were reported in CUD subjects as compared to HC. Neutrophils of CUD subjects also produced high levels of intracellular ROS and had more activated Akt and MAPKs (p38/ERK), which are essential signalling pathways involved in cell survival and NETs production. Childhood trauma scores were significantly associated with neutrophil activation and peripheral inflammation.

CONCLUSION

Our study reinforces that smoked cocaine and early life stress activate neutrophils in an inflammatory environment.

Safe inhalation pipe provision (SIPP): protocol for a mixed-method evaluation of an intervention to improve health outcomes and service engagement among people who use crack cocaine in England

BACKGROUND

Over 180,000 people use crack cocaine in England, yet provision of smoking equipment to support safer crack use is prohibited under UK law. Pipes used for crack cocaine smoking are often homemade and/or in short supply, leading to pipe sharing and injuries from use of unsafe materials. This increases risk of viral infection and respiratory harm among a marginalised underserved population. International evaluations suggest crack pipe supply leads to sustained reductions in pipe sharing and use of homemade equipment; increased health risk awareness; improved service access; reduction in injecting and crack-related health problems. In this paper, we introduce the protocol for the NIHR-funded SIPP (Safe inhalation pipe provision) project and discuss implications for impact.

METHODS

The SIPP study will develop, implement and evaluate a crack smoking equipment and training intervention to be distributed through peer networks and specialist drug services in England. Study components comprise: (1) peer-network capacity building and co-production; (2) a pre- and post-intervention survey at intervention and non-equivalent control sites; (3) a mixed-method process evaluation; and (4) an economic evaluation. Participant eligibility criteria are use of crack within the past 28 days, with a survey sample of ~ 740 for each impact evaluation survey point and ~ 40 for qualitative process evaluation interviews. Our primary outcome measure is pipe sharing within the past 28 days, with secondary outcomes pertaining to use of homemade pipes, service engagement, injecting practice and acute health harms.

ANTICIPATED IMPACT

SIPP aims to reduce crack use risk practices and associated health harms; including through increasing crack harm reduction awareness among service providers and peers. Implementation has only been possible with local police approvals. Our goal is to generate an evidence base to inform review of the legislation prohibiting crack pipe supply in the UK. This holds potential to transform harm reduction service provision and engagement nationally.

CONCLUSION

People who smoke crack cocaine in England currently have little reason to engage with harm reduction and drug services. Little is known about this growing population. This study will provide insight into population characteristics, unmet need and the case for legislative reform.

TRIAL REGISTRATION

ISRCTN12541454  https://doi.org/10.1186/ISRCTN12541454.

Cocaine-Induced Lung Damage and Uncommon Involvement of the Basal Ganglia

Cocaine use is responsible for multiorgan damage, including the brain and lungs. Bilateral and symmetrical involvement of the basal ganglia may be due to toxic, metabolic, vascular, inflammatory, infectious, or tumoral causes. Cocaine-related encephalopathy mainly affects the white matter, while basal ganglia involvement is an uncommon finding. Cocaine-induced lung damage varies clinically and even radiologically, with signs that lack specificity. The diagnosis of cocaine-induced lung or brain injury is based on suggestive radiological signs in the context of cocaine consumption and after the elimination of other etiologies likely to present the same patterns. The context of cocaine use is often not spontaneously declared, making diagnosis more complicated. We report the case of a 28-year-old male patient, with a history of freebase cocaine use, admitted to the emergency room in severe coma with respiratory distress. Brain MRI showed bilateral and symmetrical abnormalities of the basal ganglia. A chest CT scan revealed interstitial lung damage dominated by the ground-glass pattern. The urine toxicology test was positive for cocaine. Cocaine-related lesions can be reversible, and therapeutic management is essentially based on supportive care.

Cis-meQTL for cocaine use-associated DNA methylation in an HIV-positive cohort show pleiotropic effects on multiple traits

BACKGROUND

Cocaine use (CU) is associated with psychiatric and medical diseases. Little is known about the mechanisms of CU-related comorbidities. Findings from preclinical and clinical studies have suggested that CU is associated with aberrant DNA methylation (DNAm) that may be influenced by genetic variants [i.e., methylation quantitative trait loci (meQTLs)]. In this study, we mapped cis-meQTLs for CU-associated DNAm sites (CpGs) in an HIV-positive cohort (Ntotal = 811) and extended the meQTLs to multiple traits.

RESULTS

We conducted cis-meQTL analysis for 224 candidate CpGs selected for their association with CU in blood. We identified 7,101 significant meQTLs [false discovery rate (FDR) < 0.05], which mostly mapped to genes involved in immunological functions and were enriched in immune pathways. We followed up the meQTLs using phenome-wide association study and trait enrichment analyses, which revealed 9 significant traits. We tested for causal effects of CU on these 9 traits using Mendelian Randomization and found evidence that CU plays a causal role in increasing hypertension (p-value = 2.35E-08) and decreasing heel bone mineral density (p-value = 1.92E-19).

CONCLUSIONS

These findings suggest that genetic variants for CU-associated DNAm have pleiotropic effects on other relevant traits and provide new insights into the causal relationships between cocaine use and these complex traits.

