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“Tree-in-Bloom”: Severe Acute Lung Injury Induced by Vaping Cannabis Oil “Marijuana” is defined by the United States Food and Drug Administration as the original parts (dried flowers and leaves) Cannabis is the most widely smoked illicit substance in the world. It can be smoked alone in its plant form, marijuana, but it can also be mixed with tobacco. The specific effects of smoking cannabis are difficult to assess accurately and to distinguish from the effects of tobacco; however its use m … May be worth further exploring cannabinoids as potential cancer treatment, say researchers It may be worth exploring further the use of cannabidiol (‘CBD’) oil as a potential lung cancer treatment, suggest doctors in BMJ Case Reports after dealing with a daily user whose lung tumour shrank without the aid of conventional treatment. The body’s own endocannabinoids are […]

“Tree-in-Bloom”: Severe Acute Lung Injury Induced by Vaping Cannabis Oil

“Marijuana” is defined by the United States Food and Drug Administration as the original parts (dried flowers and leaves) or forms of derivatives of the plant Cannabis sativa L. (1). In 2009, because of the high potential for abuse from its psychoactive ingredients (mainly δ-9-tetrahydrocannabinol [THC]), marijuana was categorized as a hallucinogen and was assigned to controlled substance Schedule 1, which also includes opioids and derivatives (1). This remains effective to date despite marijuana legalization in many states and emerging petitions for rescheduling (2).

Marijuana may affect respiratory health differently depending on differences in formulation and in methods and intensity of use. We report a case of acute respiratory failure that developed shortly after an individual inhaled vaporized cannabis oil. To the best of our knowledge, this adverse effect has not been reported previously.

A relatively healthy 54-year-old man was admitted to the hospital through the emergency department (ED) for acute onset of dyspnea and hemoptysis. He had never smoked cigarettes but had been vaping cannabis oil approximately once weekly for several years.

One day before presentation and 6 hours after vaping cannabis oil, the man developed dyspnea. His wife noticed that his breathing was rapid and shallow. He remained dyspneic the next day and started to expectorate blood-tinged sputum, which progressed to small quantities of “pure blood.” This prompted a visit to a physician who advised him to go to an ED after he noted resting oxygen saturation (SpO2) of 82%.

In the ED, the patient’s SpO2 was 91% at rest while breathing supplemental oxygen at 6 liters per minute via nasal cannula. Physical examination was unremarkable except for tachypnea. A computed tomographic angiogram of the chest did not reveal pulmonary embolism, but instead showed extensive airspace opacification in a centrilobular nodular pattern roughly resembling a “tree in bloom” ( Figure 1 ).

Figure 1. Chest computed tomographic scan showed extensive focal airspace opacities and the centrilobular nodular pattern giving an overall appearance not of “tree in bud” but of “tree in bloom.” (Left panel) Transverse plane. (Right panel) Coronal plane.

Antibiotic therapy was initiated after blood and sputum samples were sent for culture. Urine toxicity screening was positive for cannabinoids only. The patient was admitted to the intensive care unit on 50% oxygen via nasal cannula at a high flow rate to maintain SpO2 ≥92%.

Flexible bronchoscopy yielded bloody lavage fluid suspicious for diffuse alveolar hemorrhage, with 61% neutrophils, 8% lymphocytes, and 2% eosinophils. Flow cytometry of the fluid showed a CD4/CD8 ratio of 0.46. Histopathology of alveolar tissue obtained via transbronchial biopsy showed organizing pneumonia ( Figure 2 ). Urine antigens for legionella and histoplasmosis were negative. An upper respiratory viral panel was negative and HIV serology and rheumatologic tests were all negative. Microbiologic culture was negative for all samples.

Figure 2. Focal hemorrhage, organizing pneumonia, and type 2 pneumocyte reactive hyperplasia. (Left panel) Hematoxylin and eosin staining, original magnification × 110. (Right panel) Hematoxylin and eosin staining, original magnification × 400.

