Cannabis Use Resulting in Diffuse Alveolar Hemorrhage: A Diagnosis of Exclusion

SESSION TITLE: Student/Resident Case Report Poster - Diffuse Lung Disease SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Cannabis smoking is common among adolescents and young adults. Diffuse alveolar hemorrhage (DAH) is a rare but life threatening complication of cannabis abuse. CASE PRESENTATION: A 33-year-old Hispanic male presented to our institute with dyspnea. Past medical history was significant for Diabetes Mellitus type I and end stage renal disease (ESRD) on hemodialysis. He reported recent use of Cannabis. Patient was in mild respiratory distress, afebrile with oxygen saturation of 84% on room air. Physical exam was positive for diffuse rales. Arterial blood gas revealed low pO2 and high A-a gradient. Laboratory workup revealed hemoglobin 8.7g/dl, WBC count 9800/mm3, platetlets 387000/mm3 and INR 1.1. Chest radiograph and CT scan showed diffuse bilateral patchy opacities (Fig. 1). Bronchoscopy demonstrated increased hemorrhagic patterns on serial bronchoalveolar lavage (BAL) (Fig. 2). Cytology showed abundant hemosiderin laden alveolar macrophages. BAL bacterial, viral, fungal, AFB and Pneumocystis jirovicii cultures were negative. Rapid influenza test, anti-Streptococcal antibody (Ab) and Legionella pneumophila antigen were negative. Echocardiogram revealed normal ejection fraction with no mitral stenosis. Antinuclear Ab, antineutrophil cytoplasmic Ab, glomerular basement membrane Ab, cryoglobulins, antiphospholipid Ab and rheumatoid factor were all negative. Serum toxicology screen performed on admission was positive for tetrahydrocannabinol (THC) with value of 163ng/ml (cutoff: 5ng/mL) and negative for cocaine. Patient left the hospital against medical advice and presented in 5 days with hemoptysis and worsening dyspnea, there was a drop in hemoglobin to 7.1g/dl. He was transfused one unit of packed red blood cells and managed supportively with supplemental oxygen. Again, he reported smoking Cannabis but denied cocaine use. DISCUSSION: DAH is characterized by bleeding into alveoli secondary to disruption of alveolar capillary basement membrane as a result of injury to alveolar microcirculation. Etiologies include systemic vasculitis, bland pulmonary hemorrhage and alveolar damage. Cannabis impact on respiratory system includes inflammatory edema and increased alveolar permeability. In vitro coagulation studies showed antithrombotic activity of THC. In an immunocompromised young adult with ESRD and evidence of DAH; infectious process and vasculitis were on the top of our differential diagnosis. However, extensive workup failed to identify infectious or immunologic etiology. Besides, our patient was not on anticoagulation therapy, with no evidence of bland hemorrhage under microscopy. This is the first case in English literature relating Cannabis use to DAH. CONCLUSIONS: We present a rare case of Cannabis use resulting in acute lung injury and DAH. Clinicians should have high suspicion for substance abuse in young patients presenting with DAH. Reference #1: Murray A, et al. Diffuse alveolar hemorrhage, anesthesia, and cannabis. Ann Am Thorac Soc. 2014 Oct;11(8):1338-9 DISCLOSURE: The following authors have nothing to disclose: Zaid Ammari, Shahnaz Rehman, Dawn Alita Hernandez No Product/Research Disclosure Information