Extended-release injectable naltrexone is an opioid antagonist approved for the treatment of alcohol and opioid dependence. Since the release of the drug in 2006, a literature review reveals five reported cases of drug-induced eosinophilic pneumonia. Our case highlights the clinical presentation of drug-induced eosinophilic pneumonia in the setting of extended-release injectable naltrexone. CASE PRESENTATION:A 35-year-old female with a past medical history lifelong tobacco use and alcohol dependence on extended-release injectable naltrexone presented to the ED with subjective fevers, myalgias, cough, and pleuritic chest pain. She was evaluated at urgent care two days prior and sent home on a course of Levofloxacin for bronchitis. Upon ED arrival, she was noted to be hypoxic and placed on supplemental oxygen. She was afebrile and tachycardic. Exam was pertinent for tachypnea and bilateral crackles. Initial laboratory data revealed WBC 19,500 (neutrophil predominate) and lactic acid 1.4. Chest x-ray and chest CT demonstrated extensive bilateral infiltrates. Empiric antibiotics were initiated while awaiting microbiology data. Due to escalating oxygen requirements and hemodynamic instability over the next 24 hours, the patient was intubated and bedside bronchoscopy was completed. BAL studies revealed lymphocyte predominance (46%) followed by eosinophils (27%) and neutrophils (21%). Given concern for acute eosinophilic pneumonia in the setting of extended-release injectable naltrexone, corticosteroids were started. Antibiotics were discontinued given negative culture data and our patient showed marked clinical improvement with continuation of steroid therapy.DISCUSSION: Extended-release injectable naltrexone is a long-acting opioid antagonist approved for the treatment of alcohol dependence. Clinical trials showed one diagnosed case & one suspected case of naltrexone-induced eosinophilic pneumonia. A current medical literature review reveals a paucity of cases associated with naltrexone and drug-induced AEP. While the etiology & pathogenesis remain largely unknown, it is thought to be related to an acute hypersensitivity reaction to an antigen in a genetically susceptible person. Progression from mild dyspnea to overt respiratory failure is rapid. Initial diagnostics are often nonspecific, however pleural fluid analysis demonstrates striking eosinophilia (10%-50%) and BAL fluid classically shows marked eosinophilia (25%-55%). Treatment includes supportive care, withdrawal of any eliciting medications, and glucocorticoid therapy. Most patients rapidly improve within 12-48 hours of initiation of corticosteroids. The prognosis for acute eosinophilic pneumonia is excellent with the vast majority of patients enjoying complete recovery.CONCLUSIONS: This case highlights the rare but important association between drug-induced eosinophilic pneumonia and extended-release injectable naltrexone.

In today's environment of cost-containment and utilization management, duplex ultrasound is often overused to evaluate symptoms of deep venous thrombosis/thrombophlebitis (DVT), reflecting the low diagnostic yield of such studies. We investigated the use of venous duplex scans by various medical specialties to determine whether a tendency exists to overuse this diagnostic tool by one specialty compared with others and to assess the cost-effectiveness of ordering this test for acute venous disease changes. We retrospectively reviewed the results of venous duplex ultrasound studies for 330 consecutive patients with suspected DVT for a 1-year period. Our analysis showed that 51 of 330 (16%) of all duplex scans ordered in our institution were positive for DVT. Internists, as a group, ordered 185 studies of which 26 were positive (14%). The surgeons’ requests for duplex studies resulted in 23 of 137 (17%) confirmed positive studies. The overall positive examination rate was 16 per cent, which is not only suboptimal as a diagnostic tool, but also cumbersome with regard to health care cost-containment.

Exposure to and consumption of brackish water are associated with an elevated risk of infection, hypernatremia, and hypothermia. Minimal data exist to support the diagnosis and treatment of patients with long-term brackish water exposure. We present a case of a patient who spent 5 to 10 d semisubmerged in the Elizabeth River in coastal Virginia. A 55-y-old male presented via ambulance after 5 to 10 d of being "stuck in the mud." He was hypernatremic, with a sodium of 176 mEq$L -1 , hypothermic to 34.5 C (94.1 F), and hypotensive at 88/50 mm Hg, with a sodium concentration of 176 mEq$L -1 and an osmolality of 412 mosm$kg -1 . He developed pneumonia, with respiratory cultures growing Vibrio parahemolyticus, Klebsiella oxytoca, and Shewanella algae. He had pustules, which grew Aeromonas hydrophilia and Aeromonas caviae. A nasogastric tube was placed. Using suction, 500 mL of coarse sand and gravel was removed from his stomach. Antibiotics and intravenous fluids were given. The patient fully recovered after 3 wk and was discharged to rehabilitation. Exposure to brackish water can present a unique set of infectious and metabolic complications. Initial care should include treatment of metabolic derangements, such as hypovolemia, hypernatremia, and hypothermia, and treatment of infections with antibiotics based on knowledge of the most likely causative organisms.

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