A 21-year-old male was admitted with the acute onset of hemoptysis. The night prior to admission he had smoked several (>5) marijuana joints and subsequently developed blood streaked sputum that became bloodier over time. He presented to ER found to have in no distress but was coughing up blood. Vital signs: Blood pressure 122/84 mmHg, Pulse 92 bpm, respiratory rate 20/ minute, with an oxygen saturation of 98% in ambient air. He was alert and oriented without any evidence of oronasal bleeding. His respiratory exam revealed diffuse rhonchi, remainder of his exam was unremarkable.
Additional history was significant for 2 days of nasal congestion and headaches but no fever, chills, sweats, myalgia, sore throat, skin rashes, or joint pain/ swelling. He reported smoking 2-5 non-synthetic marijuana joints per day (though denied use of any inhalant aid, i.e. bongs), and had no significant occupational exposures or other illicit drug use.
Initial evaluation included a hemoglobin of 16.4 g/dl, leukocytosis of 30.1 k/muL (83% neutrophils, normalized within 24 hours) and normal platelets. Serum chemistries, renal function, liver function, and coagulation studies were all normal. Urinalysis showed 0-2 RBC/ hpf and urine toxicology screen was positive only for tetrahydrocannabinol and negative for cocaine or any other illicit drugs. A Chest x-ray revealed diffuse patchy infiltrates, verified by a Chest CT showing extensive bilateral ground glass infiltrates with upper lobe predominance (Fig. 1) and (Fig. 2).
The patient was started on empiric antibiotics (piperacillin/tazobactum, vancomycin and ciprofloxacin). Infectious work up, including blood and sputum cultures, legionella urinary antigen, quantiferon TB test, and HIV antibodies were all negative. A respiratory viral panel was positive for rhinovirus. Echocardiogram was completely normal. Flexible bronchoscopy was performed and revealed blood-streaked secretions diffusely. Successive bronchoalveolar lavage (BAL) was performed in the right and left upper lobes (RUL, LUL), and both appeared consistent with DAH (Fig. 3, Fig. 4). Cell counts were remarkable for a RBC of 44000 cells/mul with 380 white cells /mul (79% macrophages) from the RUL, and RBC of 37000 cells/mul with 363 white cells (74% macrophages) from the LUL. BAL stains and cultures were all negative, and cytology revealed only erythrophages and hemosiderinophages. An extensive rheumatological serologic evaluation including (ESR, CRP, C-ANCA, P-ANCA, Anti-GBM, rheumatoid factor, complement levels, and ENA panel) were negative. Urine cytology did not show any dysmorphic RBCs.
The patient's condition improved with resolution of the hemoptysis, and he was discharged in stable condition. Outpatient pulmonary function testing was normal and a repeat Chest imaging had normalized. He was counseled to avoid smoking marijuana and remained symptom-free at his follow up visit.