Annals of the American Thoracic Society

To the Editor:

Marijuana use is common in the United States, yet its health effects, including its impact on the respiratory system, remain controversial (1). In the wake of recent state legislation that legalizes or decriminalizes marijuana, there has been increasing popularity of butane hash oil (BHO, known colloquially as Dabs). This form of cannabis is a concentrated resin created by passing butane through a tube filled with marijuana, obtaining reported tetrahydrocannabinol contents upward of 60% (well above the traditional smoked form at 3–6%) (24). We present here a case of acute hypoxic respiratory failure after the inhalation of BHO.

Case Report

A 19-year-old man with a history of daily marijuana use presented to the emergency department with worsening dyspnea, cough, pleuritic chest pain, and trace hemoptysis.

Six days prior, he had deeply inhaled BHO and immediately developed burning and tightness in his chest. On presentation, he endorsed previous use of BHO, rare cigarette use, and moderate alcohol consumption but denied other drug use. Bibasilar rales were noted on auscultation of the chest, and a chest radiograph showed diffuse bilateral infiltrates. The patient was started on empiric antibiotic therapy for presumed community-acquired pneumonia.

The patient’s symptoms progressed into the next day with tachypnea and worsening hypoxia. Computed tomographic imaging of the chest demonstrated worsened bilateral infiltrates (Figure 1). He was intubated for acute hypoxemic respiratory failure.

Bronchoscopy with bronchoalveolar lavage (BAL) was performed. Analysis of tracheal aspirates yielded no evidence of bacterial, fungal, or viral infection. A cell count performed on BAL fluid revealed a nonspecific alveolitis (lymphocytes 23% and eosinophils 8%). Blood cultures were negative, and connective tissue disease serologies were unremarkable. The patient was started on a high dose of a corticosteroid for acute pneumonitis. Antibiotics were discontinued.

After 2 days, the patient was extubated. His hypoxemia and functional status improved uneventfully. He was discharged home approximately 1 week later with recommendations for supplemental oxygen, a 3-month tapering course of steroids, and strict guidance to abstain from further BHO use. At the time of a 3-month follow-up visit, the patient was nearly back to baseline functional status and no longer required supplemental oxygen. Computed tomographic imaging of the chest showed resolution of pulmonary infiltrates (Figure 2).


Our case report highlights the potential life-threatening risks that may be associated with concentrating marijuana in the form of butane hash oil. To our knowledge, this represents the first reported case of severe acute pneumonitis after the inhalation of BHO. Observational studies have drawn some links between chronic respiratory disease and marijuana, but this effect remains controversial (1). Acute respiratory disease related to marijuana use is a rare occurrence and has been much more frequently described with the use of other illicit drugs, including crack cocaine and heroin (57).

In our patient, the clear temporal relationship between the exposure to the BHO and the onset of symptoms suggests a causal relationship; however, the exact underlying pathophysiological mechanism is unclear. One hypothesis is that residual butane or other impurities may have caused a direct inhalation injury. Alternatively, or possibly concurrently, a maladaptive host immunologic response may explain the delay between the insult and the culmination of his respiratory disease approximately 1 week later. The BAL findings of lymphocytosis greater than 20% suggest the possibility of an acute hypersensitivity pneumonitis.

As marijuana use among Americans increases, monitoring of the potential harms of concentrated inhalational marijuana forms is important.

1 . Volkow ND, Compton WM, Weiss SR. Adverse health effects of marijuana use. N Engl J Med 2014;371:879.
2 . Loflin M, Earleywine M. A new method of cannabis ingestion: the dangers of dabs? Addict Behav 2014;39:14301433.
3 . Jensen G, Bertelotti R, Greenhalgh D, Palmieri T, Maguina P. Honey oil burns: a growing problem. J Burn Care Res 2015;36:e34e37.
4 . Bell C, Slim J, Flaten HK, Lindberg G, Arek W, Monte AA. Butane hash oil burns associated with marijuana liberalization in Colorado. J Med Toxicol 2015;11:422425.
5 . Mégarbane B, Chevillard L. The large spectrum of pulmonary complications following illicit drug use: features and mechanisms. Chem Biol Interact 2013;206:444451.
6 . Sauvaget E, Dellamonica J, Arlaud K, Sanfiorenzo C, Bernardin G, Padovani B, Viard L, Dubus JC. Idiopathic acute eosinophilic pneumonia requiring ECMO in a teenager smoking tobacco and cannabis. Pediatr Pulmonol 2010;45:12461249.
7 . Gilbert CR, Baram M, Cavarocchi NC. “Smoking wet”: respiratory failure related to smoking tainted marijuana cigarettes. Tex Heart Inst J 2013;40:6467.

The views expressed in this article do not communicate an official position of the U.S. Army, U.S. Navy, or Department of Defense.

Author disclosures are available with the text of this letter at


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Annals of the American Thoracic Society

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