Marijuana smoking: a possible cause of diffuse alveolar hemorrhage
A 25-year man from Meghalaya, a state in the northeastern hilly region of India, presented with sudden-onset severe cough and hemoptysis for the past 3 days. There was associated breathing difficulty, especially on exertion and intermittent chest pain. There was no history of fever, chills, headache, double vision, urinary problems, constipation, nausea/vomiting, or joint pain. There was neither any history of chest trauma, pulmonary or cardiac disease, nor any known exposure to tuberculosis or the use of anticoagulation medications. He denied using alcohol or injectable drugs. However, he admitted smoking cigarettes regularly (1 pack/ day) and smoking marijuana occasionally for the last 7 years. The last occasion of marijuana smoking was 4 days prior to the hemoptysis episode. The patient was a known case of hemoglobinopathy E (HbE) (chromatographically confirmed), a common hemoglobin variant prevalent among the native population of the northeastern region of India. On examination, the patient was afebrile. There was no pallor, icterus, rash, lymphadenopathy, or pedal edema. Hemodynamically, the patient was stable (pulse: 105/ min; respiratory rate: 26/ min; BP: 110/70 mm Hg). Oxygen saturation at rest breathing room air was 84%. On respiratory system examination, there were crepitations over the right lower lobe with normal vesicular breath sound. Cardiovascular and abdominal examinations were normal. The patient was admitted for workup and management.
Laboratory investigations revealed hemoglobin 9.6 gm%, hematocrit 29%, and blood counts within normal limits without any increase in eosinophils. Serum biochemical testing showed renal and liver functions and electrolytes to be within normal limits, as were the urinalysis results. Random blood glucose was 140 mg/dL, and ESR was 12 mm/ hour. Chest X-ray showed increased interstitial markings. Further, high-resolution CT-thorax revealed ground-glass opacities in the right middle lobe (anterior to the fissure—white arrow) and right lower lobe (posterior to the fissure--black arrow) consistent with DAH (
The patient was treated with oxygen support, intravenous ceftriaxone (1 g twice daily), cough suppressants, and injection tranexamic acid. Intravenous furosemide was also administered on the day of admission, as there was initial suspicion of acute pulmonary edema, which was ruled out after cardiology review and furosemide was stopped. Later, antibiotic was also stopped as the cultures were negative. The cough and hemoptysis resolved, and breathing difficulty subsided (within 3 days) with this conservative line of management. No other etiology could be identified. The case was considered a rare example of cough and hemoptysis due to marijuana smoking-induced diffuse alveolar hemorrhage. The patient was discharged uneventfully (with counseling sessions for de-addiction) and was found to be doing well at regular follow-ups.
Marijuana is the most widely used illicit drug globally (prevalence: 2.6 to 5%). It is the second most frequently smoked substance after tobacco but is smoked in longer inhalations and greater volumes leading to greater retentions of tar and carbon monoxide in the users than while using tobacco.
Informed consent was taken from the patient to report these findings.
Am J Respir Crit Care Med.