The increasing prevalence of cannabis worldwide requires awareness of a potential, less recognized, paradoxical entity, the cannabinoid hyperemesis syndrome (CHS). This includes cyclic episodes of nausea, vomiting, and compulsive hot water bathing for alleviation in individuals with chronic cannabis use. An 18-year-old male with daily and prolonged cannabis use has excessive nausea and vomiting, is diagnosed with CHS, and is further complicated by severe and rapidly fluctuating hypophosphatemia. He was successfully managed with intravenous (IV) antiemetic (metoclopramide) and IV normal saline in the emergency department. Hypophosphatemia was treated with IV phosphorous. Although hypophosphatemia in CHS is a rare encounter, the authors share their experience to promote broader recognition and insight into successful management.

BACKGROUND: This report presents a case of cannabinoid-induced hyperemesis syndrome causing repeated violent retching in a patient with a large (8 cm) adrenal pheochromocytoma resulting in hypertensive urgency.
METHODS: A 69-year-old white male patient with a previously diagnosed pheochromocytoma presented to the emergency department with nausea and vomiting and was found to have hypertensive urgency. Computed tomography scan did not show any acute abdominal pathology and history was inconsistent with a gastrointestinal etiology. Patient had a history of daily cannabinoid use for many years and repeated self-limited hyperemesis episodes, and thus a diagnosis of cannabinoid-induced hyperemesis syndrome was made. It was concluded that the likely explanation for the hypertensive urgency was from physical compression of his adrenal tumor during the episodes of retching resulting in a catecholamine surge. The patient was given antiemetics and admitted to the intensive care unit for blood pressure management. Blood pressure was initially controlled with phentolamine and a clevidipine infusion, then transitioned to oral doxazosin and phenoxybenzamine. Hyperemesis and abdominal pain resolved after 24 hours, and his blood pressure returned to baseline. The patient was discharged with the recommendation to stop all cannabis use. On follow-up, his blood pressure remained well controlled, and he subsequently underwent adrenalectomy for tumor removal.
CONCLUSIONS: Hyperemesis can cause hypertensive events in patients with pheochromocytoma by increasing abdominal pressure, leading to catecholamine release.

BACKGROUND: Gastrointestinal (GI) symptoms are commonly observed in patients with diabetic ketoacidosis (DKA), which usually resolves completely with therapy. However, GI symptoms can persist after DKA resolves, which can pose diagnostic and management challenges for physicians, especially when dealing with an exceptional diagnosis such as cannabinoid hyperemesis syndrome (CHS).
METHODS: In this case report, we present a patient with type 1 diabetes who had been treated for DKA 6 times in the past year and was eventually diagnosed with CHS.
CONCLUSIONS: In conclusion, this case demonstrates that a presumptive and incorrect diagnosis can mislead physicians, especially when dealing with challenging diagnoses. Therefore, patients with type 1 diabetes with unusual presentations, such as unexpectedly high pH and bicarbonate levels, with hyperglycemic ketosis should be screened for illicit drug use, especially cannabis.

Cannabis is a commonly used illicit drug worldwide with many noted adverse effects and medical properties. It has been previously used in medicine for the management of chemotherapy-induced nausea and vomiting. The chronic use of cannabis is well-known to be associated with psychological and cognitive adverse effects, however, cannabinoid hyperemesis syndrome is a less commonly recognized complication of chronic long-term use of cannabis, though it does not occur in the majority of chronic cannabis users. Here we present the case of a 42-year-old male who presented with classical clinical features of cannabinoid hyperemesis syndrome.

BACKGROUND: Synthetic cannabinoids are commonly used to manage pain, nausea, and vomiting in oncology and palliative care. Despite the current acceptance of cannabinoids as a treatment option for nausea and vomiting, there is a lack of data regarding the side effects of its prolonged use leading to possible toxicity due to accumulation, and as a result, exacerbation of nausea and vomiting rather than alleviation. Case Report Presentation: The patient, a 70-year-old female, was residing in the palliative care unit with the diagnosis of small-cell lung cancer. She underwent a course of chemotherapy consisting of paclitaxel, docetaxel, and cisplatin. She presented with hair loss, sore mouth, a loss of appetite, diarrhea, neuralgia, nausea, and vomiting which developed approximately 5 h after chemotherapy. Nabilone was used for the last 5 years to manage the patient\'s neuralgia. As her cancer progressed, a dosage of nabilone was incrementally increased from 0.5 to 2 mg to control her pain; however, it exacerbated refractory nausea and vomiting. Nabilone was discontinued 7 weeks after administration due to suspicion of cannabinoid hyperemesis syndrome. Hot baths were attempted with temporary relief. Her pain became well controlled with opioids and adjuvants and there has been no recurrence of nausea and vomiting since the cessation of nabilone.
CONCLUSIONS: Successful recognition and management of cannabinoid hyperemesis syndrome is especially important in individuals with comorbid disorders in order to avoid cannabis toxicity.

