American Journal of Emergency Medicine xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Cannabinoid hyperemesis acute renal failure: a common sequela of cannabinoid hyperemesis syndrome☆,☆☆,★ Abstract We report the case of a 25-year-old man with an 8-year history of daily marijuana use diagnosed with acute renal failure secondary to cannabinoid hyperemesis syndrome. The patient presented with “constant” vomiting for over a day. His symptoms were completely relieved with compulsive hot showering and partially relieved by hot baths, by high ambient room temperature, and transiently after smoking marijuana. The patient was found to have a creatinine of 3.21 and admitted for acute renal failure secondary to cannabinoid hyperemesis syndrome. Cannabinoid hyperemesis syndrome (CHS) is a recently described condition affecting long-term marijuana users. We found 5 other case reports of acute renal failure secondary to CHS [1-5], and a total of 55 case reports of CHS. The unique combination of intractable vomiting and constant hot showers seems to put CHS patients at significant risk of severe dehydration and prerenal failure, a common and distinct entity we suggest be termed cannabinoid hyperemesis acute renal failure (CHARF). The characteristics of cannabinoid hyperemesis acute renal failure patients were similar to CHS patients, except a larger portion were over the age of 30 (4 of 6, vs 30%). Evaluating physicians should maintain a high degree of suspicion for this common sequela of CHS. A 25-year-old man presented to our emergency department with persistent vomiting for over a day. The vomiting was constant, “at least 20 times daily,” and associated with diffuse abdominal cramping, but with no fever or diarrhea. Patient admitted to long-term marijuana use, using 2 g to a quarter ounce daily for 8 years. Vomiting was best relieved with hot showers, specifically when the hot water was on his upper back and neck, which made him feel “like I can run a marathon.” He would again feel nausea while stepping out of the shower. Nausea and vomiting were only partially relieved by hot baths, by high ambient room temperature, and transiently after marijuana use. The patient was spending about 50% of his time awake in hot showers and was preoccupied with hot showering, stating, “All I can think about while you talk to me is going home to my shower.” Triage vital signs were within normal limits. On physical exam the patient appeared uncomfortable and was vomiting and had dry mucous membranes. His abdomen was soft, nontender and nondistended. He felt minimal relief after 10 mg of intravenous metoclopramide and 2 liters of normal saline. Lab work revealed a creatinine of 3.21 mg/dL, blood urea nitrogen of 24 mg/dL, and anion ☆ No support was provided. ☆☆ This was not presented at an assembly or conference. ★ There is no funding, outside support, or financial interests. There are no known conflicts of interest. There are no copyright restrictions.
gap of 32. He was admitted for acute renal failure, secondary to the dehydration caused by vomiting and the hot showers and high ambient temperatures. By the next day the creatinine had dropped to 1.4 mg/dL. The patient stated he felt better and signed out of the hospital against medical advice. He returned the next day with similar symptoms, was treated with intravenous fluids and antiemetic medications, and discharged home. CHS is a relatively newly described entity that causes persistent vomiting in heavy, long-term marijuana users. It was first reported in Adelaide Hills of Southern Australia in 2004 [6]. Approximately 55 cases have been reported [14,15], plus a retrospective chart review where the authors believe 98 cases may have been undiagnosed [9]. Two sets of diagnostic criteria have been suggested. Both characterize CHS as heavy, long-term marijuana use, cyclic vomiting and marked relief of symptoms with hot showering [6-9]. Although marijuana is widely known as an effective antiemetic [10], CHS seems to represent a paradoxical effect that can present after heavy long-term use, perhaps by a down regulation of receptors or a dependent buildup of cannabinoid, possibly near the hypothalamus, which regulates body temperature [11]. The prevalence of cannabis use in the United States is high, approximately 4% [12] and is rising. Each year more than 2.6 million Americans start using marijuana [13], a pattern that will likely maintain or increase due to recent legalization movements. We have found five other reported cases of CHS causing acute prerenal failure (Table) [1-5]. All reported cases of acute renal failure secondary to CHS were male subjects, consistent with 4:1 male/female ratio reported the literature [14]. Interestingly four of these six cases were over the age of 30, and an average age of 34.3 years old, which is not consistent with the 30% rate of CHS patients over 30 years old, and average age of 25.6 years, reported in past reviews [14]. Creatinine ranged from 3 to 10 mg/dL, which completely resolved in all patients after 1 to 5 days of intravenous hydration and supportive measures. No long-term sequelae were reported. Four of the patients in these reports presented multiple times for recurrent acute renal failure secondary to CHS. CHS is known to present with persistent vomiting and dehydration [6]. The dehydration of CHS is likely due both to the intractable vomiting and the constant hot showers. The general guideline is to not spend more than 20 minutes in a hot tub kept at 41°C to 42°C [16]. However the temperature of hot showers is often much higher, up to 49°C [17]. The unique combination of intractable vomiting and constant hot showers that can add up to many hours per day seems to put these patients at significant risk of severe dehydration and prerenal failure, a common and distinct entity we suggest be termed Cannabinoid Hyperemesis Acute Renal Failure.
