SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Illicitly manufactured fentanyl is emerging as a dangerous threat to the public. With a cheaper cost of production, it has been frequently adulterated into other substances. Two most commonly reported complications are respiratory depression and non-cardiogenic pulmonary edema. However, this case introduces a patient with opiate-induced diffuse alveolar hemorrhage (DAH) which is believed to be rare in the literature. CASE PRESENTATION: A 31-year-old man was brought to the hospital after being found unresponsive. Physical examination was significant for pinpoint pupils with Glasgow 4 points. 2 mg naloxone (IV) drastically improved his mentation. After being alert, he admitted his friend invited him to snort fancy "cocaine” earlier. He denied opioid abuse history. He progressively developed worsening hypoxia with SpO2 85%, persistently coughing up dark red blood roughly 300 mL. Chest Xray demonstrated diffuse bilateral infiltrates. ABG revealed pH 7. 27, CO2 46 mmHg, O2 90 mmHg, HCO3 20 mEq/L, and P/F 90 (FiO2 100%). He was intubated for worsening hypoxia and persistent hemoptysis. A toxicology screen was positive only for marijuana. Bronchoscopy exhibited DAH on sequential bronchoalveolar lavages (BALs). Cytology showed macrophages, neutrophils, and blood. Autoimmune work-ups were all negative. Echocardiography was normal with EF 65%. Treatment included intravenous methylprednisolone and antibiotics for aspiration pneumonia. Following chest X-ray showed dramatic improvement with nearly resolved bilateral infiltrates. Fentanyl metabolite panel (Using Liquid Chromatography/Tandem Mass Spectrometry Method) confirmed fentanyl level 2.3 ng/mL and nor-fentanyl 1.45 ng/mL. He was extubated and discharged on day 4. DISCUSSION: Fentanyl has been increasingly mixed into other substances, which raises an alarming danger to our public since it can lead to many lethal overdoses. A routine toxicology screen is unable to detect fentanyl. It is postulated that opiate-induced DAH occurs due to catecholamine-surge from rapid reversal from naloxone-induced opioid withdrawal effect or negative-pressure barotrauma. Treatment might include systemic steroids, though not proven yet in literature. CONCLUSIONS: Diffuse alveolar hemorrhage has rarely been caused by opioid overdose. To the best of our knowledge, there would be less than 4 cases ever reported before. Clinicians should be aware of this dangerous complication in the battle of the ongoing opiate epidemic. Reference #1: Mars, Sarah G et al. “Sold as Heroin: Perceptions and Use of an Evolving Drug in Baltimore, MD” Journal of psychoactive drugs vol. 50,2 (2017): 167-176. Reference #2: Mills CA, Flacke JW, Flacke WE, Bloor BC, Liu MD. Narcotic reversal in hypercapnic dogs: comparison of naloxone and nalbuphine. Can J Anaesth. 1990;37(2):238–244 Reference #3: Cole JB, Dunbar JF, McIntire SA, Regelmann WE, Slusher TM. Butyrfentanyl overdose resulting in diffuse alveolar hemorrhage. DISCLOSURES: No relevant relationships by Muneer Al Zoby, source=Web Response No relevant relationships by TRUNG LE, source=Web Response No relevant relationships by Zhao Liu, source=Web Response