High times, low sats: diffuse pulmonary infiltrates associated with chronic synthetic cannabinoid use

Abstract

Introduction: In recent years, cases of severe adverse effects from recreational use of synthetic cannabinoids (SC) have established that these agents represent a novel toxicologic hazard.

Case report: A 21-year-old male presenting as a vehicular trauma victim was noted with diffuse pulmonary infiltrates related to chronic inhalation of multiple synthetic cannabinoid-containing products. Chest imaging revealed bilateral, subacute lung infiltrates; histopathological analysis of bronchial and alveolar tissues revealed an inflammatory process. An extensive workup failed to identify infectious, malignant, autoimmune, or hematologic causes of the syndrome, and toxicological analysis of the blood and body fluids confirmed the presence of multiple synthetic cannabinoids and metabolites. The patient recovered after an 8-day ICU course, wherein he received antibiotics, steroids, and mechanical ventilation.

Discussion: This case contributes to the currently evolving knowledge about SC agents, adding a rarely described pulmonary complication to the growing list of adverse effects associated with these products.

Fig. 1

Chest X-ray on arrival

Fig. 2

Initial CT pulmonary angiogram

Fig. 3

Repeat CT scan hospital day 6

Fig. 4

Chest X-ray at discharge (hospital day 8)

Fig. 5

a and b Spice compounds submitted by the patient’s family for analysis, all of which contained AM-2201. Spice, K2, and similar SC agents are sold in colorful, deceptively packaged 1–3-g mixtures containing dried plant products which have been sprayed with one or more synthetic cannabinoids [17]. These products are marketed with deceptive labels such as “herbal incense” or “potpourri” and packets are labeled “not for human consumption”

Fig. 6

a Hematoxylin and eosin stain at ×40 magnification of transbronchial lung biopsy, showing chronic inflammatory infiltrate in the lung parenchyma. b Broncho-alveolar lavage monolayer showing numerous macrophages with a refractile, non-ferric brown pigment. (×40)

Fig. 7

a, b, and c Chemical structures of delta-9-THC, AM-2201, and JWH-018. The immune assay urine drug screen for THC (a) does not detect synthetic cannabinoids (b and c). Note that AM-2201 (middle) is essentially the same structure as JWH-018 (bottom), except that the former has a fluorine attached to its alkane tail