0735-6757/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
Please cite this article as: Habboushe J, Sedor J, Cannabinoid hyperemesis acute renal failure: a common sequelae of cannabinoid hyperemesis syndrome, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2013.12.013
2
J. Habboushe, J. Sedor / American Journal of Emergency Medicine xxx (2014) xxx–xxx
Table Marijuana use
BUN (mg/dL)/ Number of times Clinical course Cr (mg/dL) the patient presented
“Weeks” of recurrent episodes
Regular use since age 12
–/4.59
50
5 days
Heavy use × 3 years, 152/9.2 Binge × 1 week 9187/9.2 183/10.1
3
M
28
Variable
5 cannabis ‘joints’ a day since the age of 14 years
6
2013
M
36
7 days
“Chronic daily use”
Price et al.
Nov 2010
M
30
3 days
Chronic daily use for years
–/~1.9 –/~1.5 24/3.98 –/~1.9 –/~5.9 71/4.1 34/4.64 71/4.18 38/7.57 121/9.09 67/3.2
Habboushe and Sedor (our case)
Oct 2013
M
26
2 days
2 g to one quarter ounce daily for 8 years
24/3.21
2
Case report
Author
Date
Sex Age Days of vomiting
Cannabinoid hyperemesis syndrome Inducing acute prerenal failure and electrolyte disturbance Repetitive vomiting and acute renal failure as the presenting symptoms of cannabinoid hyperemesis syndrome The smoker and the nephrologist
Bramstedt and Dissmann
Aug 2011
M
36
Chang et al.
April 2013
M
Baron et al.
2011
Cannabinoid hyperemesis syndrome presenting with recurrent acute renal failure
Abodunde et al
Cannabinoid hyperemesis syndrome as the underlying cause of intractable nausea Cannabinoid hyperemesis acute renal failure (CHARF): a common sequela of cannabinoid hyperemesis syndrome
Both CHS and CHARF are likely under-diagnosed, and still not well understood [11]. Of the prior 55 CHS cases reported [9,14,15], 6, including ours, have been reported to have caused acute renal failure [1-5]. All patients were male, a larger portion of the CHARF patients were over the age of 30 compared with baseline CHS patients (4 out of 6 vs 30%). Treating clinicians should keep a high index of suspicion for acute prerenal failure in patients presenting with cannabinoid hyperemesis syndrome. Joseph Habboushe MD, MBA Beth Israel Medical Center of the Mt. Sinai School of Medicine New York, NY 10003, USA E-mail address: [email protected] Jennifer Sedor MD Department of Emergency Medicine Beth Israel Medical Center of the Mt. Sinai School of Medicine New York, NY 10003, USA http://dx.doi.org/10.1016/j.ajem.2013.12.013 References [1] Bramstedt J, Dissmann R. “Cannabinoid hyperemesis syndrome inducing acute prerenal failure and electrolyte disturbance”. Dtsch Med Wochenschr (2011) 136.34-35: 1720–722. [2] Chang Chin-Chun, Hsu Yu-Juei, Chu Pauling, et al. Repetitive vomiting and acute renal failure as the presenting symptoms of cannabinoid hyperemesis syndrome. J Med Sci 2013;33(3):163–5.