Opium, phencyclidine, and crack cocaine smoking associations with lung and upper aerodigestive tract cancers: exploratory findings from a case-control study in Los Angeles County

Background: Illicit drug use has become a global epidemic, yet it is unclear if drug smoking increases the risk of tobacco-related cancers.Objectives: We aimed to evaluate hypothesized associations between smoking three drugs - opium, phencyclidine (PCP) and crack cocaine and lung and upper aerodigestive tract (UADT) cancers.Methods: A population-based case-control study with 611 lung cancer cases (50% male), 601 UADT cancers cases (76% male), and 1,040 controls (60% male) was conducted in Los Angeles County (1999-2004). Epidemiologic data including drug smoking histories were collected in face-to-face interviews. Associations were estimated with logistic regressions.Results: Adjusting for potential confounders, ever vs. never crack smoking was positively associated with UADT cancers (aOR = 1.56, 95% CI: 1.05, 2.33), and a dose-response relationship was observed for lifetime smoking frequency (p for trend = .024). Heavy (> median) vs. never crack smoking was associated with UADT cancers (aOR = 1.81, 95% CI: 1.07, 3.08) and lung cancer (aOR = 1.58, 95% CI: 0.88, 2.83). A positive association was also observed between heavy PCP smoking and UADT cancers (aOR = 2.29, 95% CI: 0.91, 5.79). Little or no associations were found between opium smoking and lung cancer or UADT cancers.Conclusion: The positive associations between illicit drug use and lung and/or UADT cancers suggest that smoking these drugs may increase the risk of tobacco-related cancers. Despite the low frequency of drug smoking and possible residual confounding, our findings may provide additional insights on the development of lung and UADT cancers.

Lung Function in Women With and Without Human Immunodeficiency Virus

BACKGROUND

Prior studies have found that human immunodeficiency virus (HIV) infection is associated with impaired lung function and increased risk of chronic lung disease, but few have included large numbers of women. In this study, we investigate whether HIV infection is associated with differences in lung function in women.

METHODS

This was a cross-sectional analysis of participants in the Women's Interagency HIV Study, a racially and ethnically diverse multicenter cohort of women with and without HIV. In 2018-2019, participants at 9 clinical sites were invited to perform spirometry. Single-breath diffusing capacity for carbon monoxide (DLCO) was also measured at selected sites. The primary outcomes were the post-bronchodilator forced expiratory volume in 1 second (FEV1) and DLCO. Multivariable regression modeling was used to analyze the association of HIV infection and lung function outcomes after adjustment for confounding exposures.

RESULTS

FEV1 measurements from 1489 women (1062 with HIV, 427 without HIV) and DLCO measurements from 671 women (463 with HIV, 208 without HIV) met standards for quality and reproducibility. There was no significant difference in FEV1 between women with and without HIV. Women with HIV had lower DLCO measurements (adjusted difference, -0.73 mL/min/mm Hg; 95% confidence interval, -1.33 to -.14). Among women with HIV, lower nadir CD4 + cell counts and hepatitis C virus infection were associated with lower DLCO measurements.

CONCLUSIONS

HIV was associated with impaired respiratory gas exchange in women. Among women with HIV, lower nadir CD4 + cell counts and hepatitis C infection were associated with decreased respiratory gas exchange.

COVID-19 broken access: implications for individuals with substance use disorders

The impact of the COVID-19 (coronavirus) pandemic created a paradigm shift in the delivery of substance abuse treatment services. Still, it also provided an opportunity for healthcare workers and professionals, and treatment providers to adjust, problem-solve, and meet these challenges head-on. The pandemic led practitioners and healthcare professionals to change how they deliver treatment options but still ensuring that their clients received access to adequate and effective clinical services. It is suggested that during the ongoing COVID-19 pandemic, healthcare professionals should make every effort to ensure accessibility and availability of substance abuse treatment services through critical actions. This paper will address the physical health implications, as well as the trauma-stress related effects of COVID-19 on individuals with substance use disorders (SUD). In all, this article will identify barriers to treatment access, accentuate treatment strategies, and provide measures and recommendations for maintaining and improving services for substance-dependent patients.

Burden and treatment of chronic obstructive pulmonary disease among people using illicit opioids: matched cohort study in England

Objective

To understand the burden of chronic obstructive pulmonary disease among people who use illicit opioids such as heroin, and evaluate inequalities in treatment.

Design

Cohort study.

Setting

Patients registered at primary care practices in England.

Participants

106 789 patients in the Clinical Practice Research Datalink with illicit opioid use recorded between 2001 and 2018, and a subcohort of 3903 patients with a diagnosis of chronic obstructive pulmonary disease. For both cohorts, the study sampled a comparison group with no history of illicit opioids that was matched by age, sex, and general practice.

Main outcome measures

In the base cohort: diagnosis of chronic obstructive pulmonary disease and death due to the disease. In the subcohort: five treatments (influenza vaccine, pneumococcal vaccine, pulmonary rehabilitation, bronchodilators or corticosteroids, and smoking cessation support) and exacerbations requiring hospital admission.

Results

680 of 106 789 participants died due to chronic obstructive pulmonary disease, representing 5.1% of all cause deaths. Illicit opioid use was associated with 14.59 times (95% confidence interval 12.28 to 17.33) the risk of death related to chronic obstructive pulmonary disease, and 5.89 times (5.62 to 6.18) the risk of a diagnosis of the disease. Among patients with a new diagnosis, comorbid illicit opioid use was associated with current smoking, underweight, worse lung function, and more severe breathlessness. After adjusting for these differences, illicit opioids were associated with 1.96 times (1.82 to 2.12) times the risk of exacerbations requiring hospital admission, but not associated with a substantially different probability of the five treatments.

Conclusions

Death due to chronic obstructive pulmonary disease is about 15 times more common among people who use illicit opioids than the general population. This inequality does not appear to be explained by differences in treatment, but late diagnosis of the disease among people who use illicit opioids might contribute.

