Case Presentation:
A 29-year-old man with history of hypertension presented to a referring facility with subjective fever, cough, and hemoptysis. One month earlier, he had been hospitalized for similar symptoms and treated for pneumonia with complete recovery. He then had recrudescence of hemoptysis and fever 72 hours prior to presentation. He reported tobacco use but denied alcohol or other illicit drug use. He was incarcerated for several months 4 years ago, but denied known exposure to tuberculosis.
On admission, he was hypoxic, requiring 8L of oxygen by nasal cannula to maintain normal saturations. Initial labs were notable only for a white blood cell count (WBC) of 14,600 cells/mL. Chest CT showed extensive ground-glass opacities consistent with diffuse alveolar hemorrhage (DAH). He was treated with intravenous steroids, levofloxacin, and piperacillin-tazobactam, and transferred to the ICU at a tertiary care hospital.
On arrival, the patient was tachypneic but no longer requiring oxygen. His breath sounds were coarse bilaterally with no other abnormalities. A urine drug screen was negative. All infectious studies were normal including HIV antibody/antigen testing, blood cultures, respiratory viral panel, and AFB smears. Autoimmune testing, including ANA, ANCA serologies, anti-phospholipid and anti-glomerular basement membrane antibodies, and complement levels, was also unremarkable. He underwent bronchoscopy that demonstrated diffusely bloody BAL fluid but no source of hemorrhage. BAL cytology contained pigment laden macrophages consistent with injury from inhalation. Upon further questioning, the patient endorsed using synthetic marijuana two weeks earlier, as well as prior to his previous hospitalization for pneumonia. The patient experienced complete resolution of his symptoms and abnormal radiographic findings within 3 days with supportive care alone.
Discussion:
DAH has a broad differential diagnosis including systemic vasculitis, infection, hypersensitivity pneumonitis, and inhalational injury. The rapid resolution and negative evaluation indicates that this patient’s condition was most likely secondary to “spice,” or synthetic marijuana, which is not detected on routine urine drug screens. Although rare, this has been reported in a previous case describing a similar presentation and course (Alhadi et al). Recognition of this cause of DAH may become increasingly important as use of synthetic marijuana becomes more widespread, and as many patients view it as a “safer” drug providing a “legal high” (Seely KA et al).
Conclusions:
Diffuse alveolar hemorrhage causing hemoptysis and respiratory compromise is a potentially life threatening condition. The differential diagnosis is broad, but swift recognition and identification of potential causes is vital to initiating appropriate treatment. This case underscores the importance of taking a thorough social and exposure history in patients presenting with DAH.