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From the Pulmonar y Di vision, Cardiopul monary Labo-ra to ry , M iam i H eart Institu te , M iam i B each , F la .R epr in t reques ts : D r. L lam a s, M iam i H eart In s titu te , 47 01N o rth M er idian, M iam i B each 3 3140

C HEST , 73 : 6 , JUN E, 1978 ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS 811

A lle rg ic B ronchopu lm ona ryA spe rg illo s is A ssoc ia ted w ithSm ok ing M o ldy M arihuana *R ober to L lam as, M .D ., F .C .C .P .; D . R ob er t H ar t, M .B ., B .S .;and N e il S . S ch ne ider, M .D ., F .C .C .P .A 2 7-year-o ld m an who hab itua lly sm oked m anhuanadeve loped clin ica l, labo rato ry , and rad io log ic find ingscon sisten t w ith allergic bronchopu lm onary asperg illosis .C u ltu re of th e m arihuana ob ta in ed from the pa tien tssource yie ld ed heavy m ix ed grow th s of A sperg illu s .T rea tm en t w ith co rticoste ro ids wa s ef fec t ive .

T he syn drom e of as thm a w ith recurren t fever, eos ino-ph ilia o f the periphera l b lo od , pu lm on ary in filtra tes,

and b ronch ia l m ucous p lug s con ta in ing Asperg il lusfumiga tu s w as firs t desc ribed in 1952 by H inson andassociates1 and w as clas sif ied a s al lerg ic b ron chopu l-mona r y asp erg illo sis , hence d is t ingu ish ing it f romsapro phy tic and inv asive types o f a sp er gi ll os is . Inthe B ritish Is les , th is is c ons ide red by som e to be th em ost frequen t cause of p u lm onary eos inoph iia w ithas thm a.2 T he re la tive ly sm all se ries o f case rep orts fromN orth Am erica m ay re flect a failu re o f recog n itio n ,rathe r than a tru e d iffe rence in preva lence . W e reporta case o f this syn drom e as soc iated w ith th e use o f m old ymarihuana .

CA SE REPO RTA 27-yea r-o ld w hite m an w as adm it ted tohe hospital,

com pla in ing o f fev er w ith n igh t sw ea ts ,wheez ing , a nd aproductive cough fo r ten d ay s. H e h ad dem ons tra ted a topysin ce ad o lescence and h ad suffe red in frequen t asthm atica ttacks w ith bronch itis s ince the age o f 20 years . H e hadsm oked m arihuana regu la rly fo r abo u t six y ears. D uring them on th before adm is sio n , a sev ere atta ck of bro nchospasmhad b een com plica ted by m odera te eos inoph ilia o f the periph-e ra l b lood and sparse b ronchopu lm onary in filtra tes, b u tthe ep iso de reso lved q u ick ly w ithdm in istra tio n of a sing lein jection o f 40 m g of m eth y ip redn iso lone sod ium succina te(So lu -Medro l) .

T h e fin d ings from phys ica l exam in a tion w ere unrem ark-ab le , excep t fo r a rec ta l tem pera tu re o f 38 .7#{176}C (101 .7 #{176}F )and occasiona l rhonch i in bo th lu ngs . T he leuk ocy te coun tw as 11 ,400 /cu mm , w ith 2 1 percen t eo sinop h ils and theery th ro cy te sed im en tation rate w as 18 mm /h r.

