Crack lung: a case report with diagnostic confirmation

Crack lung: a case report with diagnostic confirmation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Crack lung: a case report with diagnostic confirmation Nathalia Jácome-Pérez, Diego Piamonte, Kelly C. Castro-Barajas, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7830478/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Crack lung is an uncommon and potentially life-threatening entity resulting from the inhalation of freebase cocaine. It typically presents acutely with dyspnea, cough, hemoptysis and hypoxemia secondary to alveolar–capillary injury induced by the vasoconstrictive and cytotoxic effects of the substance. The condition can mimic infectious or inflammatory processes, delaying diagnosis and treatment. We report the case of a 36-year-old man with a history of chronic kidney disease and polysubstance abuse who presented with sudden-onset dyspnea and hemoptysis. Chest radiography revealed bilateral perihilar alveolar opacities, and High-Resolution Computed Tomography (HRCT) demonstrated ground-glass opacities consistent with diffuse alveolar hemorrhage. Bronchoalveolar lavage confirmed the presence of hemosiderophages, supporting the diagnosis of crack lung. Systemic corticosteroid therapy led to complete clinical and radiologic resolution. This case highlights the importance of considering drug exposure in young patients presenting with hemoptysis and diffuse pulmonary findings, as lack of toxicological testing or denial of drug use may lead to diagnostic errors. HRCT is essential for identifying alveolar hemorrhage patterns and excluding alternative causes, while bronchoalveolar lavage can provide diagnostic confirmation in uncertain cases. The favorable response to corticosteroids supports their therapeutic role in acute pulmonary injury induced by inhaled drugs. Early recognition of crack lung and awareness of its imaging spectrum are crucial for accurate differential diagnosis of diffuse alveolar hemorrhage syndromes and to prevent unnecessary interventions. This report contributes a case with complete diagnostic confirmation and favorable outcome, emphasizing the value of clinical, imaging, and toxicologic correlation in this rare pulmonary complication. Tomography Crack Cocaine Respiratory Distress Syndrome Radiography Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Crack is the most potent form of cocaine, and inhalation is the most common route of administration. Crack lung refers to a rare acute respiratory syndrome associated with inhaled cocaine use. Pulmonary manifestations include diffuse alveolar damage with hemorrhage, appearing on imaging as findings similar to pulmonary edema or interstitial pneumonitis ( 1 ). It remains a diagnostic challenge that requires high clinical suspicion and correlation with toxicological history. This report presents a new case of crack lung debuting with alveolar hemorrhage and discusses its main clinical implications. CASE REPORT A 36-year-old man with a history of hypertension and stage V chronic kidney disease of toxic etiology reported daily use of psychoactive substances, including marijuana, cocaine, levamisole, and methyl alcohol to the point of intoxication. He presented to the emergency department with acute dyspnea and hemoptysis. Initial evaluation ruled out acute pulmonary embolism, acute coronary syndrome, and infectious causes. Chest radiography revealed bilateral perihilar alveolar opacities (Fig. 1 ). HRCT demonstrated diffuse alveolar hemorrhage characterized by confluent perihilar opacities with ground-glass appearance (Fig. 2 ). Further questioning confirmed recent inhaled cocaine use, suggesting a vasculitic mechanism secondary to drug exposure. Bronchoscopy showed no structural abnormalities, but bronchoalveolar lavage revealed hemosiderophages. Systemic corticosteroids were initiated, leading to complete clinical and radiologic resolution (Figs. 3 and 4 ). DISCUSSION Cocaine is an alkaloid derived from the Erythroxylum shrub native to South and Central America. Over 250 species have been identified, of which E. coca Lam. is the main source for extraction( 2 , 3 ). The route of administration depends on the synthesis process: the hydrochloride salt is snorted or injected, while the freebase form (crack) is smoked( 4 ). Crack is water-insoluble and combustion-resistant, enabling rapid pulmonary absorption and onset of action within 6–8 seconds, with peak stimulation occurring within 1–3 minutes( 5 ). Cocaine’s pulmonary effects may be acute or chronic. Acute effects are related to α- and β-adrenergic receptor activation, leading to increased capillary tone and bronchiolar smooth-muscle relaxation that may cause vessel