Letter to the Editor
Acute eosinophilic pneumonia associated with marijuana smoking for chronic pain management
Neumonía eosinofílica aguda asociada a inhalación de marihuana como tratamiento de dolor crónico
Ignacio Gayá García-Manso
, María Ángeles Martínez García, José Luis Pérez Pérez
Corresponding author
Servicio de Neumología, Hospital General Universitario Dr. Balmis, ISABIAL, Alicante, Spain
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"apellidos" => "Callejas-Rubio" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775322002378" "doi" => "10.1016/j.medcli.2022.03.019" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775322002378?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020622004132?idApp=UINPBA00004N" "url" => "/23870206/0000015900000006/v1_202209200648/S2387020622004132/v1_202209200648/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Acute eosinophilic pneumonia associated with marijuana smoking for chronic pain management" "tieneTextoCompleto" => true "saludo" => "To the Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "e41" "paginaFinal" => "e42" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Ignacio Gayá García-Manso, María Ángeles Martínez García, José Luis Pérez Pérez" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Ignacio" "apellidos" => "Gayá García-Manso" "email" => array:1 [ 0 => "nachogaya@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "María Ángeles" "apellidos" => "Martínez García" "email" => array:1 [ 0 => "mangelesmtnez92@gmail.com" ] ] 2 => array:3 [ "nombre" => "José Luis" "apellidos" => "Pérez Pérez" "email" => array:1 [ 0 => "joseluisperez2195@hotmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Neumología, Hospital General Universitario Dr. Balmis, ISABIAL, Alicante, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Neumonía eosinofílica aguda asociada a inhalación de marihuana como tratamiento de dolor crónico" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The entry of inhaled substances can trigger pathological reactions in the lung, including acute eosinophilic pneumonia (AEP). We report a case of acute eosinophilic pneumonia associated with marijuana inhalation, an association rarely described in the medical literature, in this case used as a treatment for chronic pain caused by an ulcer.</p><p id="par0010" class="elsevierStylePara elsevierViewall">An 88-year-old male, former smoker for 50 years, with a cumulative consumption of 20 pack-years, with no other respiratory history. Diagnosed with lower-limb chronic ischemia, with ischemic ulcer in the second toe of the left foot secondary to a dog bite, with poor progression and need for supracondylar amputation. Two months earlier, he had started using three CBD-type marijuana cigarettes a day to control his pain.</p><p id="par0015" class="elsevierStylePara elsevierViewall">He presented with cough, dyspnoea and oxygen desaturation up to 87%, with radiographic evidence of patchy bilateral pulmonary infiltrates. Chest HRCT showed extensive bilateral lung involvement with areas of ground-glass attenuation alternating with areas of normal appearance and hypoattenuation marked by air trapping.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Positive results for anti-OJ myositis-specific antibodies stood out in the blood test. Bronchoscopy with bronchoalveolar lavage was performed, with negative microbiology results including cultures, mycobacteria, fungi, CMV, <span class="elsevierStyleItalic">Pneumocystis jirovecii</span> and SARS-CoV-2. Cell count revealed eosinophilia of 19%. Biopsy of the right upper lobe carina showed no pathological findings.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The diagnosis of anti-synthetase syndrome was suggested due to the positive anti-OJ antibody, but there was no evidence of myopathy or other systemic involvement. Given the eosinophilia in the BAL and the temporal correlation between the onset of consumption, the symptoms and the appearance of pulmonary infiltrates, a diagnosis of AEP associated with marijuana inhalation was made. Furthermore, since cessation of consumption on admission, the symptoms of cough and dyspnoea had already started to improve, which establishes causality as probable according to the FDA algorithm. Nevertheless, treatment with prednisone 40 mg/day was started, with rapid tapering of the dose given the favourable progression, and great improvement in the follow-up chest HRCT at one month.</p><p id="par0030" class="elsevierStylePara elsevierViewall">AEP is a rare entity with nonspecific symptoms (cough, dyspnoea, systemic symptoms) characterized by the presence of pulmonary infiltrates, with eosinophilic infiltration in the lung parenchyma, and sometimes peripheral eosinophilia. According to the latest modified Philit criteria, bronchoalveolar lavage with eosinophilia or evidence of infiltration in biopsy samples is necessary for diagnosis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It can be idiopathic or secondary to other factors such as medications, infections, or various inhaled agents. Among the substances inhaled, tobacco stands out, mainly associated with initiation of use, but also with ex-smokers who resume use, active smokers who increase the amount or even with switching brands.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">A literature search was performed in PubMed combining the descriptor "Pulmonary Eosinophilia" and those related to marijuana ("Cannabis", "Marijuana Smoking", "Marijuana Use", "Marijuana Abuse", "Smoking, Non-Tobacco Products"), without limitation by date of publication. Only two cases have been published in adults: Liebling and Siu<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> published the case of a 60-year-old male who consumed marijuana of a different origin than usual during a trip, triggering a condition compatible with AEP; Natarajan et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> described the case of a 29 -year-old male with an episode of AEP two weeks after the start of consumption, diagnosed by VATS with marked eosinophilic infiltration. Two other cases have been published in adolescents aged 15<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and 17 years, although the latter is doubtful because the biopsy, in addition to eosinophilia, showed evidence of silicosis and compatible nodular lesions.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Two cases have been described in association with marijuana vape<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> or hashish oil vape, but together with other potentially harmful substances (vitamin  E acetate or diacetyl) which make it impossible to be sure that marijuana is the cause of AEP. Cases have also been reported with other drugs of abuse, such as amphetamines, crack or heroin.</p><p id="par0045" class="elsevierStylePara elsevierViewall">AEP is associated with a good prognosis when diagnosed and treated early, with a rapid response to steroid treatment. In addition, it is necessary to actively search for secondary causes in a case of AEP, since avoidance of the causative agent is key to prevent relapses and the treatment regimen may be shorter, as short as two weeks.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0050" class="elsevierStylePara elsevierViewall">This study has not received funding of any kind.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interests</span><p id="par0055" class="elsevierStylePara elsevierViewall">There is no conflict of interest to declare directly or indirectly related to the contents of the manuscript.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interests" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical characteristics and corticosteroid treatment of acute eosinophilic pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C.K. 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Islam" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1155/2020/9496564" "Revista" => array:3 [ "tituloSerie" => "Case Rep Pulmonol" "fecha" => "2020" "volumen" => "2020" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015900000006/v1_202209200648/S2387020622004156/v1_202209200648/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015900000006/v1_202209200648/S2387020622004156/v1_202209200648/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020622004156?idApp=UINPBA00004N" ]
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