1
5
1
Resolution of symptoms and normalization of Cr with 2 days of intravenous hydration Resolution of symptoms and normalization of BUN/Cr in 5 days with aggressive intravenous hydration and anti-emetics Resolution of symptoms and normalization of BUN/Cr in 5-7 days with intravenous hydration Resolution of symptoms and normalization of BUN/Cr within 2-3 days with intravenous hydration on each admission Resolution of symptoms and normalization of BUN/Cr after 4 days of intravenous hydration and hot showers Resolution of symptoms and normalization of BUN/Cr after 1 day of intravenous hydration
[3] Baron Marine, Haymann Jean-Philippe, Wolfromm Alice. The smoker and the nephrologist. Kidney Int 2011;79:1385–6. [4] Abodunde Oladapo A, Nakda Joseph, Nweke Nneka, et al. Cannabinoid hyperemesis syndrome presenting with recurrent acute renal failure. J Med Cases 2013;4(3):173–5. [5] Price SL, Fisher C, Kumar R, et al. “Cannabinoid hyperemesis syndrome as the underlying cause of intractable nausea and vomiting”. J Am Osteopath Assoc 2011;111(3):166–9. [6] Allen JH, De Moore GM, Heddle R, et al. Cannabinoid hypermesis: cyclical hyperemesis in association with chronic cannabis abuse. Gut 2004;53(11):1566–70. [7] Fleig S, Brunkhorst R. Hyperemesis and a high water bill. Z Gastroenterol 2011;49(11):1479–81. [8] Sontineni Siva-P. Cannabinoid hyperemesis syndrome: clinical diagnosis of an underrecognised manifestation of chronic cannabis abuse. World J Gastroenterol 2009;15(10):1264. [9] Simonetto DA, Oxentenko AS, Herman ML, et al. Cannabinoid hyperemesis: a case series of 98 patients. Mayo Clin Proc 2012;87(2):114–9. [10] Sharkey KA, Darmani NA, Parker LA, et al. “Regulation of nausea and vomiting by cannabinoids and the endocannabinoid system.”. Eur J Pharmacol 2013 n. pag. Http://www.sciencedirect.com/science/article/pii/S001429991300753X. Elsevier, 1 Nov. 2013. Web. 6 Nov. 2013. [11] Wallace Erik A, Andrews Sarah E, Garmany Chad L, et al. “Cannabinoid hyperemesis syndrome: literature review and proposed diagnosis and treatment algorithm.”. South Med J 2011:659–64. [12] Compton WM, Grant BF, Colliver JD, et al. Prevalence of marijuana use disorder in the United States: 1991–1992 and 2001–2002. JAMA 2004;291:2214–21. [13] Foley JD. Adolescent use and misuse of marijuana. Adolesc Med Clin 2006;17: 319–34. [14] Nicolson Stephen E, Denysenko Lex, Loretta Mulcare J, et al. Cannabinoid hyperemesis syndrome: a case series and review of previous reports. Psychosomatics 2012;53(3):212–9. [15] Sofka Sarah, Lerfald Nathan. Cannabinoid hyperemesis syndrome: a case series. W V Med J 2013;109(3):20–3. [16] Allison TG, Reger WE. Comparison of responses of men to immersion in circulating water at 40.0 and 41.5 degrees C. Aviat Space Environ Med 1998;69(9):845–50. [17] Levesque Benoit, Lavoie Michel, Joly Jean. Residential water heater temperature: 49 or 60 degrees Celsius? Can J Infect Dis 2004;15(1):11–2.