rupture. Chronic effects involve persistent alveolar–capillary damage and toxin accumulation, resulting in eosinophilic infiltration, immunoglobulin E deposition, and eventual fibrosis. Chronic use may also alter central respiratory control mechanisms( 6 ). Clinically, crack lung manifests with dyspnea, cough, chest pain, hemoptysis, hypoxemia, and occasionally fever. Less frequent complications include pneumothorax, pneumomediastinum, and subcutaneous emphysema secondary to Valsalva maneuvers( 2 , 7 ). Diagnosis is often limited by patient history and the absence of confirmatory toxicology tests, leading to unnecessary treatments. Radiographically, diffuse bilateral perihilar alveolar and interstitial opacities may mimic pulmonary oedema or interstitial pneumonitis. HRCT plays a fundamental role in differential diagnosis and detection of complications, although patterns may vary depending on concurrent substance use HRCT plays a fundamental role in differential diagnosis and detection of complications, although patterns may vary depending on concurrent substance use( 8 , 9 ). Typical HRCT findings include ground-glass opacities, perihilar consolidations, the halo sign, and a “crazy paving” pattern. Septal thickening and paraseptal emphysema may also be observed ( 1 , 9 ). These findings support the presence of diffuse alveolar hemorrhage caused by submucosal vessel rupture and alveolar–capillary barrier disruption ( 10 ). The differential diagnosis includes multiple conditions presenting with haemoptysis and pulmonary opacities, such as viral infections. In the absence of specific clinical or imaging findings, drug use history and toxicological confirmation are essential ( 11 ). The international literature reports only 19 cases of crack lung from 1975 to the present. Table 1 summarizes the most representative cases, ranging from the first descriptions in the 1980s to contemporary cases with complications such as cerebral vasculitis. Most cases show ground-glass opacities on CT scans, with partial or complete resolution after treatment with steroids. This case contributes to the literature one of the few reports of crack lung with complete diagnostic documentation, including initial radiography, HRCT, fiberoptic bronchoscopy, and bronchoalveolar lavage with hemosiderophages. These findings reinforce the role of HRCT in the early detection of diffuse alveolar hemorrhage and underscore the usefulness of bronchoalveolar lavage as a confirmatory tool. Author / Year Country Clinical Presentation Imaging Findings Diagnostic Method Kissner 1987 ( 12 ) USA Dyspnea, productive cough, fever Diffuse perihilar alveolar and interstitial opacities Bronchoscopy + biopsy (lymphocytes) Forrester 1990 ( 13 ) USA Acute pulmonary syndrome, fever, hemoptysis Diffuse alveolar hemorrhage Biopsy (lymphocytes, alveolar macrophages, hemosiderophages) O’Donnell 1991 ( 14 ) USA Interstitial pneumonitis Diffuse opacities Open lung biopsy (fibrosis, histiocytes) Oh 1992 ( 15 ) Canada Respiratory symptoms and fever Diffuse interstitial opacities Transbronchial biopsy (bronchoalveolar eosinophilia) Sogomonian 2015 ( 16 ) USA Hemoptysis Diffuse ground-glass opacities Bronchoalveolar lavage + transbronchial biopsy (hemosiderophages) Dolapsakis 2019 ( 17 ) India Acute toxicity Diffuse ground-glass opacities Clinical Chahdi 2024 ( 8 ) Morocco Respiratory failure Alveolar hemorrhage + cerebral vasculitis “crazy paving” Toxicology tests Reichert 2025 Germany Dyspnea, hemoptysis Bronchial wall thickening + ground-glass opacities Bronchoscopy (diffuse hemorrhage) CONCLUSION Crack lung is a rare and potentially fatal acute pulmonary syndrome secondary to inhaled crack cocaine. Early recognition and awareness of its imaging spectrum are crucial for accurate differential diagnosis and to prevent inappropriate treatment. Diagnostic confirmation relies on the triad of dyspnoea, haemoptysis, and HRCT findings of diffuse alveolar haemorrhage, together with haemosiderophages on bronchoalveolar lavage. This case demonstrates complete diagnostic confirmation and clinical improvement following corticosteroid therapy, underscoring the need for heightened clinical and toxicological suspicion in such cases. Declarations Patient consent: Written informed consent was obtained from the patient for publication of this case report and accompanying images. Data availability: All data generated or analyzed during this study are included in this published article. Human and animal rights: No experiments were conducted on humans or animals for this study. Conflicts of interest: The authors declare no conflicts of interest. Patient confidentiality: No personal data that could compromise patient identity are disclosed. Funding: None. Authors CB and NJP contributed to the interpretation of diagnostic images. All authors contributed to the writing, organization, revision, and final approval of the manuscript. References Restrepo CS, Carrillo JA, Martínez S, Ojeda P, Rivera AL, Hatta A. Pulmonary complications from cocaine and cocaine-based substances: Imaging manifestations. Radiographics. 