Pulmonary Complications & AAS

Michael Scally MD

Doctor of Medicine
10+ Year Member
Fortuna F, Galiotto T. Adult Respiratory Distress Syndrome Secondary to Intravenous Oleic Steroid Suspension: Case Report. Chest 2013;144(4_MeetingAbstracts):309A. CHEST Journal | Article

INTRODUCTION: Documented respiratory complications of accidental intravenous oil injections are extremely rare, with only a few case reports in the medical literature. We report a case of ARDS secondary to accidental anabolic steroid oil suspension injection.

CASE PRESENTATION: A 29 year old male presented to our emergency department complaining of fever, myalgias, abdominal pain, cough, and reduced urinary output that began several hours after the sixth and last injection of nandrolone decanoate oil suspension the he had received intramuscularly in the gluteal region over the last 14 days.

Soon after the last injection the symptoms began, the first being fever as high as 38.7 degrees celsius. He stated to be a long term heavyweight lifter and previous anabolic drug user, with left ventricular hypertrophy detected in previous medical evaluations, but denied intravenous drug abuse or other medical problems and was felling well before the episode.

On examination the patient was well, febrile, tachycardic and tachypneic at rest, and abdominal pain was elicited on liver palpation. Laboratory results revealed slight increases in CPK (420u/L, NR 55-170) and serum creatinine (1,43mg/dL, NR 0,6 a 1,2). Other results were all normal.

The patient was diagnosed with presumed acute complications from anabolic steroid use, and intravenoous hydration was begun. Three days later he reported no symptoms and was discharged. Four days after discharge, the patient returned to the hospital complaining of dyspnea, severe dry cough with one episode of hemoptysis, and bilateral pleuritic chest pain. His oxygen saturation on room air was 92%. Pulmonary auscultation was abnormal, with crackles heard in both lower posterior pulmonary fields.

Radiologic evaluation with CT scans demonstrated bilateral posterior lower lobe airspace consolidations with air bronchograms. Intravenous contrast material with venous protocol did not reveal any arterial occlusions. Intravenous antibiotics were initially prescribed but after reviewing culture results that were all negative were stopped. The patient received supplemental oxygen and was monitored for 5 days with good recovery, and was discharged home. At an ambulatory visit 30 days after, he reported no symptoms.

DISCUSSION: To our knowledge this is the second description of ADRS as a result of anabolic steroid injection. There are other case reports of similar symptoms or even death after accidental injection of a variety of lipid formulations, from vegetable oils to lamp oil and medical lipid contrast agents.

The pathophysiology is thought to be similar to the more common fat embolism syndrome arising from orthopedic fractures or procedures. In short, both mechanical and chemical disruption of the capillary alveolar membrane could occur after large boluses of lipid material occlude the capillary vessels, leading to leakage into alveolar space and in severe cases hypoxia and even death.

Neurologic symptoms have also been described, and even the abdominal pain referred by our patient could be secondary to lipid embolus in the hepatic visceral circulation. There are no specific treatments and supportive care is recommended.

CONCLUSIONS: Intravenous lipid injections are relatively rare medical conditions that can lead to ARDS and be potentially severe. Anabolic steroids are one potential source of lipid embolus.

Reference #1: Russell M, Storck A, Ainslie M. Acute Respiratory Distress following intravenous injection of an oil-steroid solution. Can Respir J. 2011 Jul-Aug; 18 (4): e59-61.

Reference #2: Drent M, Cobben NA, Henderson RF, Jacobs JA, Wouters EF, van Dieijen-Visser MP. BAL fluid LDH activity and LDH isoenzyme pattern in lipoid pneumonia caused by an intravenous injection of lamp oil. Eur Respir J 1996;9:2416-8.

Reference #3: Kiyokawa H, Utsumi K, Minemura K, et al. Fat embolism syndrome caused by vegetable oil injection. Intern Med 1995;34:380-3.
 
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Kimani S, Carlos W. Acute Exacerbation of IPF Caused and Treated by Steroids. Chest 2013;144(4_MeetingAbstracts):667A.
CHEST Journal | Article


INTRODUCTION: Acute exacerbations of idiopathic pulmonary fibrosis (IPF) portend a significantly worse prognosis for the affected patients in a disease with an already poor median survival of 2.5-3.5 years after diagnosis.

CASE PRESENTATION: 52-year-old white male with IPF on oxygen with activity only. He had stable symptoms for 2 months.

He presented with shortness of breath, hypoxia and fevers a few hours after he received an injection of depotestosterone.

He had stable hemodynamics but a progressive increase in oxygen need to having a saturation of 91% on 75% inspired oxygen over 3 days. A chest CT revealed new diffuse ground glass opacities superimposed on a background of honeycombing. Brain natriuretic peptide was 65 pg/ml. Bronchoalveolar lavage (BAL) demonstrated mild neutrophilia at 12%. There was no sign of airway bleeding or diffuse alveolar hemorrhage. Blood and BAL microscopy, cultures and antigen testing were negative for bacterial, mycobacterial, viral and fungal pathogens.

He continued to be more short of breath and hypoxic despite 5 days of Vancomycin, piperacilin/tazobactam, moxifloxacin and 2mg/Kg of IV methyprednisolone. His steroid dose was then increased to 1gram daily for 3 days with a rapid decline in his oxygen need from 75% down to 3 L/min over three days.

At his 2 month follow-up, he was able to walk for 6 minutes with oxygen at 5 L/min with no desaturation. His chest CT scan showed marked improvement in the ground glass opacities and stability of his underlying honeycombing. He was safely started on the topical Androgel formulation of testosterone.

DISCUSSION: We have presented a case of a patient with Idiopathic pulmonary fibrosis who developed an acute exacerbation after receiving an injection of depotestosterone. A diagnosis of an acute exacerbation of interstitial lung disease is one of exclusion (1,2).

Based on the investigations we performed, including blood and BAl cultures and antigen testing, it is unlikely that our patient had an acute infective process. He had no diffuse alveolar bleed or PE on investigation.

The proximity of his symptoms to the depotestosterone injection provides a strong suggestion of its involvement as a trigger. He was not re-challenged with the drug.

CONCLUSIONS: To our knowledge, this is the first reported case of an acute exacerbation of IPF caused by an injection of depotestosterone. It is thus important for clinicians to be aware of this and exercise caution when using this drug in patients with IPF.

Reference #1: Kim, D. S. (2012). "Acute exacerbation of idiopathic pulmonary fibrosis." Clin Chest Med 33(1): 59-68.

Reference #2: Raghu, G., H. R. Collard, et al. (2011). "An official ATS/ERS/JRS/ALAT statement: idiopathic pulmonary fibrosis: evidence-based guidelines for diagnosis and management." Am J Respir Crit Care Med 183(6): 788-824.

Reference #3: Pfizer. (2006). " DEPO-TESTOSTERONE U.S. Physician Prescribing Information (PDF)." Retrieved march 25, 2013, from http://labeling.pfizer.com/ShowLabeling.aspx?id=548.
 
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