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Meth tie to rare disease a public health concern.

MONTREAL -- The association of methamphetamine use with an unusual manifestation of a rare immunologic disease challenges the accepted management of acute respiratory distress and signals a new and immediate public health concern, Dr. Carl Kaplan said in a poster presentation at the annual meeting of the American College of Chest Physicians.

He reported two cases of an anti-glomerular basement membrane (anti-GBM) antibody-negative, Goodpasture's-like alveolar hemorrhage syndrome in 22-year-old women who were involved in the use and manufacture of methamphetamine.

Both 22-year-olds were admitted with frank hemoptysis and acute respiratory failure with no other comorbidities, said Dr. Kaplan, professor of internal medicine at St. Louis University, in an interview.

"These individuals came in with immediately, overtly life-threatening presentations. They were so profoundly ill that death was expected," he said.

Such cases normally would have been treated as severe viral pneumonia, given the absence of bacterial infection, Dr. Kaplan noted.

However--thanks to some evidence in the literature suggesting the value of open-lung biopsy in acute respiratory distress syndrome, as well as the patients' severe condition--he performed broncho alveolar lavage. The procedure demonstrated alveolar hemorrhage in both patients, with increasingly bloody lavage fluid.

Open-lung biopsy and renal biopsies were then performed. The lung biopsy confirmed the hemorrhage, with one case associated with capillaritis with areas of organization. Immunofluorescence revealed prominent linear staining of both the alveolar and glomerular basement membranes for IgG and complement C3, reported Dr. Kaplan, who is also the director of critical care services and director of respiratory care and bronchoscopy services at Saint Louis Hospital.

After the administration of parenteral corticosteroids and plasmapheresis, both patients fully recovered within 2 weeks.

"This disease [anti-GBM negative Goodpasture's-like alveolar hemorrhage syndrome] is usually classified as a pulmonary renal syndrome, with overt manifestations of both kidney disease and acute lung disease," Dr. Kaplan said. "But these patients had absolutely no signs of any kidney disease, and so normally one would eliminate even considering this diagnosis," he said. "And normally one would never do a bronchoscopy or bronchoalveolar lavage in such patients, let alone an open-lung biopsy and a kidney biopsy. It would be considered excessive and putting the patients at risk with unclear benefits."

Dr. Kaplan's decision to investigate more thoroughly was lifesaving. "The risk-benefit consideration was in favor of doing everything for them," he said. "It was lucky that we did, because it changed our management profoundly to invasive intervention."

"We have to totally rethink our paradigm," Dr. Kaplan said. "People don't usually volunteer the information that they manufacture illicit substances, and so if a young patient comes in with acute respiratory distress syndrome, this diagnosis has to be a strong consideration unless we are 100% confident that this is a bacterial pneumonia," he said.

Given the increasing availability of methamphetamine and how commonly it is manufactured in people's homes, emergency physicians should keep this diagnosis fairly high in their list of differentials, he said.

"We have a large population at risk, and these patients didn't have any warning symptoms. The presentation was immediately life-threatening. So the public health risk is death--not long term, but immediate death," Dr. Kaplan said.

He has contacted the Centers for Disease Control and Prevention and Missouri's State Board of Health to alert other emergency physicians to this new association.

BY BOB BABINSKI

Contributing Writer
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Title Annotation:adverse effects
Author:Babinski, Bob
Publication:Clinical Psychiatry News
Geographic Code:1CANA
Date:Apr 1, 2006
Words:548
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