A Bayesian approach to simultaneous adjustment of misclassification and missingness in categorical covariates

This study considers concurrent adjustment of misclassification and missingness in categorical covariates in regression models. Under various misclassification and missingness mechanisms, we derive a general mixture regression structure for regression models that can incorporate multiple surrogates of categorical covariates that are subject to misclassification and missingness. In simulation studies, we demonstrate that including observations with missingness and/or multiple surrogates of the covariate helps alleviate the efficiency loss caused by misclassification. In addition, we study the efficacy of misclassification adjustment when the number of categories increases for the covariate of interest. Using data from the Longitudinal Studies of HIV-Associated Lung Infections and Complications, we perform simultaneous adjustment of misclassification and missingness in the self-reported cocaine and heroin use variable when assessing its association with lung density measures.

Cocaine Induced Biliary Tree Obstruction in a Middle-Aged Male

A sixty-two-year-old male with a history of extensive crack cocaine use and cholecystectomy presented to the emergency department with abdominal pain, nausea, vomiting, and urobilia. The physical exam revealed moderate epigastric tenderness without scleral icterus or jaundice. The patient's total bilirubin was elevated at 5.2, and his direct bilirubin was 3.7. A computed tomography angiogram (CTA) of the abdomen and pelvis subsequently showed a 3.1 x 2.8 cm mass compressing porta hepatis. A magnetic resonance cholangiopancreatography (MRCP) showed a 4.9 x 3.0 cm mass at the porta hepatis with corresponding biliary duct obstruction at that level. An endoscopic retrograde cholangiopancreatography (ERCP) was performed with stent placement and brush biopsy, which showed predominantly benign ductal epithelium with rare, atypical cells and stenosis of the proximal common bile duct suggestive of cholangiocarcinoma. Cytology was performed on the ductal fluid and was also negative. The carbohydrate antigen (CA) 19-9 level at that time was 94.3. We discussed the possibility of performing surgery as an inpatient, but the patient had various psychosocial issues, which prompted a psychiatric evaluation. He subsequently had an internal-external biliary drain placed. The patient was discharged with plans to obtain an endoscopic ultrasound as an outpatient. He was admitted and discharged several times over the span of six months for various issues. He received an endoscopic ultrasound (EUS) at a surrounding hospital. The results were inconclusive, and a repeat EUS was recommended. On the last admission to the hospital for abdominal pain, a CT scan showed no biliary tree obstruction, which was further confirmed with an MRCP. The internal-external biliary drain was removed without recurrence of hyperbilirubinemia. We suspect that the patient's initial symptoms and radiographic findings of a biliary tree mass may have been induced by extrinsic compression secondary to lymphadenopathy caused by an adulterant used in the cutting process of abused cocaine. This is a rare occurrence that has not been described in the literature. There are associations of cocaine use to pulmonary hilar lymphadenopathy, but not biliary lymphadenopathy. We strongly suspect that this patient's obstructive jaundice and extrinsic biliary tree obstruction were caused by underlying cocaine use.

Prevalence, Clinical Characteristics, and Outcomes Among Lung Transplant Recipients of Donors With Cocaine Use

INTRODUCTION

There is limited data regarding lung transplant (LT) outcomes among recipients of donors with a history of cocaine use. We sought to assess the burden of cocaine abuse among LT donors, describe their characteristics, and evaluate the association with post-transplant outcomes.

METHODS

From the United Network for Organ Sharing database, we included adult patients (age ≥18 years) who underwent LT between 1996 and 2014 (N = 20,106; mean age 53.7 ± 13 years; male: 57%). Study groups were divided based on the donor history of recent cocaine abuse (last 6 months). Donor and recipient characteristics were compared between the 2 groups. With 1-year survival as the primary endpoint, multivariate logistic regression analysis was conducted to assess for an independent association with the donor history of cocaine use.

RESULTS

The overall frequency of donors with any history of cocaine use was 10.9% (n = 2189), although less than half were current users (n = 1001, 4.98%). Unadjusted 1-year survival was worse among recipients of donors with current cocaine use, although it did not achieve statistical significance (84.4% vs 82.2%; odds ratio 1.17, 95% confidence interval 0.99-1.38; P = .07). After adjusting for potential confounders, the current use of cocaine was not associated with 1-year survival (adjusted OR 1.06, 95% CI 0.95-1.18; P = .29).

CONCLUSIONS

A significant proportion of lung donors have a history of cocaine abuse. Although unadjusted early outcomes appear to worsen among recipients of active cocaine users, an independent association was not seen with 1-year survival. The current analysis supports the continued use of donors with a history of cocaine abuse, assuming they meet other criteria for organ quality.

Routine Use of Prescription Adderall Leading to Non-cardiogenic Pulmonary Edema and Respiratory Failure

A 47-year-old female with attention-deficit/hyperactivity disorder on prescription Adderall presented to the hospital with worsening dyspnea for the one-month duration. She was admitted to the medical intensive care unit with respiratory failure requiring non-invasive positive pressure ventilation. Cardiac catheterization confirmed the diagnosis of non-cardiogenic pulmonary edema. With the discontinuation of Adderall, use of BiPAP, and aggressive diuresis with loop diuretics, there was evidence of symptomatic, laboratory, and radiological improvement. Her symptoms were attributed to Adderall use as a diagnosis of exclusion. To our knowledge, this paper reports the first case of Adderall-induced non-cardiogenic pulmonary edema leading to respiratory failure. Although case reports of abuse or overdose of other stimulants such as amphetamine and cocaine leading to a plethora of cardiac and pulmonary complications such as acute respiratory distress syndrome (ARDS), cardiogenic pulmonary edema, and non-cardiogenic pulmonary edema exist, there are no reports that using Adderall at routine prescription doses can lead to these problems.