2007;27(4):941–56. Roque Bravo R, Faria AC, Brito-Da-costa AM, Carmo H, Mladěnka P, Dias da Silva D, et al. Cocaine: An updated overview on chemistry, detection, biokinetics, and pharmacotoxicological aspects including abuse pattern. Toxins. 2022;14(4):278. Biondich AS, Joslin JD. Coca: The history and medical significance of an ancient Andean tradition. Emerg Med Int. 2016;2016:4048764. Goldstein RA, DesLauriers C, Burda A, Johnson-Arbor K. Cocaine: history, social implications, and toxicity: a review. Semin Diagn Pathol. 2009;26(1):10–7. Cunha-Oliveira T, Rego AC, Carvalho F, Oliveira CR. Chapter 17 - Medical toxicology of drugs of abuse. In: Miller PM, editor. Principles of addiction. Cambridge: Academic Press; 2013. p. 159–75. Laposata EA, Mayo GL. A review of pulmonary pathology and mechanisms associated with inhalation of freebase cocaine (“crack”). Am J Forensic Med Pathol. 1993;14(1):1–9. Van der Klooster JM, Grootendorst AF. Severe bullous emphysema associated with cocaine smoking. Thorax. 2001;56(12):982–3. Chahdi HO, Mourabiti AY, Houssaini MS, Akammar A, Bouardi N, Haloua M, et al. Crack lung with toxic cerebral vasculitis: Case report. Radiol Case Rep. 2024;19(5):2020–3. de Almeida RR, Zanetti G, Souza AS, de Souza LS, e Silva JLP, Escuissato DL, et al. Cocaine-induced pulmonary changes: HRCT findings. J Bras Pneumol. 2015;41(4):323–9. Tashkin DP, Khalsa ME, Gorelick D, Chang P, Simmons MS, Coulson AH, et al. Pulmonary status of habitual cocaine smokers. Am Rev Respir Dis. 1992;145(1):92–100. Hinestroza S, Sofía M, Alejandra G, Godoy M, Pablo I, Analía S. Pulmón de crack: reporte de caso. Rev Am Med Respir. 2020;20(1):85–8. Kissner DG, Lawrence WD, Selis JE, Flint A. Crack lung: pulmonary disease caused by cocaine abuse. Am Rev Respir Dis. 1987;136(5):1250–2. Forrester JM, Steele AW, Waldron JA, Parsons PE. Crack lung: an acute pulmonary syndrome with a spectrum of clinical and histopathologic findings. Am Rev Respir Dis. 1990;142(2):462–7. O’Donnell AE, Mappin FG, Sebo TJ, Tazelaar H. Interstitial pneumonitis associated with “crack” cocaine abuse. Chest. 1991;100(4):1155–7. Oh PI, Balter MS. Cocaine induced eosinophilic lung disease. Thorax. 1992;47(6):478–9. Sogomonian R, Alkhawam H, Gandhi V, Zaiem F, Moradoghli Haftevani EA, McGarry T. Refractile foreign material deposits and alveolar hemorrhage in crack cocaine smoker. Respir Med Case Rep. 2015;16:48–50. Dolapsakis C, Katsandri A. Crack lung: A case of acute pulmonary cocaine toxicity. Lung India. 2019;36(4):370–2. Reichert M, Holtz T. Acute respiratory distress and hemoptysis: a case report of drug-induced lung injury aka “crack lung.” AME Case Rep. 2025;9:81. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7830478","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":536453153,"identity":"c57fc0ac-5579-40e5-a5d5-3322659cd28d","order_by":0,"name":"Nathalia Jácome-Pérez","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwklEQVRIiWNgGAWjYFCCAwwSDAw2CWB2QgHxWtISGNhAWgyItAeo5TBECwMxWswZzx68XVFzPo9fvjvxwwMDBnl+sQP4tVg2nEu2PHPsdrFkG+9mCaDDDGfOTsCvxeDAGTPJBrbbiRuO8W4AaUkwuE2Uln/nQFo2/yBeS2PbAZCWbcTaAvRLY19y4sy23G0WCQYSRPjlxtmDNxu+2SX2M5/dfPNHhY08vzQBLQwSZ1C5BJSDAH8PEYpGwSgYBaNgZAMALTVIq3Q7iPsAAAAASUVORK5CYII=","orcid":"","institution":"University of Santander","correspondingAuthor":true,"prefix":"","firstName":"Nathalia","middleName":"","lastName":"Jácome-Pérez","suffix":""},{"id":536453154,"identity":"4d92dbb8-5b6d-40c7-a386-4253239ab54f","order_by":1,"name":"Diego Piamonte","email":"","orcid":"","institution":"University of Santander","correspondingAuthor":false,"prefix":"","firstName":"Diego","middleName":"","lastName":"Piamonte","suffix":""},{"id":536453155,"identity":"3c3592d5-ded9-4692-b286-cf1cc9fcdd39","order_by":2,"name":"Kelly C. 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07:04:15","extension":"html","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":45985,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7830478/v1/7f5f41a7b7f146ae932e397d.html"},{"id":94729748,"identity":"348d41b9-9864-4e57-85c7-5661ed3255dc","added_by":"auto","created_at":"2025-10-30 07:05:22","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":26659,"visible":true,"origin":"","legend":"\u003cp\u003eInitial posteroanterior (a) and lateral (b) chest radiographs showing confluent perihilar alveolar opacities and laminar atelectasis in the middle lobe.