A42-15 Radiographic Manifestations of Intravenous Administration of Oxycodone-acetaminophen Mimicking Septic Pulmonary Emboli

Abstract Introduction Septic emboli to the lung is a common complication of infective endocarditis (IE) and can appear as multifocal pulmonary opacities on imaging. Other uncommon etiologies that may have similar imaging findings include vasculitis, atypical infections, E-cigarettes or Vaping-Associated Lung Injury (EVALI) and malignancy. Excipient lung disease or substance-induced pulmonary infiltrates is an uncommon etiology of multifocal pulmonary opacities and can present similarly to IE. Here, we present a case of multifocal pulmonary opacities due to illicit intravenous oxycodone-acetaminophen mimicking septic emboli on lung imaging. Case Presentation A 28-year-old female with history of mood disorder, vaping and IV drug use (IVDU) presented to the emergency department with 3 days of pleuritic chest pain. She was afebrile, normotensive, with normal oxygen saturation on room air. Labs were notable for leukocytosis of 10.8 K/uL and D-dimer 1.06 ug/mL FEU. Urine toxicology was positive for benzodiazepines, fentanyl, and opiates. Chest CT angiography revealed multifocal nodular and patchy pulmonary opacities and infiltrates. Due to concern for septic embolic from IE empiric vancomycin and gentamicin was started. However, transesophageal echocardiogram did not reveal vegetations and blood cultures remained negative. On hospital day 3, repeat CT imaging of the chest revealed worsening left lower lobe consolidation and stable pulmonary nodules prompting CT guided percutaneous needle biopsy of a pulmonary nodule. Pathology from the biopsy showed benign bronchial walls with polarizable material. Bacterial, acid fast, fungal stains and cultures were negative. Subsequent autoimmune and infectious workup was unremarkable. New collateral history revealed the patient had been injecting oxycodone-acetaminophen tablets dissolved in tap water intravenously prior to presentation. With discontinuation of active IVDU, the patient’s clinical condition improved, and she left against medical advice with counseling to undergo follow-up outpatient imaging to ensure resolution of pulmonary opacities and infiltrates. Discussion of Novelty and Importance Intravenous injection of dissolved medications causes foreign particulate material to become trapped in the pulmonary vascular beds. This causes an inflammatory cascade that can manifest as pulmonary hypertension, fibrosis, or in our patients, embolic nodules. Furthermore, IVDU excipients, or ingredients besides the active compound, may be present in the injected solution and precipitate further pulmonary damage. Due to the similar radiological presentation, excipient and substance induced lung injury may be initially treated as septic emboli leading to delays in diagnosis, overtreatment, and increased healthcare cost. As the prevalence of IVDU rises, it’s increasingly important that clinicians recognize unusual presentations of substance abuse. This abstract is funded by: None