Following a 4-day stay at the detox ward, a 20-year-old patient with a 5-year-long addiction to marijuana, a history of nicotinism and alcohol dependence, inhaling the so-called artificial hashish for 6 months was admitted to the lung disease department in serious condition with a suspected miliary tuberculosis. On admission, the physical examination demonstrated single bilateral rhonchi and rales over the lung fields, tachypnea, general cyanosis, and saturation of 65-72%. The patient reported catarrh lasting for 6 months; cough lasting 4 months, which was stronger for a week and a half preceding admission to hospital, 4 days of fever, diarrhea and dyspnea at rest. The patient denied hemoptysis or contact with tuberculosis.
Laboratory tests showed hypoxemic respiratory insufficiency, high titres of CRP, LDH, d-dimers, and NT-pro-BNP. Infection with HIV and HBV was excluded.
Oxygen therapy with 6 L/min of Encorton at a dose of 1 mg/kg body weight p.o., Clexane s.c. and antimycobacterial drugs were used.
Imaging examinations were ordered.
Chest X-ray showed diffuse, confluent interstitial changes of the highest intensity in the middle and inferior fields, and trace of pleural effusion. Besides, the image was unremarkable.
First HRCT showed massive generalized shading with air bronchogram in the middle and inferior fields, heterogeneous patchy changes in the superior fields. Complicated interstitial pneumonia with little pleural effusion was suggested.
Bronchofiberoscopy showed features of active inflammation of the bronchial tree.
Only Candida albicans was grown from cultures from bronchial washings; specific, non-specific flora and atypical pathogens (Bordatella pertussis, Legionella pneumophila, Mycoplasma pneumoniae, Pneumocistis jiroveci) cultures - negative.
Fluconazole p.o. was added to the above-mentioned therapy, which caused gradual clinical improvement.
A control chest HRCT performed after 3 weeks revealed normal cavities, mediastinum and pleura, disseminated confluent small nodules of varying degrees of saturation, local frosted glass-like changes, which in the inferior fields coalesced with nodules of the central part of the pulmonary lobule and thickened interlobular septa. The whole image suggested toxic lung injury to differentiate with P. jiroveci infection.
After five weeks spent in the department, initial clinical improvement and reduced oxygen therapy to 3 L/min, spirometry with diastolic test was performed. The first examination result showed a decrease in VC to 84%, FEV1 89%, FEV 1%, VC 105% of due value. In the second test after administering Berotec: VC 82%, FEV1 94%, FEV 1%, VC 113% of due value. Basing on the results there was a suspicion of restriction. Due to insufficient co-operation with the patient, plethysmography confirming the diagnosis was not performed.
In the histopathological examination (material obtained from open biopsy), the image corresponded to organizing pneumonia with lipid bodies in the organizing lesions; lesions most likely caused by inhaling irritants. A biopsied mediastinal lymph node - reactive (Figures 1-4).
(A-C) First HRCT - interstitial pneumonia, air bronchogram, pleural effusion.