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Cannabinoid Hyperemesis Syndrome in a 17-Year-Old Adolescent
Journal of Adolescent Health xxx (2015) 1e3
www.jahonline.org Clinical observation
Cannabinoid Hyperemesis Syndrome in a 17-Year-Old Adolescent Noémie Desjardins, M.D., Olivier Jamoulle, M.D., Danielle Taddeo, M.D., and Chantal Stheneur, M.D., Ph.D. * Pediatrics Department, Adolescent Medicine Section, Sainte-Justine Hospital, Montreal, Quebec, Canada
Article history: Received April 1, 2015; Accepted July 29, 2015 Keywords: Cannabis; Adolescent; Hyperemesis
A B S T R A C T
IMPLICATIONS AND CONTRIBUTION
Cannabis is the most widely used illicit drug in the world. In Canada, cannabis use has been decreasing among youth since 2008. However, it is still two times more prevalent than among adults. A distinct syndrome, characterized by recurrent vomiting associated with abdominal pain and compulsive bathing, has been increasingly recognized in chronic adult users. The cannabinoid hyperemesis syndrome (CHS) is still underdiagnosed among adults and even more among adolescents. The authors describe the case of a 17-year-old adolescent, who sought emergency care five times over a year for uncontrolled nausea, profuse vomiting, and weight loss. The patient’s symptoms were ameliorated by repetitive hot showering and by avoiding cannabis use. Cannabinoid hyperemesis syndrome is a clinical diagnosis and should be consider in every case of cyclical vomiting. A review of the clinical aspects and the treatment is presented here. Ó 2015 Society for Adolescent Health and Medicine. All rights reserved.
Cannabis is the most widely used illicit drug in the world. In Canada, cannabis use has been decreasing among youth since 2008 [1]. However, it is still two times more prevalent than among adults [1]. Recently, a distinct syndrome, characterized by recurrent vomiting associated with abdominal pain and compulsive bathing, has been recognized among chronic adult users [2]. Cannabinoid hyperemesis syndrome (CHS) is overlooked by clinicians among adults and even more among adolescents leading to an average delay before diagnosis up to 9 years [2]. Case Report A 17-year-old male adolescent presented to the emergency department (ED) with a 5-day history of nausea, vomiting, and Conflicts of Interest: The authors have indicated that they have no potential conflicts of interest and financial relationships relevant to this article to disclose. * Address correspondence to: Chantal Stheneur, M.D., Ph.D., Pediatrics Department, Adolescent Medicine Section, Sainte-Justine Hospital, 3175 CôteSainte-Catherine Road, Montreal, Quebec H3T 1C5, Canada. E-mail address: [email protected] (C. Stheneur). 1054-139X/Ó 2015 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2015.07.019
Cannabis is the most widely used illicit drug in the world. Cannabinoid hyperemesis syndrome, a challenging diagnosis, is overlooked among adult and adolescent users. This article provides a fresh look on clinical aspects and treatment. Clinicians must have a high index of suspicion in every cases of recurrent vomiting.
mild abdominal pain. Over the past year, he had presented five times to the ED and had three admissions to hospital for identical symptoms lasting around 5 days. Every episode was characterized by intractable emesis (>20/day), and the disabling nausea was only relieved by hot showers (>10/day). Over the last 2 months, he had lost 8 kg despite a normal appetite between episodes. Before this hospitalization, he had had extensive workups (abdominal X-ray, abdominal scan, cerebral scan, abdominal ultrasounds, upper endoscopy). All imaging results were normal except for an upper endoscopy showing mild gastritis. He had been previously treated with pantoprazole for more than 6 months without any improvement. Two biopsies were negative for Helicobacter pylori. He had never experienced headaches, and there is no family history of migraine. He had been smoking marijuana daily (2 g/day) for >2 years. He denied taking any prescribed medication or other psychoactive substance. The vital signs were normal. He was afebrile. The physical examination, including a complete neurologic examination, was normal except for dry buccal mucosa. A blood test revealed a
2
N. Desjardins et al. / Journal of Adolescent Health xxx (2015) 1e3
mild hypokalemia (3.2 mmol/L). Ammonia found to be normal. The patient was admitted for intravenous rehydration and potassium repletion. He received intravenous ondansetron, dimenhydrinate, and metoclopramide. Because none of these medications administered on the ward relieved his nausea, he continued to shower multiple times per day. All symptoms progressively disappeared in 3 days, and the kaliemia normalized rapidly. The diagnosis of CHS was explained to the adolescent and with a strong recommendation to discontinue cannabis use. The patient did not return to the follow-up clinic after discharge. Discussion Since the first description in 2004 by Allen et al. [3], many clinicians tried to establish clinical criteria to facilitate the recognition of CHS. The latest criterion has been proposed by Simonetto et al. [4] after reviewing a case series of 98 patients, the largest to date (Table 1). Classically, this syndrome progresses into three phases: prodromal, hyperemetic, and recovery [3e5]. The prodromal phase can last a few weeks or months [3]. The patient develops early morning nausea, a fear of vomiting, and abdominal discomfort [3e5]. He maintains a normal eating pattern and continues his regular dose or increases the amount of marijuana used believing it to have beneficial effects on relieving symptoms [2,5,6]. Then, the hyperemetic phase is characterized by paroxysms of intense and persistent cycling vomiting [2,4,5]. Most patients complain of mild abdominal pain [2e4] and begin to lose weight. Hot showering and bathing are the only alleviating measure to control symptoms, and this becomes readily a learned behavior [5]. It is nearly pathognomonic because, as mentioned in Nicolson’s review of 44 published cases, 98% reported excessive hot water bathing or showering [6]. At this point, patients frequently visit the ED for rehydration. Many will have an extensive workup that is, most of the time, normal. Most hyperemetic episodes resolve in 24e48 hours, but some may last days [5]. The recovery phase starts with the marijuana cessation and relief occurred within a week of abstinence, usually within 2e3 days [6]. Clinicians must be aware that nonclassical form of CHS can exist. In Nicolson’s review, only 50% reported cyclical vomiting, 39% had polydipsia, and 30% had a prodromal course [6]. The duration of cannabis use before the onset of CHS varies in the literature. At first, it has been thought that the mean interval between the onset of the cannabis use and the development of recurrent vomiting was 19.0 3.7 years [2]. Recently, Simonetto
et al. [4] documented the fact that 44% of patients who presented CHS will develop symptoms within 1e5 years after cannabis initiation and 32% during the first year of use. Given the prevalence of cannabis use in the adolescent population, clinicians should consider this diagnosis with every adolescent presenting with recurrent emesis and a history of marijuana use whatever the duration of cannabis use. To date, the specific etiology of CHS is unknown. Initially, proposed mechanisms by Allen et al. [3] include prolonged cannabinoid half-life caused by fat solubility, delayed gastric emptying, and thermoregulation disturbances via limbic system. Soriano-Co et al. [2] suggested that a genetic variation in cannabinoid metabolism leads to toxic accumulation of cannabis metabolites that promotes emesis. Patterson et al. [7] proposed that overstimulation of splanchnic cannabinoid receptors may cause proemetic gut effects to override its brain antiemetic effects. The definitive treatment of CHS is cessation of marijuana use. But, a supportive approach may be necessary during the hyperemetic phase to take care of the severe nausea, the abdominal pain, the volume depletion, and electrolytes disturbances. Antiemetic therapy of any kind have shown minimal or any improvement of CHS [5]. Perhaps, antipsychotics may be helpful, as Witsil and Mycyk [8] described four cases that had been successfully treated with haloperidol. Hot showering and bathing are the most efficient strategies to alleviate symptoms. But, the combination of intractable vomiting and constant hot showers might put CHS patients at greater risk of severe dehydration and prerenal failure [9]. As mentioned, complete relief of symptoms relies on cessation from marijuana intake. An excellent long-term prognosis can be achieved when abstinence is maintained [10]. CHS is a recently described phenomenon, but clinicians must have a high index of suspicion for this syndrome to limit invasive investigations. Further research is required to better understand the etiology and to adjust the medical treatment during hyperemetic phase. Acknowledgments N.D. collected clinical data, drafted the initial article, and reviewed and revised the article. O.J., C.S., and D.T. reviewed and revised the article. All authors approved the final article as submitted. Funding Sources
Table 1 Proposed clinical criteria for cannabinoid hyperemesis syndrome by Simonetto et al. [4] Essential for diagnosis - Long-term cannabis use Major features - Severe cyclic nausea and vomiting - Resolution with cannabis cessation - Relief of symptoms with hot showers or baths - Abdominal pain, epigastric, or periumbilical - Weekly use of marijuana Supportive features - Age <50 years - Weight loss of >5 kg - Morning predominance of symptoms - Normal bowel habits - Negative laboratory, radiographic, and endoscopic test results
No funding was secured for this study. References [1] Abuse CCoS. Cannabis 2014. Available from: www.ccsa.ca. Accessed May 1, 2015. [2] Soriano-Co M, Batke M, Cappell MS. The cannabis hyperemesis syndrome characterized by persistent nausea and vomiting, abdominal pain, and compulsive bathing associated with chronic marijuana use: A report of eight cases in the United States. Dig Dis Sci 2010;55:3113e9. [3] Allen JH, de Moore GM, Heddle R, Twartz JC. Cannabinoid hyperemesis: Cyclical hyperemesis in association with chronic cannabis abuse. Gut 2004; 53:1566e70. [4] Simonetto DA, Oxentenko AS, Herman ML, Szostek JH. Cannabinoid hyperemesis: A case series of 98 patients. Mayo Clinic Proc 2012;87:114e9. [5] Galli JA, Sawaya RA, Friedenberg FK. Cannabinoid hyperemesis syndrome. Curr Drug Abuse Rev 2011;4:241e9.