Please cite this article as: Habboushe J, Sedor J, Cannabinoid hyperemesis acute renal failure: a common sequelae of cannabinoid hyperemesis syndrome, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2013.12.013
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Cannabinoid hyperemesis acute renal failure: a common sequela of cannabinoid hyperemesis syndrome☆,☆☆,★ Abstract We report the case of a 25-year-old man with an 8-year history of daily marijuana use diagnosed with acute renal failure secondary to cannabinoid hyperemesis syndrome. The patient presented with “constant” vomiting for over a day. His symptoms were completely relieved with compulsive hot showering and partially relieved by hot baths, by high ambient room temperature, and transiently after smoking marijuana. The patient was found to have a creatinine of 3.21 and admitted for acute renal failure secondary to cannabinoid hyperemesis syndrome. Cannabinoid hyperemesis syndrome (CHS) is a recently described condition affecting long-term marijuana users. We found 5 other case reports of acute renal failure secondary to CHS [1-5], and a total of 55 case reports of CHS. The unique combination of intractable vomiting and constant hot showers seems to put CHS patients at significant risk of severe dehydration and prerenal failure, a common and distinct entity we suggest be termed cannabinoid hyperemesis acute renal failure (CHARF). The characteristics of cannabinoid hyperemesis acute renal failure patients were similar to CHS patients, except a larger portion were over the age of 30 (4 of 6, vs 30%). Evaluating physicians should maintain a high degree of suspicion for this common sequela of CHS. A 25-year-old man presented to our emergency department with persistent vomiting for over a day. The vomiting was constant, “at least 20 times daily,” and associated with diffuse abdominal cramping, but with no fever or diarrhea. Patient admitted to long-term marijuana use, using 2 g to a quarter ounce daily for 8 years. Vomiting was best relieved with hot showers, specifically when the hot water was on his upper back and neck, which made him feel “like I can run a marathon.” He would again feel nausea while stepping out of the shower. Nausea and vomiting were only partially relieved by hot baths, by high ambient room temperature, and transiently after marijuana use. The patient was spending about 50% of his time awake in hot showers and was preoccupied with hot showering, stating, “All I can think about while you talk to me is going home to my shower.” Triage vital signs were within normal limits. On physical exam the patient appeared uncomfortable and was vomiting and had dry mucous membranes. His abdomen was soft, nontender and nondistended. He felt minimal relief after 10 mg of intravenous metoclopramide and 2 liters of normal saline. Lab work revealed a creatinine of 3.21 mg/dL, blood urea nitrogen of 24 mg/dL, and anion ☆ No support was provided. ☆☆ This was not presented at an assembly or conference. ★ There is no funding, outside support, or financial interests. There are no known conflicts of interest. There are no copyright restrictions.
gap of 32. He was admitted for acute renal failure, secondary to the dehydration caused by vomiting and the hot showers and high ambient temperatures. By the next day the creatinine had dropped to 1.4 mg/dL. The patient stated he felt better and signed out of the hospital against medical advice. He returned the next day with similar symptoms, was treated with intravenous fluids and antiemetic medications, and discharged home. CHS is a relatively newly described entity that causes persistent vomiting in heavy, long-term marijuana users. It was first reported in Adelaide Hills of Southern Australia in 2004 [6]. Approximately 55 cases have been reported [14,15], plus a retrospective chart review where the authors believe 98 cases may have been undiagnosed [9]. Two sets of diagnostic criteria have been suggested. Both characterize CHS as heavy, long-term marijuana use, cyclic vomiting and marked relief of symptoms with hot showering [6-9]. Although marijuana is widely known as an effective antiemetic [10], CHS seems to represent a paradoxical effect that can present after heavy long-term use, perhaps by a down regulation of receptors or a dependent buildup of cannabinoid, possibly near the hypothalamus, which regulates body temperature [11]. The prevalence of cannabis use in the United States is high, approximately 4% [12] and is rising. Each year more than 2.6 million Americans start using marijuana [13], a pattern that will likely maintain or increase due to recent legalization movements. We have found five other reported cases of CHS causing acute prerenal failure (Table) [1-5]. All reported cases of acute renal failure secondary to CHS were male subjects, consistent with 4:1 male/female ratio reported the literature [14]. Interestingly four of these six cases were over the age of 30, and an average age of 34.3 years old, which is not consistent with the 30% rate of CHS patients over 30 years old, and average age of 25.6 years, reported in past reviews [14]. Creatinine ranged from 3 to 10 mg/dL, which completely resolved in all patients after 1 to 5 days of intravenous hydration and supportive measures. No long-term sequelae were reported. Four of the patients in these reports presented multiple times for recurrent acute renal failure secondary to CHS. CHS is known to present with persistent vomiting and dehydration [6]. The dehydration of CHS is likely due both to the intractable vomiting and the constant hot showers. The general guideline is to not spend more than 20 minutes in a hot tub kept at 41°C to 42°C [16]. However the temperature of hot showers is often much higher, up to 49°C [17]. The unique combination of intractable vomiting and constant hot showers that can add up to many hours per day seems to put these patients at significant risk of severe dehydration and prerenal failure, a common and distinct entity we suggest be termed Cannabinoid Hyperemesis Acute Renal Failure.
