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

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.

ASRA Pain Medicine consensus guidelines on the management of the perioperative patient on cannabis and cannabinoids

“…The immediate effects of oral or inhaled THC induces bronchodilation both in healthy subjects and those with asthma,220 221 but aerosolized THC or cannabis smoking may also result in an irritation of the airways and bronchoconstriction in some individuals with reactive airway disease 222. Evidence of harm is limited to small case series and case reports 212 223–229. A small clinical trial and several case reports of patients with acute shortness of breath and hemoptysis within hours of cannabis use have been published 230–233.…”

Perioperative and anaesthetic considerations of marijuana use

“…Cannabis use is associated with developing a pneumothorax and bullous emphysema, so caution should be used when using positive pressure ventilation (Horvath et al 2019). A case of diffuse alveolar haemorrhage in the post-anaesthesia care unit has also been reported in one chronic cannabis user (Bucchino et al 2019). Cardiovascular concerns include bradycardia and orthostatic hypotension (Beaulieu 2017).…”

Clearing up the smoke: Physical and mental health considerations regarding cannabis use in adolescents with cystic fibrosis

“…Airflow obstruction from one cannabis joint was comparable with as many as five tobacco cigarettes 24 . Cannabis, independent of CF status, is associated with developing pneumothorax 25 and hemoptysis 26 . Cannabis‐based e‐cigarette products are formulated with additives which can adversely affect the pulmonary system, as seen in e‐cigarette or vaping use‐associated lung injury 27 .…”

“…Pneumothorax 25 19. Hemoptysis 26 20. Decrease in LES pressure, gastric emptying, and slowed GI mobility 29 21.…”

“… 24 Cannabis, independent of CF status, is associated with developing pneumothorax 25 and hemoptysis. 26 Cannabis‐based e‐cigarette products are formulated with additives which can adversely affect the pulmonary system, as seen in e‐cigarette or vaping use‐associated lung injury. 27 Potential effects of oral consumption of cannabis on pulmonary function is not currently well described, yet may have possible indirect implications on lung function through drug‐drug interactions with medications used in the treatment of CF, such as the CFTR modulators.…”