N. Desjardins et al. / Journal of Adolescent Health xxx (2015) 1e3 [6] Nicolson SE, Denysenko L, Mulcare JL, et al. Cannabinoid hyperemesis syndrome: A case series and review of previous reports. Psychosomatics 2012;53:212e9. [7] Patterson DA, Smith E, Monahan M, et al. Cannabinoid hyperemesis and compulsive bathing: A case series and paradoxical pathophysiological explanation. J Am Board Fam Med 2010;23: 790e3.
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[8] Witsil JC, Mycyk MB. Haloperidol, a novel treatment for cannabinoid hyperemesis syndrome [E-pub ahead of print]. Am J Ther 2014. [9] Habboushe J, Sedor J. Cannabinoid hyperemesis acute renal failure: A common sequela of cannabinoid hyperemesis syndrome. Am J Emerg Med 2014;32:690.e1e2. [10] Cha JM, Kozarek RA, Lin OS. Case of cannabinoid hyperemesis syndrome with long-term follow-up. World J Clin Cases 2014;2:930e3.
www.jahonline.org Clinical observation
Cannabinoid Hyperemesis Syndrome in a 17-Year-Old Adolescent Noémie Desjardins, M.D., Olivier Jamoulle, M.D., Danielle Taddeo, M.D., and Chantal Stheneur, M.D., Ph.D. * Pediatrics Department, Adolescent Medicine Section, Sainte-Justine Hospital, Montreal, Quebec, Canada
Article history: Received April 1, 2015; Accepted July 29, 2015 Keywords: Cannabis; Adolescent; Hyperemesis
A B S T R A C T
IMPLICATIONS AND CONTRIBUTION
Cannabis is the most widely used illicit drug in the world. In Canada, cannabis use has been decreasing among youth since 2008. However, it is still two times more prevalent than among adults. A distinct syndrome, characterized by recurrent vomiting associated with abdominal pain and compulsive bathing, has been increasingly recognized in chronic adult users. The cannabinoid hyperemesis syndrome (CHS) is still underdiagnosed among adults and even more among adolescents. The authors describe the case of a 17-year-old adolescent, who sought emergency care five times over a year for uncontrolled nausea, profuse vomiting, and weight loss. The patient’s symptoms were ameliorated by repetitive hot showering and by avoiding cannabis use. Cannabinoid hyperemesis syndrome is a clinical diagnosis and should be consider in every case of cyclical vomiting. A review of the clinical aspects and the treatment is presented here. Ó 2015 Society for Adolescent Health and Medicine. All rights reserved.