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7830478/v1/c7817c961cd001fc58aaaead.jpeg"},{"id":94729287,"identity":"a9b36760-3293-426b-9c90-2774055a0951","added_by":"auto","created_at":"2025-10-30 07:04:44","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":28864,"visible":true,"origin":"","legend":"\u003cp\u003eInitial HRCT: axial (a), coronal (b), and sagittal (c) reconstructions showing confluent perihilar alveolar opacities predominantly in the left upper lobe associated with ground-glass opacities.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7830478/v1/c702f9ef2401a4b49899e49a.jpeg"},{"id":94709495,"identity":"d8541795-56e4-46c8-9f8f-fa3e2bcc8351","added_by":"auto","created_at":"2025-10-30 01:07:43","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":28274,"visible":true,"origin":"","legend":"\u003cp\u003eFollow-up HRCT after corticosteroid therapy: axial (a), coronal (b), and sagittal (c) views demonstrating central ground-glass opacities with subpleural sparing and improvement of previous alveolar consolidations.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7830478/v1/30294c1d6682370e018b6681.jpeg"},{"id":94709503,"identity":"d7752262-483b-41a1-8aa9-ebfd4b369942","added_by":"auto","created_at":"2025-10-30 01:07:43","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":27090,"visible":true,"origin":"","legend":"\u003cp\u003ePost-treatment posteroanterior (a) and lateral (b) chest radiographs showing complete resolution of pulmonary opacities and adequate lung expansion.\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7830478/v1/e16f39df038e25b6f71326db.jpeg"},{"id":99315282,"identity":"2025ef34-416b-433f-8704-9d076bbfc85e","added_by":"auto","created_at":"2025-12-31 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Crack lung refers to a rare acute respiratory syndrome associated with inhaled cocaine use. Pulmonary manifestations include diffuse alveolar damage with hemorrhage, appearing on imaging as findings similar to pulmonary edema or interstitial pneumonitis (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). It remains a diagnostic challenge that requires high clinical suspicion and correlation with toxicological history. This report presents a new case of crack lung debuting with alveolar hemorrhage and discusses its main clinical implications.\u003c/p\u003e"},{"header":"CASE REPORT","content":"\u003cp\u003eA 36-year-old man with a history of hypertension and stage V chronic kidney disease of toxic etiology reported daily use of psychoactive substances, including marijuana, cocaine, levamisole, and methyl alcohol to the point of intoxication. He presented to the emergency department with acute dyspnea and hemoptysis. Initial evaluation ruled out acute pulmonary embolism, acute coronary syndrome, and infectious causes.\u003c/p\u003e\u003cp\u003eChest radiography revealed bilateral perihilar alveolar opacities (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). HRCT demonstrated diffuse alveolar hemorrhage characterized by confluent perihilar opacities with ground-glass appearance (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Further questioning confirmed recent inhaled cocaine use, suggesting a vasculitic mechanism secondary to drug exposure. Bronchoscopy showed no structural abnormalities, but bronchoalveolar lavage revealed hemosiderophages. Systemic corticosteroids were initiated, leading to complete clinical and radiologic resolution (Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eCocaine is an alkaloid derived from the Erythroxylum shrub native to South and Central America. Over 250 species have been identified, of which E. coca Lam. is the main source for extraction(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The route of administration depends on the synthesis process: the hydrochloride salt is snorted or injected, while the freebase form (crack) is smoked(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Crack is water-insoluble and combustion-resistant, enabling rapid pulmonary absorption and onset of action within 6\u0026ndash;8 seconds, with peak stimulation occurring within 1\u0026ndash;3 minutes(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eCocaine\u0026rsquo;s pulmonary effects may be acute or chronic. Acute effects are related to α- and β-adrenergic receptor activation, leading to increased capillary tone and bronchiolar smooth-muscle relaxation that may cause vessel rupture. Chronic effects involve persistent alveolar\u0026ndash;capillary damage and toxin accumulation, resulting in eosinophilic infiltration, immunoglobulin E deposition, and eventual fibrosis. Chronic use may also alter central respiratory control