A Case of Pulmonary Foreign Body Granulomatosis Secondary to Intravenous Injection of Acetaminophen/Oxycodone

Abstract

Foreign body granulomatosis is a rare complication of intravenous injection of pulverized oral prescription tablets. We present the case of an active duty male who was ultimately diagnosed with foreign body granulomatosis caused by the crushing and intravenous injection of acetaminophen with oxycodone (Percocet). The 24-year-old patient initially presented with multiple syncopal episodes, hemoptysis and hypoxia. The patient presentation and imaging findings involved in foreign body granulomatosis can mimic many pulmonary disorders and can be widely variable. Diagnosis is made following lung biopsy. The disease has irreversible effects and patients usually have a progressive decline in pulmonary function. Treatment is supportive although lung transplantation may be beneficial in patients with end-stage lung disease. Pulmonary foreign body granulomatosis should be considered in patients presenting with unexplained hypoxia and imaging consistent with diffuse micronodular disease.

Identification of factors influencing tampering of codeine-containing medicines in England: a qualitative study

“…For the participants using CCM and heroin, it is important to note that no studies, as far as we are aware, have investigated the content of extracted solutions from CWE in regard to left over tablet fillers (such as talc or starch used in the manufacturing of pharmaceutical tablets). Tablet fillers can cause serious harm when injected intravenously, including infections at the injection site and pulmonary emboli [4,43]. This poses a risk specifically to those who inject the extracted codeine.…”

“…The perceived ineffectiveness of CWE procedures did not always prevent consumption of the extracted codeine amongst the participants using CCM and heroin. However, amongst the participants who only used CCM, there were comments suggesting that all the steps required for CWE such as from collecting codeine boxes from multiple pharmacies to crushing them up, dissolving them in water and completing the filtration presented as a barrier to using CWE 4,5 . Considering that pharmacies are allowed to only dispense one box per day per customer, scouring enough boxes would require visits to more than one pharmacy on the same day [9].…”

“…If you go on the drugs forums… For codeine, there's the threads at the top, the sticky posts at the top, they're all about CWE and warnings 3 8000 mg paracetamol is twice the recommended daily dose according to the BNF. 4 To provide context for interpretation, participants would require two boxes of OTC CCM (or about 60 tablets containing 8 mg codeine and 500 mg paracetamol) to produce approximately 500 mg free-base codeine (maximum achievable dose from CWE without exceeding the upper limit of paracetamol in the extracted solution). At a price of approximately £1 for a box of OTC CCM (32 tablets containing 8 mg codeine and 500 mg paracetamol), the cost of producing approximately 500 mg free-base codeine is less than £2.…”

“…Medicine tampering involves a range of procedures to manipulate different types of psychoactive medicines in order to enhance their psychoactive effects [1,2]. Reports of harm following intravenous injection of crushed oxycodone and morphine tablets highlight the risk of pulmonary granulomatosis from deposition of talc and other fillers used in the manufacturing of medicines [3,4]. Smoking of fentanyl patches (either whole patches or smaller pieces) have been reported amongst people seeking addiction treatment, setting new demands for services to negotiate severe withdrawal symptoms amongst their clients [5].…”