Spontaneous pneumothorax (SP) associated with marijuana or cocaine use is uncommon but not unknown. Although it can be difficult to demonstrate a direct effect, lung damage caused by drug use can predispose patients to pneumothorax.1 We report the case of a 39-year-old man, referred to our unit for treatment of right SP. He had already had SP in the same side 7 months previously and had admitted to occasional use of cocaine. Mechanical pleurodesis was performed via thoracoscopy with resection of the apex of the right lung. Pathology laboratory analysis showed unexpected evidence of non-necrotizing granulomas in the bronchial walls, associated with small vesicles (Fig. 1). The patient had no significant clinical history and all standard clinical laboratory test results, including mycobacteria, fungal infection and human immunodeficiency virus, were negative.

Fig. 1.

Pathology sample with hematoxylin and eosin staining (10× magnification) showing granulomas (white arrow) and small vesicles (*). Activated lymphocytes and giant inflammatory cells were observed.

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Respiratory tract deposits of particles of talc contained in cocaine were thought to have led to the formation of granulomas as a reaction to a foreign substance. Granuloma growth affected the small airways, causing air retention and bullous disease. Severe cough and bronchospasm caused by the inhalation of cocaine caused increased intra-alveolar pressure, followed by vesicle rupture and pneumothorax.

Ward et al.2 and Pare et al.3 described significant radiological changes after cocaine use, including bullous emphysema and pulmonary fibrosis. Our group recently reported vesicles similar to those seen in elderly patients in a series of 13 young habitual marijuana smokers.4,5

Granulomas as the only expression of lung damage may be explained by the fact that our patient reported intermittent and not continuous use of cocaine. However, sustained exposure to cocaine exacerbated the deposit of talc particles, causing severe lung damage, evidenced by the above-mentioned radiological changes.

Granulomas caused by sporadic use of cocaine may predispose the patient to SP, even in the absence of significant radiological changes. The best way of prevent severe parenchymal damage is to avoid the use of drugs.