mechanisms(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eClinically, crack lung manifests with dyspnea, cough, chest pain, hemoptysis, hypoxemia, and occasionally fever. Less frequent complications include pneumothorax, pneumomediastinum, and subcutaneous emphysema secondary to Valsalva maneuvers(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDiagnosis is often limited by patient history and the absence of confirmatory toxicology tests, leading to unnecessary treatments. Radiographically, diffuse bilateral perihilar alveolar and interstitial opacities may mimic pulmonary oedema or interstitial pneumonitis. HRCT plays a fundamental role in differential diagnosis and detection of complications, although patterns may vary depending on concurrent substance use\u003c/p\u003e\u003cp\u003eHRCT plays a fundamental role in differential diagnosis and detection of complications, although patterns may vary depending on concurrent substance use(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Typical HRCT findings include ground-glass opacities, perihilar consolidations, the halo sign, and a \u0026ldquo;crazy paving\u0026rdquo; pattern. Septal thickening and paraseptal emphysema may also be observed (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). These findings support the presence of diffuse alveolar hemorrhage caused by submucosal vessel rupture and alveolar\u0026ndash;capillary barrier disruption (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe differential diagnosis includes multiple conditions presenting with haemoptysis and pulmonary opacities, such as viral infections. In the absence of specific clinical or imaging findings, drug use history and toxicological confirmation are essential (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe international literature reports only 19 cases of crack lung from 1975 to the present. Table\u0026nbsp;1 summarizes the most representative cases, ranging from the first descriptions in the 1980s to contemporary cases with complications such as cerebral vasculitis. Most cases show ground-glass opacities on CT scans, with partial or complete resolution after treatment with steroids.\u003c/p\u003e\u003cp\u003eThis case contributes to the literature one of the few reports of crack lung with complete diagnostic documentation, including initial radiography, HRCT, fiberoptic bronchoscopy, and bronchoalveolar lavage with hemosiderophages. These findings reinforce the role of HRCT in the early detection of diffuse alveolar hemorrhage and underscore the usefulness of bronchoalveolar lavage as a confirmatory tool.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAuthor / Year\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCountry\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eClinical Presentation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eImaging Findings\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDiagnostic Method\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKissner 1987 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDyspnea, productive cough, fever\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDiffuse perihilar alveolar and interstitial opacities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eBronchoscopy\u0026thinsp;+\u0026thinsp;biopsy (lymphocytes)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eForrester 1990 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAcute pulmonary syndrome, fever, hemoptysis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDiffuse alveolar hemorrhage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eBiopsy (lymphocytes, alveolar macrophages, hemosiderophages)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eO\u0026rsquo;Donnell 1991 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInterstitial pneumonitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDiffuse opacities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eOpen lung biopsy (fibrosis, histiocytes)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOh 1992 (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCanada\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRespiratory symptoms and fever\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDiffuse interstitial opacities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTransbronchial biopsy (bronchoalveolar eosinophilia)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSogomonian 2015 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHemoptysis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDiffuse ground-glass opacities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eBronchoalveolar lavage\u0026thinsp;+\u0026thinsp;transbronchial biopsy (hemosiderophages)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDolapsakis 2019 (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAcute toxicity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDiffuse ground-glass opacities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eClinical\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChahdi 2024 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMorocco\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRespiratory failure\u003c/p\u003e\u003cp\u003eAlveolar hemorrhage\u0026thinsp;+\u0026thinsp;cerebral vasculitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ldquo;crazy paving\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eToxicology tests\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReichert 2025\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGermany\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDyspnea, hemoptysis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBronchial wall thickening\u0026thinsp;+\u0026thinsp;ground-glass opacities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eBronchoscopy (diffuse hemorrhage)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eCrack lung is a rare and potentially fatal acute pulmonary syndrome secondary to inhaled crack cocaine. Early recognition and awareness of its imaging spectrum are crucial for accurate differential diagnosis and to prevent inappropriate treatment. Diagnostic confirmation relies on the triad of dyspnoea, haemoptysis, and HRCT findings of diffuse alveolar haemorrhage, together with haemosiderophages on bronchoalveolar lavage. This case demonstrates complete diagnostic confirmation and clinical improvement following corticosteroid therapy, underscoring the need for heightened clinical and toxicological suspicion in such cases.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003ePatient consent:\u003c/strong\u003e Written informed consent was obtained from the patient for publication of this case report and accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u003c/strong\u003e All data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman and animal rights:\u003c/strong\u003e No experiments were conducted on humans or animals for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest:\u003c/strong\u003e The authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient confidentiality:\u003c/strong\u003e No personal data that could compromise patient identity are disclosed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e None.\u003c/p\u003e\n\u003cp\u003eAuthors CB and NJP contributed to the interpretation of diagnostic images. All authors contributed to the writing, organization, revision, and final approval of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRestrepo CS, Carrillo JA, Mart\u0026iacute;nez S, Ojeda P, Rivera AL, Hatta A. Pulmonary complications from cocaine and cocaine-based substances: Imaging manifestations. Radiographics. 2007;27(4):941\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRoque Bravo R, Faria AC, Brito-Da-costa AM, Carmo H, Mladěnka P, Dias da Silva D, et al. Cocaine: An updated overview on chemistry, detection, biokinetics, and pharmacotoxicological aspects including abuse pattern. Toxins. 2022;14(4):278.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBiondich AS, Joslin JD. Coca: The history and medical significance of an ancient Andean tradition. Emerg Med Int. 2016;2016:4048764.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGoldstein RA, DesLauriers C, Burda A, Johnson-Arbor K. Cocaine: history, social implications, and toxicity: a review. Semin Diagn Pathol. 2009;26(1):10\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCunha-Oliveira T, Rego AC, Carvalho F, Oliveira CR. Chapter 17 - Medical toxicology of drugs of abuse. In: Miller PM, editor. Principles of addiction. Cambridge: Academic Press; 2013. p. 159\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLaposata EA, Mayo GL. A review of pulmonary pathology and mechanisms associated with inhalation of freebase cocaine (\u0026ldquo;crack\u0026rdquo;). Am J Forensic Med Pathol. 1993;14(1):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVan der Klooster JM, Grootendorst AF. Severe bullous emphysema associated with cocaine smoking. Thorax. 2001;56(12):982\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChahdi HO, Mourabiti AY, Houssaini MS, Akammar A, Bouardi N, Haloua M, et al. Crack lung with toxic cerebral vasculitis: Case report. Radiol Case Rep. 2024;19(5):2020\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ede Almeida RR, Zanetti G, Souza AS, de Souza LS, e Silva JLP, Escuissato DL, et al. Cocaine-induced pulmonary changes: HRCT findings. J Bras Pneumol. 