Non-Infectious Granulomatous Lung Disease: Imaging Findings with Pathologic Correlation

Non-infectious granulomatous lung disease represents a diverse group of disorders characterized by pulmonary opacities associated with granulomatous inflammation, a relatively nonspecific finding commonly encountered by pathologists. Some lesions may present a diagnostic challenge because of nonspecific imaging features; however, recognition of the various imaging manifestations of these disorders in conjunction with patients' clinical history, such as age, symptom onset and duration, immune status, and presence of asthma or cutaneous lesions, is imperative for narrowing the differential diagnosis and determining appropriate management of this rare group of disorders. In this pictorial review, we describe the pathologic findings of various non-infectious granulomatous lung diseases as well as the radiologic features and high-resolution computed tomography imaging features.

Differential diagnoses of COVID-19 pneumonia: the current challenge for the radiologist-a pictorial essay

BACKGROUND

COVID-19 pneumonia represents the most severe pandemic of the twenty-first century and has crucial clinical, social and economical implications. The scientific community has focused attention and resources on clinical and radiological features of COVID-19 pneumonia. Few papers analysing the vast spectrum of differential diagnoses have been published.

MAIN BODY

Complexity of differential diagnosis lays in the evidence of similar radiological findings as ground-glass opacities, crazy paving pattern and consolidations in COVID-19 pneumonia and a multitude of other lung diseases. Differential diagnosis is and will be extremely important during and after the pandemic peak, when there are fewer COVID-19 pneumonia cases. The aim of our pictorial essay is to schematically present COVID-19 pneumonia most frequent differential diagnoses to help the radiologist face the current COVID-19 pneumonia challenge.

CONCLUSIONS

Clinical data, laboratory tests and imaging are pillars of a trident, which allows to reach a correct diagnosis in order to grant an excellent allocation of human and economical resources. The radiologist has a pivotal role in the early diagnosis of COVID-19 pneumonia because he may raise suspicion of the pathology and help to avoid COVID-19 virus spread.

Cracking the Opium Den: Cardiothoracic Manifestations of Drug Abuse

Recreational drug use is increasing worldwide, with emergency room visits and total deaths from drug overdose rising in recent years. Complications from prescription and recreational drug use may result from the biochemical effects of the drugs themselves, impurities mixed with substances, or from causes related to the method of drug administration. The presentation of drug overdose may be complex due to multisubstance abuse, including cigarette smoking and alcoholism, and can impact any organ system. Patients may present without history, and radiologists may be the first clinicians to suggest the diagnosis. We aim to explore the cardiothoracic manifestations of drug abuse and their multimodality imaging manifestations.

The Significance of Subpleural Sparing in CT Chest: A State-of-the-Art Review

The subpleural sparing pattern is a common finding on computed tomography (CT) of the lungs. It comprises of pulmonary opacities sparing the lung peripheries, typically 1cm and less from the pleural surface. This finding has a variety of causes, including idiopathic, inflammatory, infectious, inhalational, cardiac, traumatic, and bleeding disorders. Specific disorders that can cause subpleural sparing patterns include nonspecific interstitial pneumonia (NSIP), organizing pneumonia (OP), pulmonary alveolar proteinosis (PAP), diffuse alveolar hemorrhage (DAH), vaping-associated lung injury (VALI), cracked lung, pulmonary edema, pneumocystis jirovecii pneumonia (PJP), pulmonary contusion, and more recently, Coronavirus disease 2019 (COVID-19) pneumonia. Knowledge of the many etiologies of this pattern can be useful in preventing diagnostic errors. In addition, although the etiology of subpleural sparing pattern is frequently indistinguishable during an initial radiologic evaluation, the differences in location of opacities in the lungs, as well as the presence of additional radiologic findings, patient history, and clinical presentation, can often be useful to suggest the appropriate diagnosis. We did a comprehensive search on Pubmed and Google Scholar database using keywords of "subpleural sparing," "peripheral sparing," "sparing of peripheries," "CT chest," "chest imaging," and "pulmonary disease." This review aims to describe the primary differential diagnosis of subpleural sparing pattern seen on chest imaging with a strong emphasis on clinical and radiographic findings. We also discuss the pathogenesis and essential clues that are crucial to narrow the differential diagnosis.

The Urgent Need to Respond to HIV- and HCV-Related Risk Practices among Youth in Ottawa Who Smoke Crack

A community-based research project, Project Rock sought to provide evidence to respond to the community-identified need to more fully understand the parameters of the social and risk profiles of youth in Ottawa who smoked crack. Objectives: In this article we examine engagement in HIV and HCV risk-related smoking practices, and experiences accessing safer inhalation supplies with the objective of identifying potential intervention points and associated harm reduction interventions to initiate and support safer inhalation practices. Methods: The study comprised four sequential components - formation and facilitation of a Youth Project team, qualitative interviews, and member checking workshops - each component building on the preceding and all contributing to the final and fourth component of the interviewer-administered quantitative survey from which data for this article are drawn. Eligibility criteria: capable of informed consent; aged between 16 and 25 years; had ever injected drugs or had ever tried crack or had used two or more hard drugs in the three months preceding their interview. Recruitment cards distributed by community agencies, honoraria and debriefing offered. Separate consent obtained for collection of finger prick blood samples for HIV and HCV laboratory testing. Results: 125 young people completed personal interviews in November 2013. This article is restricted to those 97 participants who had smoked crack. High rates of engagement in documented HIV- and HCV-related crack smoking practices were reported including nonuse of mouthpieces, use of non-recommended smoking devices and frequent engagement in equipment sharing; engagement compounded by the heightened confirmed prevalence of HCV. Conclusion: The youth in our study explained the utility of crack in their lives. Given the mental health drivers of engagement, ease of accessibility and availability, engagement in smoking crack is clearly likely to continue, firmly indicating the urgent necessity to ensure its safer use through gender neutral, youth-specific enhanced programming and resource distribution.

