Cannabis-Related Diffuse Alveolar Hemorrhage in a 16-Year-Old Patient: A Case Report

Laura Bucchino

Alice Monzani

Sara Fracon

Giulia Genoni

Tiziana Cena

Simonetta Bellone

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

^{Pediatric Unit, Department of Health Sciences, University of Eastern Piedmont, Novara, Italy}

^{Anesthesiology and Intensive Care Unit, Accident and Emergency Department, University of Eastern Piedmont, Novara, Italy}

^{Neonatal and Pediatric Intensive Care Unit, Maggiore della Carità University Hospital, Novara, Italy}

Edited by: Renato Cutrera, Bambino Gesù Children Hospital (IRCCS), Italy

Reviewed by: Matthias Griese, LMU Munich, Germany; Jackson Y. W. Wong, Peak Pulmonary Specialty Clinic, Canada

*Correspondence: Alice Monzani ti.opuinu.dem@inaznom.ecila

This article was submitted to Pediatric Pulmonology, a section of the journal Frontiers in Pediatrics

Edited by: Renato Cutrera, Bambino Gesù Children Hospital (IRCCS), Italy

Reviewed by: Matthias Griese, LMU Munich, Germany; Jackson Y. W. Wong, Peak Pulmonary Specialty Clinic, Canada

Received 2019 Jul 29; Accepted 2019 Oct 28.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

Abstract

Diffuse alveolar hemorrhage (DAH) is a clinical condition characterized by the rapid onset of dyspnea, hemoptysis and acute respiratory failure (ARF). It is commonly caused by autoimmune systemic vasculitis, pulmonary infections, drugs and tumors. Here, we report a case of DAH caused by frequent cannabis smoking. A 16-year old boy presented with hemoptysis, dyspnea and ARF soon after laparoscopic surgery for varicocele in general anesthesia. The suspected diagnosis of DAH emerged from the initial chest radiography, and it was then confirmed by CT scan findings and the bronchoalveolar lavage. His general conditions completely recovered after only 24 h of oxygen supplementation and after intravenous corticosteroid and antibiotic therapy. This is the first pediatric case of DAH related to smoking marijuana, even though the inhalational anesthetic agent sevoflurane might have also been involved in this pathogenesis. Other possible causes of DAH have been considered. Negative-pressure pulmonary edema could be ruled out because no clinical evidence of upper airway obstruction was observed during general anesthesia and throughout the surgery. In addition, a possible causative role of cannabis additives/contaminants could not be excluded. Given the high prevalence of cannabis smoking in young people and that DAH can be a complication in cannabis smokers, a careful history and high index of suspicion are recommended as part of the pre-operative assessment before these patients are proceeded to receive general anesthesia.

Keywords: diffuse alveolar hemorrhage, acute respiratory failure, pediatrics, cannabis, sevoflurane, anesthesia

Abstract

Acknowledgments

The authors are thankful to the School of Medicine of the University of Eastern Piedmont, Novara, Italy, especially to Dr. Mario Pirisi, Director of the Residency Program at A.O.U. Maggiore della Carità for their educational and financial support. We also thank Dr. Marcello Arsura for proofreading the manuscript.

Acknowledgments

Glossary

Abbreviations

ARF	acute respiratory failure
DAH	diffuse alveolar hemorrhage.