0735-6757/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
Please cite this article as: Habboushe J, Sedor J, Cannabinoid hyperemesis acute renal failure: a common sequelae of cannabinoid hyperemesis syndrome, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2013.12.013
2
J. Habboushe, J. Sedor / American Journal of Emergency Medicine xxx (2014) xxx–xxx
Table Marijuana use
BUN (mg/dL)/ Number of times Clinical course Cr (mg/dL) the patient presented
“Weeks” of recurrent episodes
Regular use since age 12
–/4.59
50
5 days
Heavy use × 3 years, 152/9.2 Binge × 1 week 9187/9.2 183/10.1
3
M
28
Variable
5 cannabis ‘joints’ a day since the age of 14 years
6
2013
M
36
7 days
“Chronic daily use”
Price et al.
Nov 2010
M
30
3 days
Chronic daily use for years
–/~1.9 –/~1.5 24/3.98 –/~1.9 –/~5.9 71/4.1 34/4.64 71/4.18 38/7.57 121/9.09 67/3.2
Habboushe and Sedor (our case)
Oct 2013
M
26
2 days
2 g to one quarter ounce daily for 8 years
24/3.21
2
Case report
Author
Date
Sex Age Days of vomiting
Cannabinoid hyperemesis syndrome Inducing acute prerenal failure and electrolyte disturbance Repetitive vomiting and acute renal failure as the presenting symptoms of cannabinoid hyperemesis syndrome The smoker and the nephrologist
Bramstedt and Dissmann
Aug 2011
M
36
Chang et al.
April 2013
M
Baron et al.
2011
Cannabinoid hyperemesis syndrome presenting with recurrent acute renal failure
Abodunde et al
Cannabinoid hyperemesis syndrome as the underlying cause of intractable nausea Cannabinoid hyperemesis acute renal failure (CHARF): a common sequela of cannabinoid hyperemesis syndrome
Both CHS and CHARF are likely under-diagnosed, and still not well understood [11]. Of the prior 55 CHS cases reported [9,14,15], 6, including ours, have been reported to have caused acute renal failure [1-5]. All patients were male, a larger portion of the CHARF patients were over the age of 30 compared with baseline CHS patients (4 out of 6 vs 30%). Treating clinicians should keep a high index of suspicion for acute prerenal failure in patients presenting with cannabinoid hyperemesis syndrome. Joseph Habboushe MD, MBA Beth Israel Medical Center of the Mt. Sinai School of Medicine New York, NY 10003, USA E-mail address: [email protected] Jennifer Sedor MD Department of Emergency Medicine Beth Israel Medical Center of the Mt. Sinai School of Medicine New York, NY 10003, USA http://dx.doi.org/10.1016/j.ajem.2013.12.013 References [1] Bramstedt J, Dissmann R. “Cannabinoid hyperemesis syndrome inducing acute prerenal failure and electrolyte disturbance”. Dtsch Med Wochenschr (2011) 136.34-35: 1720–722. [2] Chang Chin-Chun, Hsu Yu-Juei, Chu Pauling, et al. Repetitive vomiting and acute renal failure as the presenting symptoms of cannabinoid hyperemesis syndrome. J Med Sci 2013;33(3):163–5.
