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A potentially new and interesting syndrome that you might already be seeing and missing!
Commentary by: Sean Nordt and Mel Herbert, MD’s
Interlude: Cheech and Chong Skit Daves Not Here. Under under fair use act.
It definitely happens. We have 4-5 similar cases in our community. The day I listened to this podcast one of our regulars was in the department when I arrived..asking to take a shower
The September 2011 issue of "Southern Medical Journal" has a literature review of cannabinoid hyperemesis syndrome, along with a proposed algorithm for diagnosis and treatment.
I had never heard of this - but already have had a bunch of people saying they have seen it but didn't know it was a described syndrome!
Sarah P., M.D.I am a 2nd Year Family Medicine resident and have personally seen 2 cases.
Worked in Cannabis Hyperemesis Syndrome Center of Excellence for a couple of years, had regulars exhibiting all of the symptoms described in a pod cast. Some carrying diagnosis of cyclical vomiting per their GI docs.
couple other observations:
- very stereotypical psychomotor agitation; rocking in bed or even dance like movement next to their gurney ( any one else noticed it )
- I noted that dilaudid, but no other opiates, works to get them comfortable
- telling them to quit pot as a part of the treatment does not go over well in many cases, I even sat down and went through the abstract with them, symptoms and treatment recommended
Interesting. I will look out for this now that i know what to look out for
I had never heard of this before, but now I think I have the diagnosis for one of our frequent er patients with "cyclic vomiting"His presentation was always very dramatic- you could hear him retching 2 streets away. Dilaudid always settled him down, but the relief was short lived. His tox screen was always positive for thc, but he never admitted to any drug use. I long suspected that he was withdrawing from opiates, but could never prove it. (and apparently I was wrong)I will share this info with his Primary Care Doc.Mel, Thanks for a great CME ..
Interesting, I had two patients in mind when listening to the podcast a few weeks ago. Well, last week both presented to the ED with retching. Dilaudid and Zofran given to both with relief. The warm shower or bathing history came up without prompting. One said his symptoms came on when he was at work, and if he had been at home he would have taken a warm shower. The cannabis use was in both, one said that he had not used for several days and used prior to his symptoms. Also, one said that he was made aware of CHS, perhaps the GI docs r catching on.
Curious----Why does Dilaudid seem to relieve symptoms of nausea in these cases?
I had a case last night with a guy who is on probation and must drug test every month. He is only smoking Spice, but had the classic syndrome..Using weed for past 10+ years, Spice for last year, 10+ hot showers a day and going to family member's houses to take them also. I ruled out all organic causes and then sent him home. Key here was that when the nurses and I asked him if he was smoking or using MJ he said no. His girlfriend piped in and said "Ya but you smoke Spice". He responded that Spice wasn't MJ. Has anyone else seen this with Spice or K2. Both have cannabanoids so I assume the mechanism is the same.
Had a 18 year old female almost fall off the exam table when I asked her if hot showers relieved the symptoms. Then I asked about her thc history: 8 years of daily use. She says she is going to quit.
Dilaudid works, yes. Even for vomiting - don't know why.Stereotypical movements, yes. Rocking back and forth on bed prominent. "Kidney stone" type agitation, although our main guy always just plops down prone on the gurney.Difficult to quit, definite yes. My primary index case is still visiting us, especially around harvest time. I had heard that a regular marijuana habit is possibly the most difficult drug habit to quit. Seeing how miserable these patients are, it looks at least as bad as a severe opiate withdrawal. The paradox of course is that the prompt resolution for alcohol or opiate withdrawal is readministration; for CHS to continue is to perpetuate the misery.
I have diagnosed this 3 times since listening to the podcast. Just yesterday a patient's eyes almost left their sockets when I asked if hot showers helped his symptoms. I then asked about his THC use, which was chronic.
I have definitely tuned into this after listening to the podcast. Hot showers is so distinct and when patients volunteer it, it's all the more impressive. Personally, I haven't found that ondansetron works all that well but 2.5mg of droperidol or haldol resolves pain and nausea almost within 5 min.
This one episode changed my whole evaluation and treatment of these patients. Thank you.
In Denver, Colorado, we are ground zero for cyclic vomiters secondary to imbibing the strong green stuff. Some providers are having success with a cocktail of diphenhydramine 25mg, promethazine 25 mg, and atropine 0.4mg, in 1L NS over 30 minutes. Anyone else out there trying this?
What you do matters.