O n adm iss ion a chest x -ray film (F ig 1) show ed pa tchybronchopu lm onary in filtra tes loca ted m ain ly in the up perlobes . F ib erop tic b ronchoscop ic exam ina tio n revea led la rge ,f irm , b row n ish -g reen m ucous p lugs ex tru d ing from the acu te lyin flam ed open ings of m any m ajo r b ronch i. S am ples o f sp u tumand bronch ia l w ash ing s con ta ined s im ila r p lug s, w hich w erefo und to be com prised of fun ga l m y ce lia , C harco t-L eyd encrys ta ls , and eo sinop h ils. A bundan t co lon ies o ffumigatusw ere cu ltu red from all o f these spec im ens. Serum ob tainedd uring th e acu te p hase of the pa tien ts illness p ro duced

th ree p rec ip i tin ban ds forA fum ig a tu s an d on e b an d forA n iger by imm unod iffu sion an d the leve l o f IgE in these rum w as e leva ted a t 1 ,15 0 g /m l (norm al adu lt leve ls,be low 300 g /m 1). In trad erm al testing w ith 50 pro te in n itro -g en un its o f A fumigatus extr a c t (H ollister-S tie r L abo ra-to r ies) pro du ced an im m edia te w heal-and -fla re re act ion 4cm in d iam ete r an d a 24-hou r de lay ed reac tio n o f indu ra-t ion that w as 6 cm in d iam eter. M ycob ac te r ium tub ercu lo s isw as no t fou nd in sp ec im ens o f spu tum , and a cu taneous tes tw ith in term ed iate -streng th p urified pro te in d eriv ative o ftub ercu lin w as negative . N o p ara site s w e re foun d in th ep atien ts s too ls.

Sam ples of m ar thu ana obtain ed from the p atien ts sto ckja r y ield ed heav y g row th s of fum iga tu s , A n iger, an d Af lavus . D ram a tic sym ptom a tic and rad iog rap h ic im p rov em entoccurred soo n a fter resta rtin g th erapy w ith stero ids.

DiscussioN

A sperg illu s is comm only presen t in decay ing vege ta -tio n and is geograph ica lly w id espread in a ir and so il,w ith a season al inc rease durin g the w in te r m onths .A ltho ugh it is an in frequ en t cause of d isease in m an ,A fum iga tu s is the u sua l o ffen de r o f th is genus . A topy ,w ith o r w ith ou t a sthm a , o ften an teda tes alle rg ic b ro ncho-pulm on ary a spe rg i llos is and m ay o ffe r a bro nch ial en -v ironm ent favo rab le to grow th o f A sp er gill us . I t is like lytha t m arihuana becom es m oldy because of cond itionsof s to rage during illeg al transsh ipm en t o r during theprocess o f ag ing , w hereby m arihuana is b uried in theso il fo r a tim e.

C hus id e t a l rep orted a case of ch ron ic pu lm on arygranu lom atous d isease du e to A fumiga tu s . In th is in -stance the organ ism w as also fo und in m arihu ana be ingsmok ed by the ir pa tien t, a s w ell as in tw o ou t o f tensam p les o f the drug w hich they o b ta ined from the U SDepar tm ent of Ju stic es Drug En forcem ent A gency inW ash ing ton , D C .

Folk lo re h as p rom oted m arihuana as a p o ten t rem edy

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87 2 O LD EN B UR G, N EW HO US E C HE S T, 7 3 : 6 , J U N E, 1 9 7 8

fo r as thm a,5 bu t usua lly it w as taken as a brew w henused fo r tha t purpose. Inve stigat ion s have s h ownb ron chodila tio n to oc cur in no rm al v o lu n te ers6 and inexperim en ta lly ind uced asthm a fo llow ing inha lation ofsm ok e from m arih uana , thus es tab lish ing a sc ien tificfou nda tio n fo r th ese ancien t bel iefs ; how ev er, h eavypro longed sm oking of the dru g appears to cause m ildbu t sign if ican t o bstru ction o f the sm all a irw ay s8 and , insom e instances , ch ron ic b ro nch itis . T he use of m arihuan am ay b e p articu larly haz ard ous for the ato p ic as thm aticsub jec t, a s th is case report sugg ests.

