Heroin-Induced Non-cardiogenic Pulmonary Edema: A Rare but Serious Complication

Non-cardiogenic pulmonary edema (NCPE) is a rare but serious complication of heroin overdose, more frequently observed in fatal cases. This report discusses a 33-year-old male patient with a history of hypertension and heroin use disorder who presented with dyspnea and hypoxia. Upon examination, his vital signs indicated an SpO₂ of 82% on room air, along with tachycardia and tachypnea. The patient disclosed heroin use the day before admission, and urine toxicology screening confirmed the presence of opioids and methadone. Pulmonary auscultation revealed bilateral crackles, while chest imaging, including chest X-ray (CXR) and computed tomography angiography (CTA) of the chest, revealed diffuse bilateral airspace opacities consistent with pulmonary edema, effectively ruling out pulmonary embolism. Arterial blood gas analysis indicated acute respiratory acidosis, which improved with oxygen therapy. A prior echocardiogram had shown normal cardiac function. Notably, diuretics were not administered, and the patient's oxygen requirements decreased within two days. NCPE is a diagnosis of exclusion, often characterized by persistent hypoxia following the resolution of opioid-induced respiratory depression, with radiographic evidence of pulmonary edema. The condition typically resolves within 24-48 hours with supportive care, as observed in this case. While NCPE is frequently identified during autopsy in heroin-related fatalities, its underlying pathophysiology remains poorly understood. NCPE should be considered in the differential diagnosis of respiratory failure in patients with heroin overdose. Given its potentially fatal consequences and the limited understanding of its pathophysiology, further research is warranted to optimize management strategies.