Cocaine vaccine dAd5GNE protects against moderate daily and high-dose "binge" cocaine use

The cocaine vaccine dAd5GNE is comprised of a disrupted serotype 5 adenovirus gene therapy vector covalently conjugated to the cocaine analog GNE. The vaccine evokes a high titer of circulating anti-cocaine antibodies that prevent cocaine from reaching its cognate receptors in the central nervous system. Prior studies have demonstrated the efficacy of dAd5GNE in models of occasional, moderate cocaine use. However, previous studies have not sufficiently evaluated the efficacy of dAd5GNE in models of the repetitive and high-dose "binge" use patterns common in human addicts. In the present study, we evaluated the capacity of dAd5GNE vaccination to protect against "binge" cocaine use and circumstances where vaccinated addicts attempt to override the vaccine. We modeled repetitive daily cocaine use in vaccinated Balb/c mice and African green monkeys, and evaluated high-dose "binge" scenarios in Balb/c mice. In each model of daily use the dAd5GNE vaccine prevented cocaine from reaching the central nervous system. In the high-dose "binge" model, vaccination decreased cocaine-induced hyperactivity and reduced the number of cocaine-induced seizures. Based on this data and our prior data in rodents and nonhuman primates, we have initiated a clinical trial evaluating the dAd5GNE anti-cocaine vaccine as a potential therapy for cocaine addicts who wish to stop cocaine use. If dAd5GNE vaccination is safe and produces high anti-cocaine antibody titers in the clinic, we hypothesize that the vaccine will restrict the access of cocaine to the central nervous system and inhibit cocaine-induced "highs" even in the context of moderate daily and high-dose "binge" use that might otherwise cause a drug-induced overdose.

[Asthma and cannabis, cocaine or heroin use]

INTRODUCTION

The use of cannabis, cocaine or heroin can be responsible for many respiratory complications including asthma.

OBJECTIVES

The aim of this systematic literature review of data was to expose the relations between cannabis, cocaine or heroin use and asthma.

RESULTS

Cannabis, cocaine or heroin use by inhalation may be responsible for respiratory symptoms (cough, wheezing), asthma onset, acute asthma exacerbations (which may require intubation and invasive ventilation) or deaths related to asthma. Lower adherence to asthma treatment is also observed. Cannabis induces a rapid bronchodilator effect. In contrast, its chronic use may induce a decrease in specific airway conductance. Studies on forced expiratory volume in one second (FEV1) reduction or decline are discordant.

CONCLUSION

Cannabis, cocaine or heroin use must be considered in cases of acute respiratory symptoms or asthma exacerbation in young persons and practitioners must help illicit substance users to stop their consumption.

Adaptation of contingency management for stimulant use disorder during the COVID-19 pandemic

The current coronavirus disease (COVID-19) pandemic has rapidly spread across the world. Individuals with stimulant use disorder are a vulnerable population, who are particularly at risk of negative outcomes during this pandemic due to several risk factors, including mental and physical comorbidities, weakened immune responses, high-risk behaviors, and barriers to healthcare access. Engaging patients with stimulant use disorder in regular treatment has become even more difficult during this pandemic, which has resulted in many cuts to addiction treatment programs. The most effective treatment options for stimulant use disorder are psychosocial interventions, which rely heavily on in-person interactions, posing an added challenge during physical distancing. In particular, contingency management (CM) is a behavioral therapy that utilizes tangible reinforcements to incentivize targeted behavior changes, and is an effective treatment intervention used for stimulant use disorder. This paper highlights the treatment challenges for individuals with stimulant use disorder and the importance of adapting CM programs during COVID-19. We present strategies for how CM can be adapted and its role expanded in a safe way during the COVID-19 pandemic to help prevent infection spread, stimulant use relapse, and worsened psychosocial consequences.

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Stimulant users face increased risk of relapse and infection during a pandemic.

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Contingency management is an effective treatment for stimulant use disorder.

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Contingency management can be adapted to mitigate negative outcomes of COVID-19.

Mitigating and learning from the impact of COVID-19 infection on addictive disorders

The COVID-19 pandemic and the measures required to address it are cutting a swathe through people’s lives and the global economy. People with addictive disorders are particularly badly affected as a result of poverty, physical and mental health vulnerabilities and disruption of access to services. The pandemic may well increase the extent and severity of some addictive disorders. Current research is suffering from the termination of face-to-face data collection and other restrictions. There is an urgent need to coordinate efforts nationally and internationally to mitigate these problems and to find innovative ways of continuing to provide clinical and public health services to help people with addictive disorders.

Cocaine-Induced Giant Bullous Emphysema

Background

Emphysematous bullae, defined as airspaces of greater than or equal to one centimeter in diameter, have a variety of etiologies such as tobacco use and alpha-1 antitrypsin being the most common. Emphysematous bullae have also been reported in patients using cocaine usually involving the lung periphery and sparing the central lung parenchyma. We present a case of a male with a history of cocaine abuse found to have a singular giant emphysematous bulla occupying >95% of the right hemithorax requiring video-assisted thoracic surgery (VATS) with a favorable outcome. Case Presentation. A 50-year-old male with a history of chronic cocaine abuse was found unresponsive in the field and given multiple doses of naloxone without any improvement in mental status. On presentation to the emergency department, chest X-ray as well as CT scan of the chest were performed which were suggestive of an extensive pneumothorax of the right lung requiring placement of a chest tube. The patient was subsequently intubated and underwent bronchoscopy with right chest VATS which found a giant bulla encasing the entire right pleural cavity. During the procedure, he underwent resection of the bullae and a partial right pleurodesis. After the procedure, patient's respiratory status significantly improved, and he was discharged in a stable condition.

Conclusion

Cocaine use is a rare but identifiable factor that can cause giant bullous emphysema (GBE) resulting in severe complications and even death. The purpose of this case presentation is to support early identification and treatment of GBE using bullectomy with VATS, improving outcomes and decreasing morbidity and mortality.

