Images in clinical medicine. Pulmonary granulomas in an intravenous drug user

A 28-year-old woman with a history of heroin use was admitted for increasing dyspnea. A chest radiograph (Panel A) showed diffuse bilateral pulmonary infiltrates that were predominantly interstitial. An open-lung biopsy was performed. Histologic analysis showed medial hypertrophy of medium-sized pulmonary arteries indicative of pulmonary hypertension, as well as occasional foreign-body granulomas.