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Marijuana smoke can cause thermal injury, and since legalization and increased use of marijuana in our society, differentiating, diagnosing, and managing this condition have become mandatory. A case of a 28-year-old male with Quincke’s disease secondary to marijuana inhalation is presented.
Quincke’s disease, or isolated uvular angioedema, was first described in 1882 and has since been a relatively rare form of angioedema of the upper airway. Although it is typically caused by an immediate Type I hypersensitivity reaction, uvular edema can also be caused by trauma, thermal injury, and infections. Smoking marijuana is the most common and efficient way of using Cannabis and has grown in popularity over the years. With the recent legalization of marijuana in several states of America, the healthcare practitioner must become aware of the potential complications of this drug. Typical complications include xerostomia, leukoedema, and an increased incidence of Candida albicans. Quincke’s diseases, however, is a relatively rare, life-threatening complication seen with marijuana use and is characterized by localized swelling of the deeper layers of the skin and fatty tissues beneath the skin. The pathophysiology, differential diagnosis, and treatment of this disease will be discussed.
A 28-year-old male presented to emergency department with difficulty swallowing with associated shortness of breath for 1 day. He reported no recent history of trauma and denied swelling of the face, pruritus, fever, or any sick contact. His past medical history was significant for atypical hemolytic uremic syndrome, malignant hypertension, and end-stage renal disease on hemodialysis. The patient also denied any history of illicit drug abuse.
Physical examination revealed temperature of 36.1°C, heart rate of 65 beats/min, respiratory rate of 12 with oxygen saturation of 99% on room air. Upon examination of the oral cavity, it was noted that the uvula was edematous but without any lesion [ Figure 1 ]. The visualized pharynx and dentition were within normal limits, and the patient had no pain with palpation of his trachea. The remainder of the physical examination was normal.
Photograph demonstrating uvular edema
Soft-tissue radiograph of the neck was obtained and showed swollen uvula [ Figure 2 ]. A complete blood count revealed white blood cell count of 4.7 (4.5–11), hemoglobin 12.4 (14–18), hematocrit 38 (40–54), and platelets 210 (140–440). A basic metabolic profile revealed sodium of 132 (136–145), potassium 5.2 (3.5–5.1), chloride 100 (98–107), CO2 24 (22–29), blood urea nitrogen 32 (9–21), creatinine 4.9 (0.7–1.3), glomerular filtration rate 14, and glucose 82 (70–105). Both flu A and B were also negative.
Lateral radiograph of the neck demonstrating a swollen uvula
The patient was treated with intravenous (IV) steroids, diphenhydramine and admitted to the intensive care unit for further airway monitoring. While on the floor, the patient subsequently admitted to using marijuana just prior to the onset of symptoms and was diagnosed with cannabinoid-induced Quincke’s disease.
Quincke’s disease, or isolated uvular angioedema, was first described in 1882 and has since been a relatively rare form of angioedema of the upper airway. Due to the rarity of this illness, the clinician should develop a detailed differential diagnosis for a patient with acute onset of difficulty swallowing with associated with shortness of breath. Within this differential epiglottitis, retropharyngeal abscess and peritonsillar abscess should all be considered.
Epiglottitis is a rare, life-threatening disease caused by inflammation of the epiglottis that can occur at any age. Common clinical manifestations of epiglottitis include acute high fever, severe sore throat, and difficulty swallowing with the sitting up and leaning forward position and drooling. The most common organism is Haemophilus influenzae Type B (HIB). The “thumb sign” is the standard finding on lateral radiograph of the neck. Our patient presented with the absence of fever, sore throat, and drooling supported by no thumb sign on the neck radiograph excluding this diagnosis.
Retropharyngeal abscess is an infection in one of the deep spaces of the neck and can pose an immediate life-threatening emergency. It is a rare finding in adults and reported as a result of local trauma, such as foreign body ingestion or instrumental procedures. Aerobic, anaerobic, and Gram-negative organisms can cause abscesses in this space. Clinical symptoms are variable and nonspecific. Computed tomography (CT) is used for the diagnosis. Our patient did not report any trauma or recent procedure; hence, retropharyngeal abscess was excluded.
Peritonsillar abscess is the most common deep infection of the head and neck in adults and is typically caused by both aerobic and anaerobic bacterial infections. The clinical presentation includes fever, throat pain, and trismus. Ultrasonography and CT scanning are used for diagnosis. Our patient did not present with signs of infection and no trismus was found on examination; therefore, peritonsillar abscess was excluded.
Once the diagnosis of Quincke’s disease is suspected, management is based on the etiology with clues collected during the history and physical examination. Although it is typically caused by an immediate Type I hypersensitivity reaction, uvular edema can also be caused by trauma, thermal injury, and infections.
Suggested laboratory workup is blood and surface cultures of pharynx and uvula, latex agglutination studies for HIB and Streptococcus pneumoniae antigens in blood and urine, lateral neck films, and toxicology on urine and blood must be done Fever is highly suggestive of infectious etiology. Group A beta-hemolytic Streptococcus, HIB, and S. pneumoniae are the most common causative organisms. Immediate IV antibiotic is to be started for an infectious isolated uvular angioedema after laboratory workup collected. For patient with posttraumatic or inhalant uvulitis, steroids must be administered. Epinephrine and diphenhydramine should be added in allergic reaction induced isolated uvular angioedema. The premise for uvular edema following marijuana smoking is that marijuana burns at a higher temperature than tobacco and can be more irritating to the mucous membranes.
