Pulmonary granulomatosis associated with insoluble fillers in a heroin addict

We report a case of acute respiratory distress syndrome (ARDS) and pulmonary granulomatosis after intravenous injection of heroin. This 46-year-old male had a 2-year history of heroin addiction. The recent admission was due to loss of consciousness after intravenous injection of diluted heroin with unknown filler. Initial chest X-ray revealed a picture of ARDS. Blood routine and biochemistry were normal except for leukocytosis. Urine morphine test was positive. The blood and sputum culture yielded no pathogens. After supportive treatment, his condition improved, and the follow-up chest X-ray showed diffuse micronodules in both lung fields. Subsequently, open-lung biopsy of the right upper and lower lobes on the 26th hospital day showed large amounts of foreignbody granulomas distributed over perivascular areas, bronchiolar areas and interstitium. Staining for bacteria, fungi, and mycobacteria was all negative. The morphology of foreign-bodies could be divided into 2 types: 1) periodic acid-Schiff (PAS)-positive, aggregated fine crystals in round form; and 2) PAS-negative, yellow long crystals. The pathological diagnosis of pulmonary granulomatosis was made based on the finding of filler foreign bodies. The nature of these foreign bodies remained undetermined. The case suggests that pulmonary granulomatosis with the radiographic appearance of chronic interstitial pneumonia can occur in patients with a history of heroin use.