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In November 2006 a 33-year-old man was admitted with acute respiratory distress following a suicide attempt (50 hydroxyzine tablets and a vial of diazepam). The patient’s medical history included a heroin and cocaine addiction which was substituted by methadone 4 years previously; epilepsy treated with valproic acid; and manic-depressive disorder treated with cyamemazine, olanzapine, zopiclone and diazepam. As a tobacco (15 pack-years) and cannabis smoker, the patient reported noticing that grit sand was mixed into a new batch of cannabis that he had changed to 2 weeks previously. He had smoked 5–6 non-filtered adulterated joints a day and complained of dyspnoea after each inhalation. A physical examination revealed dyspnoea with hypoxaemia at rest and diffuse rales, a high-pitched mid-inspiratory squeak and expiratory wheezing. The chest radiograph showed diffuse bilateral infiltrative shadows, mainly in the upper segments. No signs of clubbing, vasculitis or heart failure were identified. An axial thin-section CT scan revealed multiple patchy ground-glass opacities with accentuated interlobular septal thickening in both upper lung fields. Mediastinal lymphadenopathy was also observed (fig 1).
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