CANNABIS-ASSOCIATED SECONDARY SPONTANEOUS PNEUMOTHORAX

Abstract

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Cannabis is the second most commonly smoked substance in US after tobacco. Marijuana smokers, especially young individuals, tend to develop similar symptoms as tobacco smokers. We present a patient with spontaneous secondary pneumothorax due to apical bullous disease possibly due to daily heavy marijuana usage. CASE PRESENTATION: A 30-year-old man with pmh of traumatic left-sided pneumothorax presented to the ED with one week history of progressive pleuritic chest pain and shortness of breath. He denied any history of trauma. Patient reported history of heavy daily marijuana smoking (more than five blunts a day for six years). He denied tobacco use. Physical examination revealed hyperresonance on percussion along with decreased right lung sounds. Bedside US of chest showed absence of lung sliding. Chest x-ray demonstrated large right-sided pneumothorax. Patient underwent left chest tube placement. Repeat CXR showed resolution of pneumothorax. CT scan of the chest was performed and showed multiple bilateral apical sub-pleural bullae, most prominent at the right apex and along the left upper lobe medially. Patient did not have family history of pneumothorax and no benign skin lesions, arachnodactyly, or joint hyper-mobility. Laboratory analysis showed negative HIV test and normal rheumatoid factor, homo-cysteine, and alpha-1 antitrypsin levels. Patient underwent right-sided VATS, right upper lobe wedge resection and mechanical pleurodesis. The patient was clinically and radio-logically stable following the removal of his chest tube and discharged home with the appropriate follow-up appointments DISCUSSION: The exact mechanism of cannabis-induced bullous lung disease and secondary spontaneous pneumothorax is not well known. The proposed mechanism involves common marijuana smoking techniques: breath holding, Valsalva and Muller’s maneuvers. Prolonged Valsalva maneuver during breath holding following deep inhalation of the smoke pressurizes the air in the lungs and could result in barotrauma to the lungs with rupture of sub pleural blebs. Furthermore, marijuana smoking is associated with significant airway inflammation, mucus hypersecretion and ciliated epithelial cell reduction, changes similar to those seen in tobacco smokers [5]. Diagnosis of cannabis-induced secondary pneumothorax is established by a process of exclusion of other apical bullous lung diseases. This patient was a habitual marijuana smoker who consistently performed breath holding and Valsalva maneuvers; he had no other risk factors for development of bullous disease or pneumothorax. The combination of prolonged breath holding and the toxic components in marijuana led to the barotrauma and pneumothorax. CONCLUSIONS: Penumothorax in young population can be secondary to different etiologies. Our case underlines the importance of maintaining a high index of suspicion for Cannabis as a cause of bullous lung disorder. Reference #1: Wu TC, Tashkin DP, Djahed B, Rose JE. Pulmonary hazards of smoking marijuana as compared with tobacco. N. Engl. J. Med. 1988; 318: 347–51. Reference #2: Tashkin DP, Gliederer F, Rose J et al. Effects of varying marijuana smoking profile on deposition of tar and absorption of CO and δ-9-THC. Pharmacol. Biochem. Behav. 40, 651–656 (1991). Reference #3: Roth MD, Arora A, Barsky SH, Kleerup EC, Simmons M, Tashkin DP. Airway inflammation in young marijuana and tobacco smokers. Am J Respir Crit Care Med 1998;157:928–937. DISCLOSURES: No relevant relationships by Obed Adarkwah, source=Web Response No relevant relationships by dina ahmed, source=Web Response no disclosure on file for Farhad Arjomand; No relevant relationships by Laila Cordero, source=Web Response No relevant relationships by Louis Gerolemou, source=Web Response No relevant relationships by Nabil Mesiha, source=Web Response No relevant relationships by Ankur Mogla, source=Web Response No relevant relationships by jad sargi, source=Web Response