(1236) Causing a Bloody Mess While Hot Rolling Meth

Introduction: Diffuse alveolar hemorrhage (DAH) is a life-threatening disorder characterized by blood in the alveolar spaces causing dyspnea, hemoptysis and anemia. It is associated with autoimmune and coagulation disorders, infection and with illicit substance use. Toxic injury from inhalation, injection, or ingestion can manifest as pulmonary edema, acute respiratory distress syndrome (ARDS), DAH or pneumonia. DAH has been reported with cocaine and fentanyl use, but rarely with methamphetamine.

Description: A 37-year-old male with polysubstance use disorder arrived by EMS after being found unresponsive. He responded to intranasal naloxone, then developed respiratory distress with blood tinged sputum. Vitals were BP 116/72, HR 153, RR 37, Temp 97.7 F. Labs included pH 7.1, PaO2 61 mmHg, PaCO2 76 mmHg, P/F ratio 61 and lactate 6. Urine drug screening (UDS) was positive for amphetamines. He was intubated for airway protection and admitted to the ICU for acute respiratory failure due to severe ARDS and toxic-metabolic encephalopathy due to methamphetamine use. Chest CT revealed bilateral consolidations concerning for aspiration pneumonitis. Bronchoscopy with bronchoalveolar lavage (BAL) revealed serial aliquots with increasing blood-tinged fluid, confirming DAH. Bronchial washings grew Beta-hemolytic group C Streptococcus. Methylprednisolone and piperacillin-tazobactam were initiated. P/F ratio improved and he was extubated on hospital day 3.

Discussion: Methamphetamine use in U.S. adults increased by 66% between 2015 and 2019 with overdose deaths increasing by 170%. In individuals with respiratory symptoms and unclear etiology, drug-induced lung injury (DILI) should be considered. Pulmonary edema is frequent in DILI and diagnostic tools like chest imaging, bronchoscopy with BAL and UDS are necessary for diagnosis. DAH often demonstrates hemosiderin-laden alveolar macrophages 48-72 hours after bleeding. Management is supportive, though glucocorticoids may play a role if autoimmunity is suspected. Thus far, there has been no evidence of using steroids in methamphetamine-induced lung injury.
This case emphasizes the need to consider methamphetamine as a potential cause of drug-induced DAH. Further research is required to understand the mechanism behind methamphetamine-induced DAH to improve patient care.