Cocaine Use and Pulmonary Hypertension

Evidence linking cocaine to the risk of pulmonary hypertension (PH) is limited and inconsistent. We examined whether cocaine use, in the absence of other known causes of PH, was associated with elevated systolic pulmonary artery pressure (sPAP) and increased probability of PH. We compared patients with documented cocaine use to a randomly selected age, sex, and race-matched control group without history of cocaine use. All participants had no known causes of PH and underwent echocardiography for noninvasive estimation of sPAP. We used routinely reported echocardiographic parameters and contemporary guidelines to grade the probability of PH. In 88 patients with documented cocaine use (mean age ± standard deviation 51.7 ± 9.5 years), 33% were women and 89% were of Black race. The commonest route of cocaine use was smoking (74%). Cocaine users compared with the control group had significantly higher sPAP (mean ± standard deviation, 30.1 ± 13.1 vs 22.0 ± 9.8 mm Hg, p <0.001) and greater likelihood of PH (25% vs 10%, p = 0.012). In multivariable analyses adjusted for potential confounders including left ventricular diastolic dysfunction, cocaine use conferred a fivefold greater odds of echocardiographic PH (p = 0.006). Additionally, a stepwise increase in the likelihood of PH was noted across cocaine users with negative or no drug screen on the day of echocardiography to cocaine users with a positive drug screen (multivariable p for trend = 0.008). In conclusion, cocaine use was associated with a higher sPAP and an increased likelihood of echocardiographic PH with a probable acute-on-chronic effect.

[Pulmonary complications in cocaine users]

Cocaine can be responsible for many psychiatric and/or somatic disorders. The aim of this systematic literature review of data was to expose relations between cocaine use and pulmonary complications. Cocaine can be responsible for acute respiratory symptoms (cough, black sputum, hemoptysis, dyspnea, wheezing, chest pain) and for various pulmonary disorders including barotrauma (pneumothorax, pneumomediastinum, subcutaneous emphysema, pneumopericardium), airway damage, asthma, bronchiolitis obliterans with organizing pneumonia, acute pulmonary edema, alveolar hemorrhage, alveolar pneumonia with carbonaceous material, bullous emphysema, acute eosinophilic pneumonia, pulmonary granulomatosis caused by talc or cellulose, interstitial pneumonitis and pulmonary fibrosis, vasculitis, pulmonary hypertension, pulmonary embolism and pulmonary infarction, mycotic pulmonary arterial aneurysms, septic emboli, aspiration pneumonia, community-acquired pneumonia, HIV-related opportunistic infections, latent tuberculosis infection, pulmonary tuberculosis, lung cancer and crack lung. Some of these complications are serious and may have a fatal outcome. Pulmonary function tests, thoracic tomodensitometry, bronchial fibroscopy with bronchoalveolar lavage and lung scintigraphy may be an aid to the diagnosis of these pulmonary compications. Cocaine use must be sought in case of respiratory symptoms in young persons.

[Acute eosinophilic pneumonia and illicit psychoactive substance use]

Illicit psychoactive substance (IPAS) use can lead to a number of respiratory complications, including acute eosinophilic pneumonia (AEP). Systematic literature review of data on AEP in IPAS users (cannabis, cocaine, heroin and amphetamine). Of two cases of cannabis and tobacco users reported to have developed AEP, one, a teenage15 year old boy presented with acute respiratory distress syndrome (ARSD) which necessitated extracorporeal membrane oxygenation (ECMO). Five cases of AEP in cocaine smokers (crack) are reported, one of which was fatal. The patient presented with acute pulmonary edema and ARDS which progressed to ventricular fibrillation and asystole. A 24-year-old woman presented with AEP after repeated inhalation of heroin. Finally, a case of an amphetamine abuser who developed AEP and ARDS after amphetamine inhalation is reported. The time between the first IPAS use and admission in cases reported ranged from 7 days to 4 years, while time between the last IPAS use and admission was short (less than 15 days). IPAS use must be sought in case of AEP, especially in young adults, and practitioners must advise and help users to stop their consumption.

Pneumomediastinum and subcutaneous emphysema: complication of cocaine use

Pneumomediastinum is more frequent in young men and usually presents in association with subcutaneous emphysema. It can occur in case of oesophageal or chest trauma, be iatrogenic or develop spontaneously, in case of emesis, coughing or forceful straining. Use of illicit drugs, such as cocaine, has been associated with multiple respiratory complications, including pneumomediastinum and subcutaneous emphysema. The pathogenesis of subcutaneous emphysema and pneumomediastinum after cocaine inhalation is not completely known, but it is thought that the physical manoeuvers used to increase its absorption and effect may lead to alveolar rupture, resulting in air escaping into the mediastinum and fascial planes of the neck and chest. Chest X-ray is usually diagnostic, but CT can be used as complementary study, allowing evaluation of adjacent structures. A case of pneumomediastinum and subcutaneous emphysema after cocaine inhalation in an otherwise healthy man is presented.

