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 non- distended. 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

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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 character- ize 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/(C) 2014

690.e2 J. Habboushe, J. Sedor / American Journal of Emergency Medicine 32 (2014) 690.e1–690.e2

Table

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: joehabb@yahoo.com

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

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