Cannabis is the most widely used illicit drug in the world. In Canada, cannabis use has been decreasing among youth since 2008 [1]. However, it is still two times more prevalent than among adults [1]. Recently, a distinct syndrome, characterized by recurrent vomiting associated with abdominal pain and compulsive bathing, has been recognized among chronic adult users [2]. Cannabinoid hyperemesis syndrome (CHS) is overlooked by clinicians among adults and even more among adolescents leading to an average delay before diagnosis up to 9 years [2]. Case Report A 17-year-old male adolescent presented to the emergency department (ED) with a 5-day history of nausea, vomiting, and Conflicts of Interest: The authors have indicated that they have no potential conflicts of interest and financial relationships relevant to this article to disclose. * Address correspondence to: Chantal Stheneur, M.D., Ph.D., Pediatrics Department, Adolescent Medicine Section, Sainte-Justine Hospital, 3175 CôteSainte-Catherine Road, Montreal, Quebec H3T 1C5, Canada. E-mail address: [email protected] (C. Stheneur). 1054-139X/Ó 2015 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2015.07.019
Cannabis is the most widely used illicit drug in the world. Cannabinoid hyperemesis syndrome, a challenging diagnosis, is overlooked among adult and adolescent users. This article provides a fresh look on clinical aspects and treatment. Clinicians must have a high index of suspicion in every cases of recurrent vomiting.
mild abdominal pain. Over the past year, he had presented five times to the ED and had three admissions to hospital for identical symptoms lasting around 5 days. Every episode was characterized by intractable emesis (>20/day), and the disabling nausea was only relieved by hot showers (>10/day). Over the last 2 months, he had lost 8 kg despite a normal appetite between episodes. Before this hospitalization, he had had extensive workups (abdominal X-ray, abdominal scan, cerebral scan, abdominal ultrasounds, upper endoscopy). All imaging results were normal except for an upper endoscopy showing mild gastritis. He had been previously treated with pantoprazole for more than 6 months without any improvement. Two biopsies were negative for Helicobacter pylori. He had never experienced headaches, and there is no family history of migraine. He had been smoking marijuana daily (2 g/day) for >2 years. He denied taking any prescribed medication or other psychoactive substance. The vital signs were normal. He was afebrile. The physical examination, including a complete neurologic examination, was normal except for dry buccal mucosa. A blood test revealed a
2
N. Desjardins et al. / Journal of Adolescent Health xxx (2015) 1e3
mild hypokalemia (3.2 mmol/L). Ammonia found to be normal. The patient was admitted for intravenous rehydration and potassium repletion. He received intravenous ondansetron, dimenhydrinate, and metoclopramide. Because none of these medications administered on the ward relieved his nausea, he continued to shower multiple times per day. All symptoms progressively disappeared in 3 days, and the kaliemia normalized rapidly. The diagnosis of CHS was explained to the adolescent and with a strong recommendation to discontinue cannabis use. The patient did not return to the follow-up clinic after discharge. Discussion Since the first description in 2004 by Allen et al. [3], many clinicians tried to establish clinical criteria to facilitate the recognition of CHS. The latest criterion has been proposed by Simonetto et al. [4] after reviewing a case series of 98 patients, the largest to date (Table 1). Classically, this syndrome progresses into three phases: prodromal, hyperemetic, and recovery [3e5]. The prodromal phase can last a few weeks or months [3]. The patient develops early morning nausea, a fear of vomiting, and abdominal discomfort [3e5]. He maintains a normal eating pattern and continues his regular dose or increases the amount of marijuana used believing it to have beneficial effects on relieving symptoms [2,5,6]. Then, the hyperemetic phase is characterized by paroxysms of intense and persistent cycling vomiting [2,4,5]. Most patients complain of mild abdominal pain [2e4] and begin to lose weight. Hot showering and bathing are the only alleviating measure to control symptoms, and this becomes readily a learned behavior [5]. It is nearly pathognomonic because, as mentioned in Nicolson’s review of 44 published cases, 98% reported excessive hot water bathing or showering [6]. At this point, patients frequently visit the ED for rehydration. Many will have an extensive workup that is, most of the time, normal. Most hyperemetic episodes resolve in 24e48 hours, but some may last days [5]. The recovery phase starts with the marijuana cessation and relief occurred within a week of abstinence, usually within 2e3 days [6]. Clinicians must be aware that nonclassical form of CHS can exist. In Nicolson’s review, only 50% reported cyclical vomiting, 39% had polydipsia, and 30% had a prodromal course [6]. The duration of cannabis use before the onset of CHS varies in the literature. At first, it has been thought that the mean interval between the onset of the cannabis use and the development of recurrent vomiting was 19.0 3.7 years [2]. Recently, Simonetto