2015;41(4):323\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTashkin DP, Khalsa ME, Gorelick D, Chang P, Simmons MS, Coulson AH, et al. Pulmonary status of habitual cocaine smokers. Am Rev Respir Dis. 1992;145(1):92\u0026ndash;100.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHinestroza S, Sof\u0026iacute;a M, Alejandra G, Godoy M, Pablo I, Anal\u0026iacute;a S. Pulm\u0026oacute;n de crack: reporte de caso. Rev Am Med Respir. 2020;20(1):85\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKissner DG, Lawrence WD, Selis JE, Flint A. Crack lung: pulmonary disease caused by cocaine abuse. Am Rev Respir Dis. 1987;136(5):1250\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eForrester JM, Steele AW, Waldron JA, Parsons PE. Crack lung: an acute pulmonary syndrome with a spectrum of clinical and histopathologic findings. Am Rev Respir Dis. 1990;142(2):462\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eO\u0026rsquo;Donnell AE, Mappin FG, Sebo TJ, Tazelaar H. Interstitial pneumonitis associated with \u0026ldquo;crack\u0026rdquo; cocaine abuse. Chest. 1991;100(4):1155\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOh PI, Balter MS. Cocaine induced eosinophilic lung disease. Thorax. 1992;47(6):478\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSogomonian R, Alkhawam H, Gandhi V, Zaiem F, Moradoghli Haftevani EA, McGarry T. Refractile foreign material deposits and alveolar hemorrhage in crack cocaine smoker. Respir Med Case Rep. 2015;16:48\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDolapsakis C, Katsandri A. Crack lung: A case of acute pulmonary cocaine toxicity. Lung India. 2019;36(4):370\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eReichert M, Holtz T. Acute respiratory distress and hemoptysis: a case report of drug-induced lung injury aka \u0026ldquo;crack lung.\u0026rdquo; AME Case Rep. 2025;9:81.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Tomography, Crack Cocaine, Respiratory Distress Syndrome, Radiography","lastPublishedDoi":"10.21203/rs.3.rs-7830478/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7830478/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eCrack lung is an uncommon and potentially life-threatening entity resulting from the inhalation of freebase cocaine. It typically presents acutely with dyspnea, cough, hemoptysis and hypoxemia secondary to alveolar\u0026ndash;capillary injury induced by the vasoconstrictive and cytotoxic effects of the substance. The condition can mimic infectious or inflammatory processes, delaying diagnosis and treatment.\u003c/p\u003e\u003cp\u003eWe report the case of a 36-year-old man with a history of chronic kidney disease and polysubstance abuse who presented with sudden-onset dyspnea and hemoptysis. Chest radiography revealed bilateral perihilar alveolar opacities, and High-Resolution Computed Tomography (HRCT) demonstrated ground-glass opacities consistent with diffuse alveolar hemorrhage. Bronchoalveolar lavage confirmed the presence of hemosiderophages, supporting the diagnosis of crack lung. Systemic corticosteroid therapy led to complete clinical and radiologic resolution.\u003c/p\u003e\u003cp\u003eThis case highlights the importance of considering drug exposure in young patients presenting with hemoptysis and diffuse pulmonary findings, as lack of toxicological testing or denial of drug use may lead to diagnostic errors. HRCT is essential for identifying alveolar hemorrhage patterns and excluding alternative causes, while bronchoalveolar lavage can provide diagnostic confirmation in uncertain cases. The favorable response to corticosteroids supports their therapeutic role in acute pulmonary injury induced by inhaled drugs.\u003c/p\u003e\u003cp\u003eEarly recognition of crack lung and awareness of its imaging spectrum are crucial for accurate differential diagnosis of diffuse alveolar hemorrhage syndromes and to prevent unnecessary interventions. This report contributes a case with complete diagnostic confirmation and favorable outcome, emphasizing the value of clinical, imaging, and toxicologic correlation in this rare pulmonary complication.\u003c/p\u003e","manuscriptTitle":"Crack lung: a case report with diagnostic confirmation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-30 01:07:39","doi":"10.21203/rs.3.rs-7830478/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"573688c4-0d1a-45e0-ad79-58600fa39557","owner":[],"postedDate":"October 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-28T05:08:40+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-30 01:07:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7830478","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7830478","identity":"rs-7830478","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}