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The patient’s oxygen requirement declined rapidly after the first day. He was discharged to home on Day 5 with ambulatory SpO2 >95% while breathing ambient air. Because of the rapid improvement, he was not treated with a corticosteroid. A repeat computed tomographic scan of the chest obtained 2 weeks after discharge showed complete resolution of lung opacities ( Figure 3 ).

Figure 3. Repeated computed tomographic chest scan 2 weeks after the initial one, showing complete resolution of the airspace opacities.

We believe that vaping a product sold as cannabis oil was the cause of our patient’s respiratory failure, given the temporal relationship between inhalation and the onset of symptoms, his rapid improvement without further exposure, and the fact that no other plausible cause was identified. The findings of pulmonary alveolar hemorrhage, neutrophil-predominant lavage, a reverse CD4/CD8 ratio (3), and organizing pneumonia in lung tissue biopsy specimens further support acute inhalational lung injury as the cause of respiratory failure.

Detrimental respiratory effects have been associated with the inhalation of combustion products of marijuana, including smoking hand-rolled leaves (joints) or water pipes (bong). Acute use can cause pneumothorax (4) and bronchodilation, which was exploited to treat asthma in the 19th century (5). Habitual use increases the prevalence of respiratory symptoms such as chronic cough and dyspnea (6). Chronic bronchitis is likely caused by products of combustion, which include pyrolytics such as tar and irritants such as ammonia and nitrogen oxides (7). Whether inhalation of marijuana smoke can cause emphysema or lung cancer is controversial (6, 8, 9). Marijuana smoke inhalation, which may be associated with damage to the pulmonary epithelial barrier (10), has rarely been reported to cause severe lung injury (11–13).

Vaporizing systems were developed with the goal of reducing the adverse respiratory effects of inhaling tobacco and cannabis derivatives. Ideally, cannabis vaporizers should have high efficiency for delivering THC and should minimize the generation of deleterious byproducts. Currently available products are designed to achieve those goals by heating dried marijuana parts to a temperature above 180°C (to vaporize cannabinoids) and below 230°C (to avoid combustion) (14, 15). Cannabis oil vaping is a newer method of use; a prefilled cartridge of cannabinoid concentrated oil is loaded into a hand-held vaporizer, which has a battery-operated heating system. This method avoids vaporizing crude marijuana parts and is thought to be safer.

However, some oil products are extracted from marijuana using additives such as propylene glycol which, although classified as “generally recognized as safe” by the Food and Drug Administration when ingested orally, can potentially cause lung injury when inhaled at a high temperature (16). Heating can also transform propylene glycol into carbonyls such as formaldehyde, a carcinogen and respiratory irritant (17). Flavoring ingredients, including diacetyl, may also pose risks to respiratory health (18); although it is more recognized in e-cigarette use, it can be present in cannabis oil vaping.

Our patient reported using “pure cannabis oil” containing 32–40% of THC extracted with CO2 with no additives. Although we found only cannabinoids on toxicological screening of his urine, we cannot exclude the possibility that lung injury was caused by some contaminant. Other possible contributors to his severe adverse lung reaction include the method used to extract the oil, the combustion temperature, and barotrauma from a forceful Valsalva maneuver during or after vaping. Further studies are needed to confirm our observation and to identify risk factors.

Damaging Effects of Cannabis Use on the Lungs

Cannabis is the most widely smoked illicit substance in the world. It can be smoked alone in its plant form, marijuana, but it can also be mixed with tobacco. The specific effects of smoking cannabis are difficult to assess accurately and to distinguish from the effects of tobacco; however its use may produce severe consequences. Cannabis smoke affects the lungs similarly to tobacco smoke, causing symptoms such as increased cough, sputum, and hyperinflation. It can also cause serious lung diseases with increasing years of use. Cannabis can weaken the immune system, leading to pneumonia. Smoking cannabis has been further linked with symptoms of chronic bronchitis. Heavy use of cannabis on its own can cause airway obstruction. Based on immuno-histopathological and epidemiological evidence, smoking cannabis poses a potential risk for developing lung cancer. At present, however, the association between smoking cannabis and the development of lung cancer is not decisive.