Analysis of lncRNA-miRNA-mRNA Interactions in Hyper-proliferative Human Pulmonary Arterial Smooth Muscle Cells

We previously reported enhanced proliferation of smooth muscle cells on the combined exposure of HIV proteins and cocaine leading to the development of HIV-pulmonary arterial hypertension. Here, we attempt to comprehensively understand the interactions between long noncoding RNAs (lncRNAs), mRNAs and micro-RNAs (miRNAs) to determine their role in smooth muscle hyperplasia. Differential expression of lncRNAs, mRNAs and miRNAs were obtained by microarray and small-RNA sequencing from HPASMCs treated with and without cocaine and/or HIV-Tat. LncRNA to mRNA associations were conjectured by analyzing their genomic proximity and by interrogating their association to vascular diseases and cancer co-expression patterns reported in the relevant databases. Neuro-active ligand receptor signaling, Ras signaling and PI3-Akt pathway were among the top pathways enriched in either differentially expressed mRNAs or mRNAs associated to lncRNAs. HPASMC with combined exposure to cocaine and Tat (C + T) vs control identified the following top lncRNA-mRNA pairs, ENST00000495536-HOXB13, T216482-CBL, ENST00000602736-GDF7, and, TCONS_00020413-RND1. Many of the down-regulated miRNAs in the HPASMCs treated with C + T were found to be anti-proliferative and targets of up-regulated lncRNAs targeting up-regulated mRNAs, including down-regulation of miR-185, -491 and up-regulation of corresponding ENST00000585387. Specific knock down of the selected lncRNAs highlighted the importance of non-coding RNAs in smooth muscle hyperplasia.

Effects of drug abuse, smoking and alcohol on donor hearts and lungs

Potential heart and lung donors with a history of illicit drugs and/or smoking and alcohol are frequently offered, though there is no clear guidance on when it is safe to use these organs. A review of the literature on effects of drugs, alcohol and smoking on donor outcomes, and the effects of these on the intact heart and lung was undertaken. There has been a marked increase in deaths from opioid abuse in many developed countries, though recent evidence suggests that outcomes after cardiothoracic transplantation are equivalent to nonopioid donor causes of death. For donor smoking, there is an increased risk with lung transplantation; however, that risk is less when compared to further waiting on the transplant list for a nonsmoking alternative. Heavy alcohol consumption does not adversely affect heart transplantation, and there is no clear evidence of adverse outcomes after lung transplantation. There are no overall effects of cannabis or cocaine on survival after heart or lung transplantation. In all these cases, careful donor assessment can establish if a particular organ can be used. In most cases, use of drugs requires careful assessment, but is not in of itself a contraindication to cardiothoracic transplantation.

[Asthma and cocaine use]

INTRODUCTION

Cocaine use can be responsible for many respiratory complications including asthma.

OBJECTIVES

Systematic literature review of data on asthma in cocaine users.

DOCUMENTARY SOURCES

PubMed/Medline search, on the period 1980-2017 with the following keywords: "asthma*" or "bronchospasm" and "cocaine" or "freebase*" or "crack", limits "title/abstract"; the selected languages were English or French. Among 108 articles, 43 abstracts underwent dual reading to select 22 studies.

RESULTS

In four case reports of asthma associated with cocaine use including 11 patients (mean age: 28.3 years [22-33 years]; sex-ratio: 2.5 [males: 71.5%]), cocaine was sniffed [snorted] (9%), smoked (36.5%) or both sniffed and smoked (54.5%). A medical history of childhood asthma was observed in 45.4% of the cases. Acute respiratory failure, requiring intubation and mechanical ventilation, was observed in 45.4% of the cases. Outcome was rapidly favorable in 82%; 9/11, progressively favorable in one patient, and fatal in another patient. Other studies included 6 cross-sectional studies, 4 case-control studies and 8 longitudinal studies (7 retrospective studies and one prospective study). The mean age was 36.6 years (women: 44.7%). Twenty percent of the subjects used cocaine exclusively, and 80% used cocaine combined with other addictive drugs (cocaine and heroin: 62%). The prevalence of cocaine users was higher in asthmatic subjects and the prevalence of asthma was higher in cocaine users. Cocaine use can be responsible for asthma onset and acute asthma exacerbation. In the case of asthma exacerbation, cocaine users were more likely to be admitted in intensive care units and to require intubation and invasive ventilation. Asthma exacerbations may be fatal in spite of resuscitation measures. Asthma treatment observance was lower in cocaine users.

CONCLUSION

Cocaine use may be responsible for asthma onset, acute asthma exacerbations (which may require intubation and invasive ventilation) or death related to asthma. Cocaine use must be systematically considered in the case of asthma exacerbation and practitioners must help cocaine users to stop their consumption.

Cocaine-Induced Bronchospasm Mimicking Acute Asthma Exacerbation

Cocaine can cause a myriad of changes in the lung, which can range from bronchoconstriction to destruction of the alveolar-capillary membrane and acute lung injury. Cocaine-induced bronchospasm is a diagnosis of exclusion that should be considered when the clinical presentation of acute hypoxic and hypercapneic respiratory failure cannot be explained by chronic obstructive pulmonary disease or asthma exacerbation, anaphylaxis to food or medications, exercise, or infection. Here, we present two patients with acute hypoxic and hypercapneic respiratory failure that was ultimately attributed to cocaine use shortly prior to symptom onset.

Cocaine-Induced Pneumopericardium: Safe for Discharge? A Case Report and Literature Review

A 29-year-old male presented at the Emergency Department (ED) with chest pain and neck tenderness after intranasal cocaine usage. Physical exam of the patient demonstrated moderate subcutaneous emphysema on the right side of his neck. The ECG did not demonstrate any changes associated with cocaine-induced cardiac ischemia, and blood analysis was normal (negative troponins). A chest X-ray revealed subtle evidence of pneumomediastinum. Subsequent thoracic CT confirmed the presence of subcutaneous emphysema with a pneumopericardium and a large pneumomediastinum along with a small pneumothorax. The patient was managed conservatively and kept overnight for observation. He was discharged from the ED the following day with ambulatory follow-up. A repeat thoracic CT performed two weeks later demonstrated that the findings identified in the first CT had resolved. Pneumopericardium, -mediastinum, and -thorax are rare conditions reported after cocaine abuse. A conservative approach with a period of observation in a suitable ambulatory unit is acceptable, as current literature suggests that the condition is usually self-limiting.