Glossary

Footnotes

^{https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system}

^{https://www.pneumotox.com/drug/index/}

Footnotes

References

1. Franks TJ, Koss MN. Pulmonary capillaritis. Curr Opin Pulm Med. (2000) 6:430–5. [[PubMed]
2. Martínez-Martínez MU, Oostdam DAH, Abud-Mendoza C. Diffuse alveolar hemorrhage in autoimmune diseases. Curr Rheumatol Rep. (2017) 19:27. 10.1007/s11926-017-0651-y [] [[PubMed]
3. Spira D, Wirths S, Skowronski F, Pintoffl J, Kaufmann S, Brodoefel H, et al. . Diffuse alveolar hemorrhage in patients with hematological malignancies: HRCT patterns of pulmonary involvement and disease course. Clin Imaging. (2013) 37:680–6. 10.1016/j.clinimag.2012.11.005 [] [[PubMed]
4. Kim EA, Lee KS, Primack SL, Yoon HK, Byun HS, Kim TS, et al. . Viral pneumonias in adults: radiologic and pathologic findings. Radiographics. (2002) 22:S137–49. 10.1148/radiographics.22.suppl_1.g02oc15s137 [] [[PubMed]
5. Underner M, Perriot J, Wallaert B, Peiffer G, Meurice JC, Jaafari N. [Alveolar hemorrhage and cocaine use]. Rev Mal Respir. (2018) 35:134–48. French. 10.1016/j.rmr.2017.06.005 [] [[PubMed]
6. Peters NF, Gosselin R, Verstraete KL. A rare case of diffuse alveolar hemorrhage following oral amphetamine intake. JBR-BTR. (2014) 97:42–3. [[PubMed]
7. Alhadi S, Tiwari A, Vohra R, Gerona R, Acharya J, Bilello K. High times, low sats: diffuse pulmonary infiltrates associated with chronic synthetic cannabinoid use. J Med Toxicol. (2013) 9:199–206. 10.1007/s13181-013-0288-9 ] [
8. Loschner A, Cihla A, Jalali F, Ghamande S. Diffuse alveolar hemorrhage: add “greenhouse effect” to the growing list. Chest. (2011) 140:149A 10.1378/chest.1119854 [[PubMed]
9. Grassin F, André M, Rallec B, Combes E, Vinsonneau U, Paleiron N. [Fatal alveolar haemorrhage following a “bang” of cannabis] Rev Mal Respir. (2011) 28:919–23. French. 10.1016/j.rmr.2011.05.005 [] [[PubMed]
10. Shafi M, Liaquat S, Auckley D. Up in smoke: an unusual case of diffuse alveolar hemorrhage from marijuana. Respir Med Case Rep. (2018) 25:22–24. 10.1016/j.rmcr.2018.05.028 ] [
11. Murray AW, Smith JD, Ibinson JW. Diffuse alveolar hemorrhage, anesthesia, and cannabis [letter]. Ann Am Thorac Soc. (2014) 11:1338–9. 10.1513/AnnalsATS.201407-337LE [] [[PubMed]
12. Shi Y, Lenzi M, An R. Cannabis liberalization and adolescent cannabis use: a cross-national study in 38 countries. PLoS ONE. (2015) 10:e0143562. 10.1371/journal.pone.0143562 ] [
13. Kraus L, Guttormsson U, Leifman H, Arpa S, Molinaro S, Monshouwer K, et al Results from the European School Survey Project on Alcohol and Other Drugs. European Monitoring Centre for Drugs and Drug Addiction; (2015). [PubMed][Google Scholar]
14. G.U. 30/12/16. Public Law No. 242. 2–5 (December 2, 2016).
15. Lichtenberger JP, Digumarthy SR, Abbott GF, Shepard JAO, Sharma A. Diffuse pulmonary hemorrhage: clues to the diagnosis. Curr Probl Diagn Radiol. (2014) 43:128–39. 10.1067/j.cpradiol.2014.01.002 [] [[PubMed]
16. Cortese G, Nicali R, Placido R, Gariazzo G, Anrò P. Radiological aspects of diffuse alveolar haemorrhage. Radiol Med. (2008) 113:16–28. 10.1007/s11547-008-0229-x [] [[PubMed]
17. Nasser M, Cottin V. Alveolar hemorrhage in vasculitis (primary and secondary). Semin Respir Crit Care Med. (2018) 39:482–93. 10.1055/s-0038-1668533 [] [[PubMed]
18. Monfort M, Larakeb A, Gouraud F. [Hemoptysis in a young man smoking cannabis]. Arch Pédiatrie. (2013) 20:637–9. French. 10.1016/j.arcped.2013.03.008 [] [[PubMed]
19. Greydanus DE, Hawver EK, Greydanus MM, Merrick J. Marijuana: current concepts (†). Front. Public Heal. (2013) 1:42. 10.3389/fpubh.2013.00042 ] [
20. Kann L, McManus T, Harris WA, Shanklin SL, Flint KH, Queen B, et al. . Youth Risk Behavior Surveillance — United States, 2017. Morbidity and Mortality Weekly Report Centers for Disease Control and Prevention (2017). [[PubMed]
21. Tashkin DP. Airway effects of marijuana, cocaine, and other inhaled illicit agents. Curr Opin Pulm Med. (2001) 7:43–61. [[PubMed]
22. Hao D, Basnet S, Melnick S, Kim J. Negative pressure pulmonary edema-related diffuse alveolar hemorrhage associated with sevoflurane and cigarette smoking. J Community Hosp Intern Med Perspect. (2019) 9:247–51. 10.1080/20009666.2019.1608140 ] [
23. Mersh R, Ross C. Postoperative diffuse alveolar haemorrhage: insidious negative pressure or sevoflurane induced?BMJ Case Rep. (2018) bcr-2017-222010. 10.1136/bcr-2017-222010 ] [
24. Austin A, Modi A, Judson MA, Chopra A. Sevoflurane induced diffuse alveolar hemorrhage in a young patient. Respir Med Case Rep. (2017) 20:14–15. 10.1016/j.rmcr.2016.11.001 ] [
25. Kim CA, Liu R, Hsia DW. Diffuse alveolar hemorrhage induced by sevoflurane. Ann Am Thorac Soc. (2014) 11:853–5. 10.1513/AnnalsATS.201402-067LE [] [[PubMed]
26. Choi WK, Lee JM, Kim JB, Im KS, Park BH, Bin YS, et al. . Diffuse alveolar hemorrhage following sugammadex and remifentanil administration: a case report. Med Baltimore. (2019) 98:e14626. 10.1097/MD.0000000000014626 ] [