UNASSIGNED: Superior mesenteric artery syndrome (SMAS) occurs when the third portion of the duodenum is compressed between the superior mesenteric artery (SMA) and the aorta, causing duodenal obstruction. This condition most commonly arises from marked weight loss that reduces the size of the fat pad between these vessels, causing greater acuity of angulation. We present an unusual case of SMAS occurring in an adolescent due to precipitous weight loss resulting from cannabinoid hyperemesis syndrome (CHS).
UNASSIGNED: A 17-year-old adolescent presented emergently with voluminous bilious emesis. She endorsed a history of recent weight loss and a longstanding history of chronic heavy cannabis use associated with recurrent nausea and vomiting. Her chronic symptoms satisfied the Rome IV criteria for cannabinoid hyperemesis syndrome, but her acute vomiting symptoms were more extreme. Evaluation was significant for mild abdominal tenderness and fullness of the epigastrium. Contrast abdominal CT demonstrated moderate gastric and proximal duodenal distention with tapering of the lumen between the SMA and the aorta, consistent with SMAS.
UNASSIGNED: To our knowledge, this is the first reported case of SMAS occurring as the result of CHS. Clinicians should be aware of this possible juxtaposition, when a patient with a history of chronic excessive cannabis use, stereotypical vomiting resembling cyclic vomiting syndrome, and considerable rapid weight loss presents with a sudden exacerbation of symptoms, even when a normal BMI is maintained.

We report the death of a 22-year-old woman, with a 3½ year history of cyclic vomiting and cannabis use since age 14, who developed torsades de pointes cardiac arrythmia while being treated in the emergency room for nausea and vomiting. Resuscitation restored spontaneous cardiac circulation, however, due to post-cardiac arrest anoxic brain injury, she never regained consciousness and was declared brain dead 4 days later. Postmortem examination confirmed hypoxic-ischemic encephalopathy, in keeping with the in-hospital diagnosis of brain death. The heart was anatomically normal but showed signs of acute post-cardiopulmonary arrest reperfusion injury. As a consequence of limited survival in hospital in a neuro-vegetative state, early bronchopneumonia and isolated pulmonary thromboemboli were seen. Toxicological studies confirmed cannabis use, in addition to the presence of haloperidol and ondansetron. Genetic studies were performed to rule out a possible channelopathy and revealed a mutation in the MYBPC3 and RYR2 genes. Death in this woman with cannabinoid hyperemesis syndrome was attributed to a fatal cardiac arrhythmia complicating vomiting-induced hypokalemia and treatment with QT interval prolonging and potentially arrhythmogenic medications, with the identified cardiac genetic mutations listed as contributing factors. The emphasis of this report is a) to raise awareness that death can occur due to cyclic vomiting, b) provide a brief but practical overview of cannabinoid hyperemesis syndrome, c) describe the findings from our postmortem examination and come to the most reasonable cause and mechanism of death, d) comment on the risk factors associated with torsades de pointes cardiac arrythmia, and e) conclude that a complete postmortem examination is needed to exclude an anatomical or toxicological cause of death in cannabinoid hyperemesis syndrome, a disabling but preventable disorder.

BACKGROUND: Cannabis use is on the rise. Several cases of cannabinoid hyperemesis syndrome, secondary to chronic cannabis intoxication, have been described worldwide, but few cases have described this entity in pregnant women.
METHODS: We describe a 29-year-old pregnant patient that had consumed cannabis and experienced uncontrolled vomiting. The use of hot baths, the rapid improvement in symptoms, and results of complementary examinations suggested a diagnosis of cannabinoid hyperemesis syndrome. The patient could return home, and she continued her pregnancy and childbirth without peculiarities.
CONCLUSIONS: Cannabinoid hyperemesis syndrome should be considered in the differential diagnosis of vomiting in pregnancy. Consumption of cannabis must be systematically included in the anamnesis. However, it seems to be somewhat unacceptable socially or medically. Consumption must be stopped to manage symptoms.

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The use of cannabis for recreational as well as medicinal use is on the rise recently with more states legalizing it. We conducted a review analysis of the literature published on acute respiratory failure from vaping cannabis oil. We have also summarized the clinical details (age, length of stay, mode of ventilation, common clinical findings, and steroid use) along with common laboratory abnormalities. This article aims to educate health care providers on the clinical manifestations and management strategies for vaping-induced acute respiratory failure. We also discussed the different available formulations of cannabis oil and key ingredients responsible for the vaping-associated lung injury.