et al. [4] documented the fact that 44% of patients who presented CHS will develop symptoms within 1e5 years after cannabis initiation and 32% during the first year of use. Given the prevalence of cannabis use in the adolescent population, clinicians should consider this diagnosis with every adolescent presenting with recurrent emesis and a history of marijuana use whatever the duration of cannabis use. To date, the specific etiology of CHS is unknown. Initially, proposed mechanisms by Allen et al. [3] include prolonged cannabinoid half-life caused by fat solubility, delayed gastric emptying, and thermoregulation disturbances via limbic system. Soriano-Co et al. [2] suggested that a genetic variation in cannabinoid metabolism leads to toxic accumulation of cannabis metabolites that promotes emesis. Patterson et al. [7] proposed that overstimulation of splanchnic cannabinoid receptors may cause proemetic gut effects to override its brain antiemetic effects. The definitive treatment of CHS is cessation of marijuana use. But, a supportive approach may be necessary during the hyperemetic phase to take care of the severe nausea, the abdominal pain, the volume depletion, and electrolytes disturbances. Antiemetic therapy of any kind have shown minimal or any improvement of CHS [5]. Perhaps, antipsychotics may be helpful, as Witsil and Mycyk [8] described four cases that had been successfully treated with haloperidol. Hot showering and bathing are the most efficient strategies to alleviate symptoms. But, the combination of intractable vomiting and constant hot showers might put CHS patients at greater risk of severe dehydration and prerenal failure [9]. As mentioned, complete relief of symptoms relies on cessation from marijuana intake. An excellent long-term prognosis can be achieved when abstinence is maintained [10]. CHS is a recently described phenomenon, but clinicians must have a high index of suspicion for this syndrome to limit invasive investigations. Further research is required to better understand the etiology and to adjust the medical treatment during hyperemetic phase. Acknowledgments N.D. collected clinical data, drafted the initial article, and reviewed and revised the article. O.J., C.S., and D.T. reviewed and revised the article. All authors approved the final article as submitted. Funding Sources
Table 1 Proposed clinical criteria for cannabinoid hyperemesis syndrome by Simonetto et al. [4] Essential for diagnosis - Long-term cannabis use Major features - Severe cyclic nausea and vomiting - Resolution with cannabis cessation - Relief of symptoms with hot showers or baths - Abdominal pain, epigastric, or periumbilical - Weekly use of marijuana Supportive features - Age <50 years - Weight loss of >5 kg - Morning predominance of symptoms - Normal bowel habits - Negative laboratory, radiographic, and endoscopic test results
No funding was secured for this study. References [1] Abuse CCoS. Cannabis 2014. Available from: www.ccsa.ca. Accessed May 1, 2015. [2] Soriano-Co M, Batke M, Cappell MS. The cannabis hyperemesis syndrome characterized by persistent nausea and vomiting, abdominal pain, and compulsive bathing associated with chronic marijuana use: A report of eight cases in the United States. Dig Dis Sci 2010;55:3113e9. [3] Allen JH, de Moore GM, Heddle R, Twartz JC. Cannabinoid hyperemesis: Cyclical hyperemesis in association with chronic cannabis abuse. Gut 2004; 53:1566e70. [4] Simonetto DA, Oxentenko AS, Herman ML, Szostek JH. Cannabinoid hyperemesis: A case series of 98 patients. Mayo Clinic Proc 2012;87:114e9. [5] Galli JA, Sawaya RA, Friedenberg FK. Cannabinoid hyperemesis syndrome. Curr Drug Abuse Rev 2011;4:241e9.
N. Desjardins et al. / Journal of Adolescent Health xxx (2015) 1e3 [6] Nicolson SE, Denysenko L, Mulcare JL, et al. Cannabinoid hyperemesis syndrome: A case series and review of previous reports. Psychosomatics 2012;53:212e9. [7] Patterson DA, Smith E, Monahan M, et al. Cannabinoid hyperemesis and compulsive bathing: A case series and paradoxical pathophysiological explanation. J Am Board Fam Med 2010;23: 790e3.
3
[8] Witsil JC, Mycyk MB. Haloperidol, a novel treatment for cannabinoid hyperemesis syndrome [E-pub ahead of print]. Am J Ther 2014. [9] Habboushe J, Sedor J. Cannabinoid hyperemesis acute renal failure: A common sequela of cannabinoid hyperemesis syndrome. Am J Emerg Med 2014;32:690.e1e2. [10] Cha JM, Kozarek RA, Lin OS. Case of cannabinoid hyperemesis syndrome with long-term follow-up. World J Clin Cases 2014;2:930e3.