Treatment is aimed at maintaining a patent airway in conjunction with antihistamines, glucocorticoids, and epinephrine if needed. Rapid access to proper equipment and personnel for intubation or tracheostomy is necessary. Table 1 summarizes the suggested treatments for the most common etiologies-induced Quincke’s disease.
Most common etiologies and suggested treatment for Quincke’s disease
Marijuana is commonly used in our society and although most of its side effects are known, Quincke’s disease, or isolated uvular angioedema, is a relatively uncommon presentation which can compromise airway and potentially be life-threatening. The premise for uvular edema following marijuana smoking is that marijuana burns at a higher temperature than tobacco and can be more irritating to the mucous membranes. Treatment is aimed at maintaining a patent airway in conjunction with antihistamines, glucocorticoids, and epinephrine if needed.
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Articles from Journal of Family Medicine and Primary Care are provided here courtesy of Wolters Kluwer — Medknow Publications
THC Accelerates Head and Neck Cancer Growth
Researchers at the University of California San Diego School of Medicine have identified the molecular mechanism activated by the presence of tetrahydrocannabinol (THC) in the bloodstream that accelerates cancer growth in patients with HPV-positive head and neck squamous cell carcinoma.
“HPV-related head and neck cancer is one of the fastest growing cancers in the United States, while at the same time, exposure to marijuana is accelerating. This is a huge public health problem,” said Joseph A. Califano III, MD, senior author and professor and vice chief of the Division of Otolaryngology in the school’s Department of Surgery.
Head and neck squamous cell carcinoma is the sixth most common cancer worldwide, the school reports. These cancers begin in the cells that line the mucous membranes inside the mouth, nose, and throat. About 30% of cases are related to HPV infection, and these cases in particular are on the rise.
Califano suggests that increased marijuana use may be a driving factor in this increase. Previous studies have linked daily marijuana exposure to an increased prevalence of HPV-related throat cancer. However, a mechanism linking cannabis exposure to increased growth of the cancer was unknown.
Now, the researchers have outlined how the presence of THC in the bloodstream activates the p38 MAPK pathway, which controls programmed cell death, or apoptosis. When activated, p38 MAPK prevents apoptosis from occurring, allowing cancer cells to grow uncontrollably.
The researchers used both animal and human cell lines to show that THC turns p38 MAPK on and were able to stop the growth of HPV-positive head and neck cancer by turning off the pathway.
Then, the researchers analyzed blood samples from patients with HPV-related throat cancer who had their genomes comprehensively mapped to define activated gene pathways. Similar to the cell lines, the blood samples showed p38 MAPK activation and loss of apoptosis in tumors from patients with THC in their blood.
Studies and public opinion suggestions that THC and other cannabis products have cancer-fighting properties need additional, more critical evaluation, the researchers said. Past studies showing anticancer effects from THC and other cannabinoids often used levels of THC higher than those found with recreational use, but doses used recreationally activate a cancer-causing pathway, Califano said.
“We now have convincing scientific evidence that daily marijuana use can drive tumor growth in HPV-related head and neck cancer,” said Califano. “Marijuana and other cannabis products are often considered benign, but it is important to note that all drugs that have benefits can also have drawbacks. This is a cautionary tale.”
HPV infections are responsible for about 35,000 new cancer diagnoses each year in the United States, according to the Centers for Disease Control and Prevention (CDC). Infection is so common that nearly all men and women will get at least one type of HPV at some point in their lives. Most clear up on their own, without the person ever knowing they’ve had it.
Several available vaccines can prevent most HPV-related cancers. The vaccines work best when they are given before a person is exposed to the virus. The CDC recommends vaccinating boys and girls age 11 to 12 years old, but it can be administered as early as age 9.
According to the National Institute on Drug Abuse, 15% of youth age 12 to 17 and 47% of adults age 26 and older have used or tried marijuana. Together, a low HPV vaccination rate and increased marijuana use among youth has the makings of a storm, said Califano, who also is physician in chief and director of the Head and Neck Cancer Center at Moores Cancer Center at UC San Diego Health.
Moores Cancer Center is one of only 51 National Cancer Institute-designated Comprehensive Cancer Centers in the country and the only such center in San Diego County.
Treatment options for patients with early-stage or late-stage head and neck cancers include minimally invasive surgery, reconstruction and rehabilitation, proton therapy and other radiation therapy, innovative clinical trials, and targeted therapy, including immunotherapy.
The Head and Neck Cancer Center provides comprehensive care that includes counseling, education and support groups, nutrition, dental rehabilitation, speech and language therapy, and social workers to help patients through every step of the process beginning with diagnosis to support lifelong wellness.
The researchers are now looking at whether cannabidiol (CBD) has a similar effect to THC. CBD is another major chemical compound found in marijuana but does not produce the same high and is now commonly used in various over the counter products such as lotions, ointments, and edibles. The researchers also are investigating whether p38 MAPK can be targeted with drugs to stop HPV-related head and neck cancer from growing.