Epidemiology, clinical features and management of patients presenting to European emergency departments with acute cocaine toxicity: comparison between powder cocaine and crack cocaine cases

Objective: To analyse the epidemiology, clinical picture and emergency department (ED) management of a large series of patients who presented to European EDs after cocaine consumption, comparing data from powder (C₁ group) and crack (C₂ group) consumers. Methods: Between October 2013 and December 2016, the Euro-DEN Plus Registry recorded 17,371 consecutive acute recreational drug toxicity presentations to 22 EDs in 14 European countries. Epidemiological and demographic data, co-ingestion of alcohol and other drugs, clinical features, ED management and outcome (death) were analysed for cocaine cases, and comparison of clinical picture in C₁ and C₂ patients were performed adjusting for alcohol and other drug co-ingestion. Results: We included 3002 cases (C₁: 2600; C₂: 376; mixed consumption: 26): mean age 32(9) years, 23% female. The proportion of presentations involving cocaine varied significantly between countries (>30% in Malta, Spain, France, Denmark) and only centres in France, United Kingdom, Poland, Ireland and Malta recorded crack-related cases. Cocaine was frequently used with ethanol (74.3%, C₁>C₂) and other drugs (56.8%, C₂>C₁), the most frequent amphetamine (19.4%, C₁>C₂) and opioids (18.9%, C₂>C₁). C₂ patients were more likely to have clinically significant episodes of hypotension (adjusted OR = 2.35; 95%CI = 1.42-3.89), and bradypnea (1.81; 1.03-3.16) and systolic blood pressure >180 mmHg on ED arrival (2.59; 1.28-5.25); while less likely anxiety (0.51; 0.38-0.70), chest pain (0.47; 0.31-0.70), palpitations (0.57; 0.38-0.84), vomiting (0.54; 0.32-0.90), and tachycardia on ED arrival (0.52; 0.39-0.67). Sedative drugs were given in 29.3%. The median length of hospital stay was 4:02 h, 22.1% patients were hospitalized, and 0.4% (n = 12) died. Conclusion: Cocaine is commonly involved in European ED presentations with acute recreational drug toxicity, but there is variation across Europe not just in the involvement of cocaine but in the proportion related to powder versus crack. Some differences in clinical picture and ED management exist between powder cocaine and crack consumers.

Pulmonary foreign body granulomatosis in a chronic user of powder cocaine

We describe the case of a 33-year-old man, a chronic user of powder cocaine, who presented with dyspnea, fever, night sweats, and significant weight loss. Chest HRCT revealed centrilobular nodules, giving an initial impression of miliary tuberculosis. Therefore, he was started on an empirical, four-drug antituberculosis treatment regimen. Four weeks later, despite the tuberculosis treatment, he continued to have the same symptoms. We then performed transbronchial lung biopsy. Histopathological analysis of the biopsy sample revealed birefringent foreign body granuloma. A corroborative history of cocaine snorting, the presence of centrilobular nodules, and the foreign body-related histopathological findings led to a diagnosis of pulmonary foreign body granulomatosis. This report underscores the fact that pulmonary foreign body granulomatosis should be included in the differential diagnosis of clinical profiles resembling tuberculosis.

Network of MicroRNAs Mediate Translational Repression of Bone Morphogenetic Protein Receptor-2: Involvement in HIV-Associated Pulmonary Vascular Remodeling

BACKGROUND

Earlier, we reported that the simultaneous exposure of pulmonary arterial smooth muscle cells to HIV proteins and cocaine results in the attenuation of antiproliferative bone morphogenetic protein receptor-2 (BMPR2) protein expression without any decrease in its mRNA levels. Therefore, in this study, we aimed to investigate the micro RNA-mediated posttranscriptional regulation of BMPR2 expression.

METHODS AND RESULTS

We identified a network of BMPR2 targeting micro RNAs including miR-216a to be upregulated in response to cocaine and Tat-mediated augmentation of oxidative stress and transforming growth factor-β signaling in human pulmonary arterial smooth muscle cells. By using a loss or gain of function studies, we observed that these upregulated micro RNAs are involved in the Tat- and cocaine-mediated smooth muscle hyperplasia via regulation of BMPR2 protein expression. These in vitro findings were further corroborated using rat pulmonary arterial smooth muscle cells isolated from HIV transgenic rats exposed to cocaine. More importantly, luciferase reporter and in vitro translation assays demonstrated that direct binding of novel miR-216a and miR-301a to 3'UTR of BMPR2 results in the translational repression of BMPR2 without any degradation of its mRNA.

CONCLUSIONS

We identified for the first time miR-216a as a negative modulator of BMPR2 translation and observed it to be involved in HIV protein(s) and cocaine-mediated enhanced proliferation of pulmonary smooth muscle cells.

Stimulants and Pulmonary Arterial Hypertension: An Update

The connection between stimulants and pulmonary arterial hypertension (PAH) was first made apparent in the 1960s during an outbreak associated with anorexigen (amphetamine-like appetite suppressants) use. Since then, a total of 16 drugs and toxins have been linked to PAH (ie, drug and toxin-associated PAH [DT-APAH]), including illicit stimulants like methamphetamine. Recently, basic science research and novel genomic studies have started to shed light on possible pathologic and genetic mechanisms implicated in disease development, namely loss of function variants in genes involved in drug detoxification. This review will discuss the history and current state of knowledge regarding stimulants and their association with PAH. It will also discuss clinical management of patients with DT-APAH. Lastly, it will highlight the importance of ongoing research efforts to identify susceptibility factors implicated in DT-APAH and the need for increased pharmacovigilance and awareness to identify new drugs that may be risk factors for PAH. Ultimately, this may be our best strategy to improve clinical outcomes and prevent deadly future outbreaks of DT-APAH.