Recurrent Hemoptysis and Bronchial Artery Abnormalities in a 64-Year-Old Man with Cannabinoid Vaping

Abstract

Introduction: E-cigarette, or vaping, product use associated lung injury (EVALI) is a newly recognized form of toxic lung injury largely associated with cannabinoid-containing products. Increasing recognition of EVALI cases demonstrate heterogeneous manifestations of respiratory injury that may represent distinct clinical syndromes. We present a probable case of EVALI in a patient with recurrent small-volume hemoptysis and pulmonary vascular abnormalities. Case: A 64-year-old male with history of allergic rhinitis, osteoarthritis, and anxiety presented with recurrent small-volume hemoptysis. His symptoms began two weeks prior during a coughing episode that led to expectoration of blood and dark clot for which he was first admitted. He reported no tobacco smoking history. Three years prior he started vaping cannabis cartridges and later switched to vaping marijuana for anxiety. Contrasted computed tomography (CT) of the chest was without evidence of pulmonary embolism, extravasation, pulmonary arteriovenous malformations, bronchiectasis, or consolidation. Flexible bronchoscopy showed fresh clot and bleeding in the right lower lobe (RLL). Bronchial alveolar lavage gram stain and cultures, including acid-fast bacilli smear and culture, were unrevealing. Serologic evaluation included negative anti-neutrophil cytoplasmic antibody (ANCA), antinuclear antibody (ANA), anti-glomerular basement membrane antibody, and cryoglobulins. C-reactive protein was measured at 1.6mg/L and erythrocyte sedimentation rate (ESR) was 2mm/h. Urine toxicology was positive for cannabinoids. His hemoptysis resolved spontaneously, and he was discharged. Two days later he was re-admitted with small-volume hemoptysis. Contrasted CT chest demonstrated bilateral bronchial wall thickening and RLL opacities. Repeat sputum culture grew moderate E. coli for which levofloxacin was initiated. Bronchial arteriography displayed tortuous and beaded-appearing hypertrophied bronchial arteries with diffuse vascular shunting between bronchial arteries and both pulmonary arteries and pulmonary veins, greatest in the RLL. No embolization was performed due to concern for systemic distribution of embolic material through vascular shunts. His hemoptysis resolved, and he was discharged with instructions to discontinue vaping. In the four-week outpatient follow-up visit, he reported abstinence from vaping and no recurrent hemoptysis. Discussion: EVALI is a poorly understood clinical syndrome with a range of symptoms and severity. Initial reports have suggested an increased association of adverse outcomes with vaping cannabinoids. To the best of our knowledge, this is the first reported case to suggest recurrent hemoptysis with vaping cannabinoids. The history, arteriography findings, and temporal proximity of symptom resolution to vaping termination led us to this diagnosis. It remains unclear whether vaping induced pulmonary vascular abnormalities or if pre-existent abnormalities predisposed the patient to EVALI.