J. Šidlo, A. Šoral, J. Bauerová, S. Valko, B. Muráriková, J. Mlynár, *J. Valuch
Pulmonary macrophages in heroin addiction
Institute of Forensic Medicine, Slovak Postgradual Academy of Medicine and St. Cyril and Method‘s Hospital,
Head: Jiřina Bauerová, MD, PhD, Prof. assoc.
*Institute of Forensic Medicine, School of Medicine and Faculty Hospital, Comenius University, Bratislava, Slovakia
Head: Mirko Mego, MD, PhD, Prof. assoc.
Background: The pulmonary complications of illicit drug abuse may be the most common form of drug-induced lung disease. Main purpose: The aim of the study was to determine pulmonary complications associated with intravenous heroin abuse. Pacients and methods: Lung tissue samples from 43 drug addicts and 28 "normal" persons submitted for medico-legal autopsy at the Institute of Forensic Medicine of Slovak Postgradual Academy of Medicine and Institute of Forensic Medicine of School of Medicine of the Comenius University in Bratislava were evaluated by method of light microscopy. Results: In the heroin addict cases pulmonary oedema in 49% and emphysema in 7% of cases were found. Statisticaly significant (p > 0,05) increased number of hemosiderin-negative pulmonary macrophages in 88% of cases of drug addicts was found. Conclusions: The Increased number of pulmonary macrophages in the group of heroin addicts can indicate may lung defense mechanism defects and/or direct heroin influence on macrophages as well. The possible conclusion of this study for practical application: occurrence of increased number of hemosiderin-negative pulmonary macrophages by negative autopsy findings in young people points to the probability of heroin abuse as well as for the necessity to investigate option this in a person's history.
Key words: heroin addiction, morphology, pulmonary macrophages
Introduction
The prevalence of drug abuse is thought to be increasing in Slovak Republic in last ten years (Novomeský, 1996). The patterns of drug abuse prevalent in a given population are determined by a variety of factors such as the cost or availability of particular substances, peer pressure, local customs, and legal pressures. The pulmonary complications of illicit drug abuse may be the most common form of drug-induced lung disease (Rosenow et al., 1992). The potential for respiratory system complications depends not only on the drug used but also on the route of administration, the origin of the drug, the presence of contaminants, whether or not there is sharing of paraphernalia, and the host response of the individual user (Glassroth et al., 1987).
Worldwide, heroin is the most common substance taken by intravenous drug abusers (Hind, 1990). Heroin is usualy acetylated from the parent compound morphine and arrives in a pure form as a white powder. Pure heroin is rogressively adulterated ("cut") by diluting it 20- to 100 fold with soluble "fillers" such as quinine, lactose, maltose, mannitol, baking soda, starch, barbiturates, and chloroquine (O'Gorman et al., 1987). The concentration of heroin in the product sold to the user by the pusher varies from 0 to 20 percent. The user mixes the dry white powder in unsterile water or in saliva. The mixture is heated in a spoon or bottle cap held over a lighted flame and removed from the heat as soon as bubbles appear. Other forms of heroin such as "brown" heroin are poorly soluble in water and require acidification with substances such as lemon juice or vinegar before heating. The heroin mixture is aspirated into a syringe through a ball of cotton wool to filter out the larger impurities. The intravenous injection ("mainlining") is performed without sterilization of the skin, often in the presence of other users, who then share the syringe and needle without sterilization (Hind, 1990).
Intravenous drug abusers are at risk from infection and a wide range of lung parenchymal and vascular lesions unrelated to infection (tab. I), because the lung plays a very important role also in filtering foreign material entering the blood stream from an intravenous drug injection.
Patients and methods
Lung tissue samples from 43 drug addicts and 28 "normal" persons submitted for medico-legal autopsy at the Institute of Forensic Medicine of Slovak Postgradual Academy of Medicine and Institute of Forensic Medicine of School of Medicine of The Comenius University in Bratislava were fixed in formalin, processed by routine method and embedded in paraffin. Sections were stained with hematoxylin-eosin and Perl‘s reaction for evidence of hemosiderin and evaluated by method of light microscopy. Besides morphological findings described in the literature (tab. I) the presence of pulmonary macrophages (Fig. 1) was evaluated. The characteristics of both groups studied are included in table II. The control group was comprised above all of motor vehicle accident victims. The data obtained was statistically evaluated by means of Chi-quadrat test for table 2x2. The qualitative detection of morphine as a metabolite of heroin in the urine samples obtained by autopsy by means of latex agglutination immunoassay technique (ONTRAK) were tested. The concentration of opiates and their metabolites in urine samples by means of semi-quantitative fluorescence polarisation immunoassay technology (Abbott) was detected.
Results
In the group of intravenous heroin abusers of all pulmonary complications (tab. I) only parenchymal lesions as pulmonary oedema connected with intraalveolar bleeding in 21 of 43 cases i.e. 49 percent and emphysema in 3 of 43 cases i.e. 7 percent were found. Statisticaly significant (p > 0,05) increased number of hemosiderin-negative pulmonary macrophages (Fig. 2) in 38 of 43 cases of heroin addicts i.e. 88 percent compared with 11 of 28 cases i.e. 39 percent in control group (tab. III) was found. In the group of heroin addicts toxicological investigation of urine in 41 of 43 cases i.e. in 95 percent was performed. The presence of opiates and their metabolites in all of cases examined was found. Two patients survived for some days and toxicological investigation by autopsy was not necessary.
Table I. Pulmonary complications associated with intravenous drug abuse (Hasleton, 1996).
Infections Human Immunodeficiency Virus Pneumonia Community Acquired Aspiration Septic Pulmonary Emboli Fungal Lung Abscess Tuberculosis Vascular Lesions Foreign Body Embolism Talc Microcrystalline Cellulose Cornstarch Cotton Mercury Needles Pulmonary Artery Medial Hypertrophy Mycotic Aneurysm Parenchymal Lesions Pulmonary Oedema Progressive Massive Fibrosis Emphysema Interstitial Pneumonia/Fibrosis Hemosiderosis
|
Table II. Characteristics of analysed groups.
group of addicts
|
control group |
|
No. Cases |
43 |
28 |
Age (years) |
17-43 |
15-29 |
Age average |
21 |
21 |
Table III. Occurrence of pulmonary macrophages.
Pulmonary |
Group of addicts
|
Control group |
||
Macrophages |
No.
|
No. |
||
Fe Negative |
Cases
|
% |
Cases |
% |
Resent
|
38 |
88 |
11 |
39 |
Absent
|
5 |
12 |
17 |
61 |