Introduction: Since legalization of cannabis in the United States, its use has been rising. Currently, 29 states and the District of Columbia have laws legalizing marijuana in some form. An inhalation method of cannabis concentrate (e.g. butane hash oil) called “dabbing” has been used for over a decade. Dabbing produces a faster, more potent euphoric high than other methods of cannabis ingestion. This process uses a hot platform, often made of quartz, ceramic, or titanium, heated with a blow torch. Once heated, a water pipe with a cannabis concentrate is applied, resulting in immediate vaporization for inhalation. Dabbing has been associated with psychosis and cardiotoxicity. Additionally, the process of dabbing creates toxic degradation products with the potential for pulmonary toxicity.
Case report: A 33 year old male without significant past medical history presented to the emergency department (ED) with 3 weeks of cough productive of clear sputum and shortness of breath. He had a chest CT demonstrating diffuse patchy ground glass opacities and nodular consolidation. He was discharged with azithromycin and a bronchodilator. He returned to the ED 5 days later with persistent symptoms. Associated symptoms included subjective fevers, myalgias, headaches and pleuritic chest pain. He installs commercial flooring for a living. He denied exotic travel. He smoked cannabis in the form of dabbing nightly. On admission the patient was febrile and hypoxemic, requiring 3L of oxygen via nasal cannula. His WBC count was 11,000 and the remainder of his labs were unremarkable. Blood cultures, sputum culture, respiratory viral panel, Strep Pneumo urine antigen, Legionella urine antigen, Histoplasma urine antigen, beta D glucan and aspergillus galactomannin were negative. A bronchoscopy was performed. Bronchoalveolar lavage studies including PJP, viral studies, and AFB cultures were negative. Transbronchial biopsy pathology showed mixed interstitial inflammation (composed of lymphocytes, plasma cells and scattered eosinophils). AFB and GMS stains were negative. He was diagnosed with hypersensitivity pneumonitis due to inhalation of cannabis concentrates in the form of dabbing. He improved without steroid treatment and was discharged home with instructions to no longer inhale cannabis in any form.
Discussion: Cannabis continues to be classified as a schedule 1 drug. Meanwhile there is limited data on the adverse effects of chronic inhalational use. Cannabis inhalation has been associated with chronic bronchitis and pneumothoraces. This case report highlights another form of cannabis inhalation that is potentially harmful, and in this case, led to acute hypersensitivity pneumonitis.
Full conference title:
- ATS 2018