P2.C056: Diffuse Alveolar Hemorrhage Secondary to Non-Prescribed Fentanyl Overdose in a Young Child

Introduction: Critical illness and death related to ingestion of non-prescribed fentanyl is rising in the pediatric population with fentanyl-related deaths quadrupling from 2018 to 2021. Diffuse alveolar hemorrhage (DAH) is a rare and life-threatening complication of fentanyl ingestion described in adult populations. We present an unusual case of DAH secondary to unintentional fentanyl inhalation in an infant.

Case Description: A previously healthy 16-month-old presented to the emergency department for unresponsiveness preceded by rolling back of the eyes. She received 8 rounds of cardiopulmonary resuscitation with return of spontaneous circulation. She was intubated without difficulty and her chest x-ray was unremarkable. Naloxone was administered in the emergency department resulting in agitation. She was admitted to the pediatric intensive care unit (PICU) for management of acute hypoxic respiratory failure. She continued to remain hypoxic on arrival to the PICU with the need for bag mask ventilation and new presence of profuse, bloody endotracheal secretions. Placement on extra-corporeal membrane oxygenation was aborted given the presence of profuse pulmonary hemorrhage. She was placed on airway pressure release ventilation mode of ventilation and inhaled nitric oxide therapy to maintain her oxygenation. Her peak oxygenation index (OI) was 49. Her endotracheal secretions remained bloody, and her hemoglobin dropped precipitously from 10.1 g/dL to 7.9 g/dL within 12 hours of PICU admission requiring packed red blood cells transfusion. Her chest x-rays in the PICU revealed diffuse haziness of bilateral lung fields that worsened over the next several days before improvement. Investigations for pulmonary hemorrhage including respiratory viral panel, bacterial cultures, echocardiogram, urinalysis, complete blood count, coagulation profile, brain computed tomography (CT) scan, and electroencephalogram were negative. An expanded toxicology screen revealed fentanyl, norfentanyl, 4-anilino-N-phenethylpiperidine (fentanyl derivative), methamphetamine, and cotinine. There were no intravenous injection marks, and her nasogastric aspirate was minimal. The patient’s endotracheal secretions gradually cleared, and she was extubated after 8 days. She did not have any respiratory or neurologic sequelae and was discharged later.

Discussion: DAH is caused by bleeding from alveolar capillaries and manifests as hemoptysis, acute anemia, diffuse lung infiltration, and acute respiratory failure as seen in our patient. The mechanism for DAH in fentanyl overdose is postulated to be secondary to the catecholamine surge triggered by acute opioid withdrawal following naloxone administration. This catecholamine surge leads to increased cardiac afterload and direct injury to pulmonary endothelial cells from severe constriction of the pulmonary circulation. The infant was most probably exposed to inhaled non-prescribed fentanyl leading to fentanyl overdose and DAH.

Conclusion: In the current drug overdose epidemic, narcotic overdose should be considered in the differential diagnosis of DAH in any age group. Early identification and diagnosis of DAH is vital for improving patient outcomes.