1
5
1
Resolution of symptoms and normalization of Cr with 2 days of intravenous hydration Resolution of symptoms and normalization of BUN/Cr in 5 days with aggressive intravenous hydration and anti-emetics Resolution of symptoms and normalization of BUN/Cr in 5-7 days with intravenous hydration Resolution of symptoms and normalization of BUN/Cr within 2-3 days with intravenous hydration on each admission Resolution of symptoms and normalization of BUN/Cr after 4 days of intravenous hydration and hot showers Resolution of symptoms and normalization of BUN/Cr after 1 day of intravenous hydration
[3] Baron Marine, Haymann Jean-Philippe, Wolfromm Alice. The smoker and the nephrologist. Kidney Int 2011;79:1385–6. [4] Abodunde Oladapo A, Nakda Joseph, Nweke Nneka, et al. Cannabinoid hyperemesis syndrome presenting with recurrent acute renal failure. J Med Cases 2013;4(3):173–5. [5] Price SL, Fisher C, Kumar R, et al. “Cannabinoid hyperemesis syndrome as the underlying cause of intractable nausea and vomiting”. J Am Osteopath Assoc 2011;111(3):166–9. [6] Allen JH, De Moore GM, Heddle R, et al. Cannabinoid hypermesis: cyclical hyperemesis in association with chronic cannabis abuse. Gut 2004;53(11):1566–70. [7] Fleig S, Brunkhorst R. Hyperemesis and a high water bill. Z Gastroenterol 2011;49(11):1479–81. [8] Sontineni Siva-P. Cannabinoid hyperemesis syndrome: clinical diagnosis of an underrecognised manifestation of chronic cannabis abuse. World J Gastroenterol 2009;15(10):1264. [9] Simonetto DA, Oxentenko AS, Herman ML, et al. Cannabinoid hyperemesis: a case series of 98 patients. Mayo Clin Proc 2012;87(2):114–9. [10] Sharkey KA, Darmani NA, Parker LA, et al. “Regulation of nausea and vomiting by cannabinoids and the endocannabinoid system.”. Eur J Pharmacol 2013 n. pag. Http://www.sciencedirect.com/science/article/pii/S001429991300753X. Elsevier, 1 Nov. 2013. Web. 6 Nov. 2013. [11] Wallace Erik A, Andrews Sarah E, Garmany Chad L, et al. “Cannabinoid hyperemesis syndrome: literature review and proposed diagnosis and treatment algorithm.”. South Med J 2011:659–64. [12] Compton WM, Grant BF, Colliver JD, et al. Prevalence of marijuana use disorder in the United States: 1991–1992 and 2001–2002. JAMA 2004;291:2214–21. [13] Foley JD. Adolescent use and misuse of marijuana. Adolesc Med Clin 2006;17: 319–34. [14] Nicolson Stephen E, Denysenko Lex, Loretta Mulcare J, et al. Cannabinoid hyperemesis syndrome: a case series and review of previous reports. Psychosomatics 2012;53(3):212–9. [15] Sofka Sarah, Lerfald Nathan. Cannabinoid hyperemesis syndrome: a case series. W V Med J 2013;109(3):20–3. [16] Allison TG, Reger WE. Comparison of responses of men to immersion in circulating water at 40.0 and 41.5 degrees C. Aviat Space Environ Med 1998;69(9):845–50. [17] Levesque Benoit, Lavoie Michel, Joly Jean. Residential water heater temperature: 49 or 60 degrees Celsius? Can J Infect Dis 2004;15(1):11–2.
Please cite this article as: Habboushe J, Sedor J, Cannabinoid hyperemesis acute renal failure: a common sequelae of cannabinoid hyperemesis syndrome, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2013.12.013
