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A6597 - Use of Venovenous Extracorporeal Membrane Oxygenation for Diffuse Alveolar Hemorrhage Due to Inhaled Synthetic Cannabinoids or ""Spice""
Author Block: M. Patel1, L. M. Tormoehlen2, D. Gutteridge1; 1Department of Pulmonary/Critical Care Medicine, Methodist Hospital, Indiana University Health, Indianapolis, IN, United States, 2Department of Neurology, Methodist Hospital, Indiana University Health, Indianapolis, IN, United States.
Introduction: Synthetic cannabinoids (“Spice” or “K2”) are marketed under the guise of selling incense or potpourri, and are viewed as a “legal” alternative to marijuana. Their popularity in the United States is increasing as it allows users to achieve a more intense high than marijuana, as well as avoid detection during standard drug testing. The myth that synthetic cannabinoids (SCs) are a safe alternative to marijuana is incorrect. Well described adverse effects include severe and sometimes permanent psychosis, self-mutilation, seizures, myocardial toxicity, and acute tubular necrosis. Diffuse alveolar hemorrhage (DAH) is not a commonly reported adverse effect. We present a case of DAH due to SCs with severe hypoxia requiring venovenous extracorporeal membrane oxygenation (VV-ECMO).
Case Presentation: A 21-year-old man with polysubstance abuse history was brought to the emergency room after being found unconscious. On arrival, he was awake and appeared intoxicated. His urine toxicology screen and serum ethanol test were negative. His labs revealed a mild acute kidney injury. He admitted to smoking “Spice” recently. Within two hours from presentation, he had two seizures and developed status epilepticus, for which he was intubated. During this time, he was noted to have worsening hypoxia, rapidly progressing diffuse infiltrates on chest X-ray, and after intubation was failing high-PEEP lung-protective ventilation. Given rapid clinical deterioration, a 27-French bi-caval dual lumen (Avalon®) catheter was used to cannulate the right internal jugular vein, and he was initiated on VV-ECMO within 9 hours of presentation. Bronchoscopy revealed a bloody bronchoalveolar lavage, and serum ANA and ANCA titers were negative. He was diagnosed with DAH, likely due to “Spice” inhalation. For the first 36 hours, VV-ECMO and ventilator settings were unable to be weaned, and so he was started on methylprednisolone 125mg every 8 hours. With this, a drastic clinical and radiographic improvement was seen within 24 hours. VV-ECMO decannulation, followed by extubation were achieved 64 hours after the initiation of steroids. Magnetic Resonance Imaging of the brain did not show any structural abnormalities, and his seizures were attributed to SCs. A urine screen returned positive for the metabolites 5F-ADB 3,3-dimethyl-butanoic acid and FUB-AMB 3-methyl-butanoic acid, confirming use of SCs.
Discussion: To our knowledge, there are only two abstracts that describe DAH in patients due to the use of SCs. However, this is the first reported case of life-threatening DAH due to SCs where VV-ECMO was used successfully as a bridge to recovery.