ARDS INDUCED BY “DABBING” IN A 16-YEAR-OLD FEMALE

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Marijuana use in the United States among adolescents is increasing including novel inhalant routes such as “dabbing” of butane hash oil (BHO). Our case describes a 16-year-old girl who developed pediatric acute respiratory distress syndrome (pARDS) after inhalation of BHO. CASE PRESENTATION: A 16-year-old female presented to an emergency center with fever, cough and emesis for four days. She had labored breathing with bi-basilar crackles. Laboratory data revealed a leukocytosis and elevated c-reactive protein. A chest radiograph (e-Figure 1) revealed bilateral dense airspace opacities concerning for pneumonia. She developed worsening radiographic evidence of disease (e-Figure 2) and acutely decompensated requiring mechanical ventilation. Flexible bronchoscopy revealed diffuse mucosal erythema and thick secretions. Chest CT revealed bibasilar consolidations and ground glass opacities (e-Figure 3). Her condition progressed to pARDS and she received antibiotics, inhaled nitric oxide, and Meduri protocolized corticosteroids. Twenty-three days into her hospitalization it was disclosed that she was dabbing BHO in the weeks preceding hospitalization. As her cultures remained negative, this was the presumptive etiology of her symptomatology. She gradually improved, was extubated 4 weeks after admission and discharged to inpatient rehabilitation. DISCUSSION: “Dabbing” refers to inhalation of tetrahydrocannabinol (THC) containing BHO. THC levels in BHO are 50-90%1 as compared to 12-20% in traditional marijuana. Butane acts as a liquid solvent for dried marijuana cannabis. The liquid is heated (“blasted”) and butane evaporates to create the product with street names including: “dabs”, “shatter”, “honeycomb” and “wax” depending on color and consistency. This product is then vaporized using a concentrated water pipe or “oil rig” for inhalation. Two existing case reports describe acute lung injury2 and associated pneumonitis3 after BHO inhalation. Respiratory pathophysiology associated with dabbing remains unclear but may be related to thermal injury or inhalation of solvent degradation products, such as methacrolein or benzene.1 CONCLUSIONS: Dabbing BHO with THC has gained popularity due to a perceived intensified high, but may lead to significant respiratory pathology described in our case. Clinicians must maintain a high degree of suspicion to determine the etiology of pARDS. Research is needed to better understand pathophysiology, ideal treatment, and the social/healthcare impact of dabbing on youth. Reference #1: Meehan-Atrash J, Luo W, Strongin RM. Toxicant Formation in Dabbing: The Terpene Story. ACS Omega. 2017;2(9):6112-6117. doi:10.1021/acsomega.7b01130 Reference #2: Anderson RP, Zechar K. Lung injury from inhaling butane hash oil mimics pneumonia. Respir Med Case Rep. 2019;26:171-173. Published 2019 Jan 4. doi:10.1016/j.rmcr.2019.01.002 Reference #3: McMahon MJ, Bhatt NA, Stahlmann CG, Philip AI. Severe Pneumonitis after Inhalation of Butane Hash Oil. Ann Am Thorac Soc. 2016;13(6):991-992. doi:10.1513/AnnalsATS.201602-101LE DISCLOSURES: No relevant relationships by Scott McKinley, source=Web Response No relevant relationships by Brett Russi, source=Web Response No relevant relationships by Anthony Sochet, source=Web Response