Hémorragies intra-alvéolaires et consommation de cocaïne

[Diffuse alveolar hemorrhage in cannabis smokers. A systematic literature review]

Cannabis is the most widely used illicit psychoactive substance in France. It can be responsible for numerous pulmonary complications, including diffuse alveolar hemorrhage (DAH). The objective of this systematic review of the literature was to present data concerning the relationship between cannabis smoking and DAH, which has rarely been reported in the literature. The review was based on a Medline search covering the 1980-2022 period and utilizing data drawn from 10 articles. DAH diagnosis is based on an association of hemoptysis, anemia and diffuse alveolar opacities on chest radiography with siderophages in the Bronchoalveolar Lavage Fluid (BAL). The 11 patients identified in this review were daily or regular cannabis smokers; in 4 cases they presented recent or recurrent hemoptysis with anemia; imaging revealed diffuse alveolar opacities in 10 of them, while BAL endoscopy highlighted a diffuse hemorrhage in the bronchial tree, and siderophages were observed in 6 cases. While evolution was favorable when cannabis consumption was discontinued, resumption occasioned DAH recurrence, and one patient died. Advice to quit should systematically be accompanied by addictological follow-up.

Cocaine-induced pulmonary complications: A diagnosis of waiting and watching

Pulmonary complications of cocaine among users are common. Manifestations include lung congestion, intra-alveolar edema, and diffuse alveolar hemorrhage (DAH). Direct cellular toxicity, eosinophilia, barotrauma, and vasoactive effects of cocaine are believed to induce DAH. We present a rare case of cocaine-associated focal alveolar hemorrhage mimicking malignancy on imaging. Initially contemplated biopsy was avoided based on rapid growth of concerning lung lesion, with subsequent near resolution on follow-up. This case illustrates the importance of epidemiologic and temporal multimodality correlation when evaluating indeterminate lung lesions.

[Pulmonary complications in cocaine users]

Cocaine can be responsible for many psychiatric and/or somatic disorders. The aim of this systematic literature review of data was to expose relations between cocaine use and pulmonary complications. Cocaine can be responsible for acute respiratory symptoms (cough, black sputum, hemoptysis, dyspnea, wheezing, chest pain) and for various pulmonary disorders including barotrauma (pneumothorax, pneumomediastinum, subcutaneous emphysema, pneumopericardium), airway damage, asthma, bronchiolitis obliterans with organizing pneumonia, acute pulmonary edema, alveolar hemorrhage, alveolar pneumonia with carbonaceous material, bullous emphysema, acute eosinophilic pneumonia, pulmonary granulomatosis caused by talc or cellulose, interstitial pneumonitis and pulmonary fibrosis, vasculitis, pulmonary hypertension, pulmonary embolism and pulmonary infarction, mycotic pulmonary arterial aneurysms, septic emboli, aspiration pneumonia, community-acquired pneumonia, HIV-related opportunistic infections, latent tuberculosis infection, pulmonary tuberculosis, lung cancer and crack lung. Some of these complications are serious and may have a fatal outcome. Pulmonary function tests, thoracic tomodensitometry, bronchial fibroscopy with bronchoalveolar lavage and lung scintigraphy may be an aid to the diagnosis of these pulmonary compications. Cocaine use must be sought in case of respiratory symptoms in young persons.

Cannabis-Related Diffuse Alveolar Hemorrhage in a 16-Year-Old Patient: A Case Report

Diffuse alveolar hemorrhage (DAH) is a clinical condition characterized by the rapid onset of dyspnea, hemoptysis and acute respiratory failure (ARF). It is commonly caused by autoimmune systemic vasculitis, pulmonary infections, drugs and tumors. Here, we report a case of DAH caused by frequent cannabis smoking. A 16-year old boy presented with hemoptysis, dyspnea and ARF soon after laparoscopic surgery for varicocele in general anesthesia. The suspected diagnosis of DAH emerged from the initial chest radiography, and it was then confirmed by CT scan findings and the bronchoalveolar lavage. His general conditions completely recovered after only 24 h of oxygen supplementation and after intravenous corticosteroid and antibiotic therapy. This is the first pediatric case of DAH related to smoking marijuana, even though the inhalational anesthetic agent sevoflurane might have also been involved in this pathogenesis. Other possible causes of DAH have been considered. Negative-pressure pulmonary edema could be ruled out because no clinical evidence of upper airway obstruction was observed during general anesthesia and throughout the surgery. In addition, a possible causative role of cannabis additives/contaminants could not be excluded. Given the high prevalence of cannabis smoking in young people and that DAH can be a complication in cannabis smokers, a careful history and high index of suspicion are recommended as part of the pre-operative assessment before these patients are proceeded to receive general anesthesia.

Hémorragies intra-alvéolaires

L’hémorragie intra-alvéolaire (HIA), maladie rare, est une urgence thérapeutique, car elle peut conduire rapidement vers une insuffisance respiratoire aiguë asphyxiante avec décès. La triade, hémoptysie–anémie–infiltrat radiologique, suggère le diagnostic d’HIA, mais elle peut manquer dans deux tiers des cas, y compris chez des patients en détresse respiratoire. La tomodensitométrie thoracique peut aider dans les formes atypiques. Le diagnostic d’HIA repose sur la réalisation d’un lavage bronchoalvéolaire. Les étiologies en sont très nombreuses. Il importera de séparer, en urgence, les HIA d’origine non immune, avec un dépistage de celles d’origine septique qui doivent bénéficier d’une enquête microbiologique ciblée et cardiovasculaire avec la réalisation d’une échographie cardiaque, des HIA immunes (les vascularites liées aux anticorps anticytoplasme des polynucléaires neutrophiles, les connectivites et le syndrome de Goodpasture), avec la recherche d’autoanticorps et la réalisation de biopsies au niveau des organes facilement accessibles. La biopsie pulmonaire doit rester exceptionnelle. En cas d’HIA immune inaugurale, un traitement par stéroïdes et cyclophosphamide peut être débuté. Les indications du rituximab commencent à être mieux établies. Le bénéfice des échanges plasmatiques est débattu. En cas de réapparition d’infiltrats pulmonaires, chez un patient suivi pour une HIA immune, on s’efforcera d’écarter une infection dans un premier temps.