Ri E N C E s1H in son KFW , M oon A J , P lum m e r N S : B ro nch opulm on ary

a spe rg i llos is: A rev iew and repo rt o f eig h t n ew case s.Tho rax 7 :31 7-333 , 1952

2 H enderso n AH : A llerg ic asp erg illosis : R eview o f 32 cases.Thorax 23 :50 1-5 12 , 19 68

3 McCa r t h y D S, Pepy s J : A lle rg ic b ronchopu lm onary asp er -gillos is. C lin A llerg y 1:2 61-286 , 1 97 1

4 Chusid M J, G elfand JA , N utte r C , e t al: Pu lm onary asper-g illo sis , in halatio n o f con tam in ated m ari juan a sm ok e,chron ic g ranu lom atou s d isease . A nn In te rn M ed 82 :682 -683 , 19 75

5 M k u r i y a TH: Hi s t o r i c a l a s p e c t s o fannabis sativa inw este rn m edic ine . N ew Phys ic ian 18 :9 02-90 8 , 1969

6 V acho l L , F itzgera ld MX , S olliday N H , e t al: S in g le d oseeffec t o f m ariju ana sm ok e: B ronch ia l dy nam ics and res-piratory c e n t r e sensitivity in n orm al sub jec ts. N E ng IJM ed 289 :3 36-34 1 , 197 3

7 T ash k in D P , Shap iro B J, LeeE, et a l: E ffect o f sm okedm ar ijuana in experim en tally induced as thm a. A m RevR esp ir D is 112 :377 -386 , 1975

8 T ash k in D P , Shap iro B J, L ee Y E , e t a l: Sub acu te ef fec tso f heav y m arijuana sm oking on pu lm on ary fun c tion inh ea lthy m en . N EngI J M ed 294 :12 5-129 , 197 6

Cereb ra l D ye Em bo lus *A C o m p l i c a f o n o f S e l e c t i v e B r o n c h o g r a p h yfo llo w in g T ra n s b ro n c h ia l B io p s yF rederick A . O ldenburg, J r. , M .D .; #{1 76 }# {1 76 }ndM ichael T. N ew house, M.D ., M .Sc.f

Cerebra l em bo liza tion of an aqueou s so lu tion of p ropyli-odone (D ionos i l ) occurred during selec tiv e broncho-graph ic stud ies fo llow ing aibe rop t ic bronchoscop ic p ro -cedure w ith tran sbronch ia l b iop sy in a patien t undergo-ing inv estiga tion of a pu lm onary lesion . T he em boliza tionresu lted in a grand m idse izu re and tran sien t n euro log icdefic its . This po ten t ia l complication ha s no t been prev i-ou sly reported . W e suggest t h a t se lective b ro nch ograp hicstud ies be avoid ed when the tran sbronch ia l b iop sy is asso -c ia ted with endobronch ia l b leed ing .#{176}From the R egiona l R e sp irato ry U nit , S t. Jo sep hs H osp ita l,and the D epartm en t o f M edic ine , M cM aste r U nivers ityM edica l S ch oo l, H am ilton , O n ta rio .

Lung A sso cia tion Fe llow .tH ead , R eg ion a l C hest and A lle rgy U nit, and A ssoc ia teC lin ica l P ro fesso r.

R eprint requ ests: D r. N ewhouse, St . Joseph s H ospital,H am ilto n , On tario , Can ada

T he va lue of a fibe rop tic bro nch oscop ic p ro ced urew ith transbronch ia l b iop sy in th e d iagn osis of v ari-

ou s pu lm onary d iseases has been recen tly rev iew ed .1 B ron ch ograph y is also a w ell re cog niz ed te chn iqu e fo rid en tify ing endobro nch ial le sio ns and abnorm al b ro nch iala na tom ic f ind ing s. B ron cho sco py w ith sim ultaneousselec tiv e b ron chograph y is a less frequ en tly used b utaccep ted techn ique of exam in in g m ore periph eral le s io nsan d unu su al b ron ch ial an atom ic find ings . T h is rep ortde scr ibe s a prev io usly u nrepor ted com plicat ion of tra ns-bro nch ia l b iopsy fo llow ed by se lec tiv e b ronchog raph icstud ies .

