A case of cannabinoid hyperemesis syndrome highlighting related key paediatric issues

CASE PRESENTATION

A 17-year-old female presented to hospital alone complaining of thirst, tingling of her fingers and lips, and dizziness after greater than 10 bouts of emesis in class earlier that morning. She reported nausea throughout most of the night and into the morning. She had taken a hot shower in the morning in an attempt to relieve her symptoms, which had worked in the past. The patient also reported that she has had viral like symptoms with nasal congestion and cough for roughly 1 week prior without fever.

Over the past few months, she endorsed episodes of vomiting, not associated with diarrhea or fever. Those had all self-resolved without any visit to a physician. She denied any blood or bilious emesis, diarrhea, or urinary symptoms. Upon further questioning, the patient reported smoking a large quantity of cannabis the previous night and in the days preceding it. She gains regular access to cannabis from her mother’s medicinal cannabis prescription and occasionally from friends at school. The patient had started smoking increasing amounts of cannabis daily for the past several months to alleviate her anxiety and to help with sleep.

Past medical history was significant for anxiety and depression being controlled on 20 mg of Citalopram for roughly one and a half years. She was also taking daily oral contraceptive pills.

History and physical examination of her respiratory, cardiovascular, abdominal, gynecologic, and neurologic systems were unremarkable. Her temperature was 36.4°C, pulse of 85 beats/minute, blood pressure was 101/60 mmHg, respiratory rate 16/minute, and 100% O₂ saturation. Her capillary blood glucose was 5.6 mmol/L. Her ECG, electrolytes, urea, creatinine, and urinalysis were unremarkable. Her pregnancy test was negative.

In the ED, the patient was prescribed ondansetron in an attempt to alleviate her symptoms of nausea and was trialed on oral fluids. Her parents joined her later in the admission and she was also seen by the ED social worker and provided with education around the effects of cannabis. She opted not to participate in a community-based substance use and addiction treatment services at this point.

DISCUSSION

When seen in outpatient follow-up later that month, a diagnosis of cannabinoid hyperemesis syndrome (CHS) was made based on the patient’s following symptoms: nausea, vomiting, reduction of nausea after cannabis cessation, previous cyclical nausea, and negative workup for other conditions. Clinical features of CHS are presented in Tables 1 and 2 (1,2). Diagnosis of CHS in practice has been challenging due to limited literature surrounding CHS and unclear symptom recognition for both physicians and patients (3).

Table 1.

Cannabinoid hyperemesis syndrome features

Considerations	Feature
Essential Feature	1. History of long-term cannabis use
Major Features	2. Reduction and/or resolution of symptoms after cannabis cessation
	3. Relief of symptoms with hot showers or baths
	4. Abdominal pain (epigastric or periumbilical)
	5. History of frequent, even daily use of marijuana
Supportive Features	1. Male majority
	2. Patient usually less than 40 years of age
	3. Negative laboratory, radiographic and endoscopic results
	4. Weight loss not a prominent feature

Table 2.

Rome IV criteria

All three criteria must be present and must be fulfilled for at least 3 months with symptom onset at least 6 months before diagnosis

(1) Stereotypical episodic vomiting resembling cyclic vomiting syndrome in terms of onset, duration, and frequency (i.e., at least one discrete episode in the prior year and two episodes in the past 6 months, occurring at least 1 week apart)

(2) Presentation after prolonged excessive cannabis use (three to five times daily for at least 2 years)

(3) Relief of vomiting episodes by sustained cessation of cannabis use

While considering the full Rome IV criteria, an international effort to provide standards for diagnosis of gastrointestinal functional disorders, 2 years of daily cannabis use may not be fully reported in a paediatric population. Therefore, consideration of weekly cannabis, which is the minimum use reported to result in CHS, may be a more useful measure (4). An additional issue that needs to be taken into account while considering CHS among youth, is how perceived benefits related to cannabis use, such as anti-anxiety in this case, may mitigate the impact of cessation recommendations. The complexity of taking care of CHS in the paediatric population is also highlighted in this case according to disclosure and confidentiality as the patient was joined by her parents later on in this admission. It is also important to note that even in a legal market the paediatric population may still have difficulty disclosing cannabis use out of fear of reprimanding from parental figures or authorities.

Currently recognized CHS was first reported in 2004 by Allen et al. to describe cases of cyclical vomiting syndrome coinciding with heavy cannabis usage (5). This novel finding was particularly surprising given prior research describing the antiemetic properties of cannabis (particularly in the setting of chemotherapy patients). Recent studies suggest that prolonged exposure to cannabinoids may decrease transient receptor potential vanillinoid subtype 1 (TRVP1) signalling, which leads to nausea and emesis through decreased gastric motility (4). As TRVP1 receptors can be activated in high temperatures and through capsaicin, this may explain reports describing patients who find symptom relief with hot showers and topical capsaicin creams (3–5).

As in cases of cyclical vomiting syndrome, anti-emetics such as promethazine and ondansetron would often be prescribed for CHS but have been found to be ineffective. Early case reports highlight the ineffectiveness of these medications, with only IV fluids for 24 to 48 hours being sufficient enough to discharge the patient (3,6). The only definite treatment option identified has been abstinence (7). If cannabis usage is not halted, symptoms usually reappear within weeks to months of cannabis re-consumption. Supportive and symptomatic care options include intravenous fluids, the use of capsaicin cream, proton pump inhibitors, and haloperidol (4,7,8).

A recent study by Hernandez et al. conducted in Hamilton, Ontario looked at CHS in the adult population (9). This multicentre retrospective chart review identified patients with a chief complaint of vomiting and/or a discharge diagnosis of vomiting or cyclical vomiting. Cannabis was specifically indicated in 73 charts (19.4%) and 39 (10.4%) of these charts quantified cannabis use greater than three times per week. Interestingly, patients were more likely to disclose cannabis use following legalization. Only two charts in their study identified legal, medicinal users of cannabis and therefore, it is assumed that the remainder were using cannabis for recreational purposes. The study also found repeat visits, blood work, and fluid resuscitation were all more common among high-frequency users. The study concluded that there is a significant lack of screening for CHS.

Descriptions of CHS in the paediatric literature are limited. To date, there have been only a few reported cases (3,10). A 2013 retrospective cohort study from Colorado found an increase in unintentional cannabis ingestion after modification of drug enforcement laws, and a 2016 retrospective cohort study demonstrated that paediatric cannabis exposures in Colorado increased significantly after legalization of cannabis (11,12). Recently, there have now been reported deaths in young adults due to CHS through a mechanism of hypokalemia and dehydration which may be ameliorated through increased screening (13). As cannabis exposure can have a wide spectrum of presentations in the paediatric population, there is a need for improved recognition and diagnosis of CHS in order to provide effective treatment.

CLINICAL PEARLS

1. It is important for health care providers to investigate the amount, frequency, and symptoms associated with cannabis use and to educate young people about CHS.

2. Health care providers should keep CHS high on their differential for negative diagnostic workup of other conditions in the paediatric setting.

3. It should be recognized that antiemetics such as ondansetron may not alleviate the symptoms of CHS and capsaicin and haloperidol should be considered as therapeutic options in addition to supportive care including IV fluid for acute treatment.

4. Counselling for cannabis reduction/cessation may decrease long term symptoms and should be offered even in the emergency department setting.

Funding: There are no funders to report for this submission.

Potential Conflicts of Interest: All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.