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Keywords: Cannabinoids; Cannabis; Lung diseases; Marijuana; Respiratory health; Respiratory risk.

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Daily use of cannabidiol (‘CBD’) oil may be linked to lung cancer regression

It may be worth exploring further the use of cannabidiol (‘CBD’) oil as a potential lung cancer treatment, suggest doctors in BMJ Case Reports after dealing with a daily user whose lung tumour shrank without the aid of conventional treatment.

The body’s own endocannabinoids are involved in various processes, including nerve function, emotion, energy metabolism, pain and inflammation, sleep and immune function.

Chemically similar to these endocannabinoids, cannabinoids can interact with signalling pathways in cells, including cancer cells. They have been studied for use as a primary cancer treatment, but the results have been inconsistent.

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Lung cancer remains the second most common cancer in the UK. Despite treatment advances, survival rates remain low at around 15% five years after diagnosis. And average survival without treatment is around 7 months.

The report authors describe the case of a woman in her 80s, diagnosed with non-small cell lung cancer. She also had mild chronic obstructive pulmonary disease (COPD), osteoarthritis, and high blood pressure, for which she was taking various drugs.

She was a smoker, getting through around a pack plus of cigarettes every week (68 packs/year).

Her tumour was 41 mm in size at diagnosis, with no evidence of local or further spread, so was suitable for conventional treatment of surgery, chemotherapy, and radiotherapy. But the woman refused treatment, so was placed under ‘watch and wait’ monitoring, which included regular CT scans every 3-6 months.

These showed that the tumour was progressively shrinking, reducing in size from 41 mm in June 2018 to 10 mm by February 2021, equal to an overall 76% reduction in maximum diameter, averaging 2.4% a month, say the report authors.

When contacted in 2019 to discuss her progress, the woman revealed that she had been taking CBD oil as an alternative self-treatment for her lung cancer since August 2018, shortly after her original diagnosis.

She had done so on the advice of a relative, after witnessing her husband struggle with the side effects of radiotherapy. She said she consistently took 0.5 ml of the oil, usually three times a day, but sometimes twice.

The supplier had advised that the main active ingredients were Δ9-­tetrahydrocannabinol (THC) at 19.5%, cannabidiol at around 20%, and tetrahydrocannabinolic acid (THCA) at around 24%.

The supplier also advised that hot food or drinks should be avoided when taking the oil as she might otherwise feel stoned. The woman said she had reduced appetite since taking the oil but had no other obvious ‘side effects’. There were no other changes to her prescribed meds, diet, or lifestyle. And she continued to smoke throughout.

This is just one case report, with only one other similar case reported, caution the authors. And it’s not clear which of the CBD oil ingredients might have been helpful.

“We are unable to confirm the full ingredients of the CBD oil that the patient was taking or to provide information on which of the ingredient(s) may be contributing to the observed tumour regression,” they point out.

And they emphasise: “Although there appears to be a relationship between the intake of CBD oil and the observed tumour regression, we are unable to conclusively confirm that the tumour regression is due to the patient taking CBD oil.”

Cannabis has a long ‘medicinal’ history in modern medicine, having been first introduced in 1842 for its analgesic, sedative, anti-inflammatory, antispasmodic and anticonvulsant effects. And it is widely believed that cannabinoids can help people with chronic pain, anxiety and sleep disorders; cannabinoids are also used in palliative care, the authors add.

“More research is needed to identify the actual mechanism of action, administration pathways, safe dosages, its effects on different types of cancer and any potential adverse side effects when using cannabinoids,” they conclude.

Notes for editors
Please note: out of respect for patient confidentiality we don’t have the names or contact details of the cases reported in this journal.

Funding: None declared

Link to Academy of Medical Sciences labelling system
https://press.psprings.co.uk/ AMSlabels.pdf

Externally peer reviewed? Yes
Evidence type: Single case report
Subjects: People

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