CASE R EPOR TAn asym p tom atic 72 -ye ar-o ld m an w as refe rred to the res -

p ira to ry se rv ice fo r evaluat ion o f a rig h t low er p oste rio r seg -m en tal m ass se en on a rou tin e che st x -ra y fi lm . T o e stab lisha d iag nos is , th e patien t underwen t fib ero p tic bronchosco picexam in ation w ith fluoroscopic co ntro l. N o endobronch ia l le-sio ns w e re v isua liz ed . B rush ing s, w a sh ings , and three tra ns-b ron ch ial spec im ens fo r b io psy w e re o bta ined under d irectflu oro sco pic co ntro l. Fo llow in g th e th ird b iopsy , the re w a s am odera te am ount o f hem orrh age , w hich c lea red fo llow ingthe end obron ch ial instilla tion of 20 un itsf v aso pre ssin( P i t r e ss i n ) .

A selective bro nch og ram was then o bta ined bec ause thep ossib i lity of an in tra lob ar sequ estra tio n had b een rais ed . Asm all po lyure thane cathe te r w as in trod uced th roug h theb ron ch oscope an d w as d ire cte d in to the p osterio r ba sal s eg-m ent of the righ t low e r lo be. A pp rox im a tely 4 .0 m l of anaq ueous so lu tion of p ropy liodo ne (D ionos il) w as in jec ted .T he co ntra st m ate ria l d em ons tra ted an irre gu lar bronchus ,w hich appeared to be o rien ted in an unu sua l d irec tion . T hedye tended to p oo l; how ever, it w as noted th at som e ofhecon tra st m a teria l w as stre am ing m edia lly in a pulsati le fash iontow a rds the lef t atrium an d th en via the left ven tr ic le in tothe system ic c ircu lat ion . Th en jection w as imm ed iate ly te rm i-na ted , bu t the p a tien t had a g en eralized ton ic c lon ic se izu reand b ecam e tem porarily unrespon sive . H is v ita l s igns re -m ained u nchanged . T he pa tien t w as g iven th erap y w ithstero ids to redu ce c erebra l ed em a an d w as transfe rred to thei n t en s i v e c a r e u n i t .

W ith in fiv e m inu tes the p atie n t w as alert. N eu ro log ic ex -am ination rev ealed n o fo cal neu ro log ic d efic its , ex cep t fo r h ism ental s ta tus . T h e pa tien t w as orien ted on ly to person an dw as ab le to answ er on ly sim p le qu est ion s. X -ray f ilm s of thesku ll re vea led no v isib le c erebra l a ccum u lat ion of con tras t m a-teria l. In traveno us adm in istra tio n of dexam ethasone (D eca -dron , 6 m g ev ery six h ours) w as con tin ued . O ve r th e nex t 24hours , th ere w ere sh if ts in the patien ts m enta l s ta tu s f r o mtotal ob tundat ion to alm o st n orm al a le rtness , w ith a secondg ran d m a ! se izu re o ccurrin g fo ur hours a fte r the p rocedure .

T hree days afte r th e bronchoscop ic p ro cedu re , the pa tien tstill com pla ined o f h eadache and m inor d ip lop ia , bu t h e w asale rt and o rien ted , and fu l l tes ting of m en ta l s tatus revea ledno ab norm alitie s . B y the fo llow ing m orn in g , th ese sym ptom shad c lea red , and the p atien ts v isua l fie ld s w ere n orm al, a l-tho ugh h e no ted a bu rn ing sensation of h is lip s and tongue ,w h ich lasted severa l w eeks .

B ron ch oscop ic exam ina tion fa iled to dem on stra te abnorm al

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DOI 10.1378/chest.73.6.8711978;73; 871-872Chest

R Llamas, D R Hart and N S Schneidermarihuana.

Allergic bronchopulmonary aspergillosis associated with smoking moldy

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