Hémorragies intra-alvéolaires de l’adulte d’origine immunitaire

[Diffuse alveolar hemorrhage in cannabis smokers. A systematic literature review]

Cannabis is the most widely used illicit psychoactive substance in France. It can be responsible for numerous pulmonary complications, including diffuse alveolar hemorrhage (DAH). The objective of this systematic review of the literature was to present data concerning the relationship between cannabis smoking and DAH, which has rarely been reported in the literature. The review was based on a Medline search covering the 1980-2022 period and utilizing data drawn from 10 articles. DAH diagnosis is based on an association of hemoptysis, anemia and diffuse alveolar opacities on chest radiography with siderophages in the Bronchoalveolar Lavage Fluid (BAL). The 11 patients identified in this review were daily or regular cannabis smokers; in 4 cases they presented recent or recurrent hemoptysis with anemia; imaging revealed diffuse alveolar opacities in 10 of them, while BAL endoscopy highlighted a diffuse hemorrhage in the bronchial tree, and siderophages were observed in 6 cases. While evolution was favorable when cannabis consumption was discontinued, resumption occasioned DAH recurrence, and one patient died. Advice to quit should systematically be accompanied by addictological follow-up.

[The acute pulmonary renal syndrome: An unusual presentation of granulomatosis with polyangiitis]

INTRODUCTION

We report a case of acute pulmonary renal syndrome mimicking septic shock, which led to the diagnosis of granulomatosis with polyangiitis.

CASE REPORT

A 70-year-old man was hospitalized because of acute kidney injury and acute respiratory distress syndrome with diffuse alveolar hemorrhage associated with a serum procalcitonin level of 18 μg/L. Initially, septic shock was suspected and antibiotic therapy was started. The absence of microbiological isolates and the patient's rapid clinical deterioration prompted laboratory testing for autoimmune disease, which confirmed the diagnosis of granulomatosis with polyangiitis. Immunosuppressive therapy was promptly initiated with corticosteroids, cyclophosphamide and several plasma exchanges, which resulted in a rapid clinical improvement and ICU discharge.

CONCLUSIONS

Granulomatosis with polyangiitis is a systemic necrotizing vasculitis with antineutrophil cytoplasmic antibodies, which can present with acute pulmonary renal syndrome, combining acute respiratory distress syndrome and acute kidney injury. This misleading presentation must prompt an autoimmune disease testing in order to yield an early diagnosis of a vasculitis, allowing for timely initiation of immunosuppressive treatment. Serum procalcitonin levels can be markedly elevated and this must not override the possibility of a vasculitis where the patient shows a compatible symptomatology.