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IMAGES IN MEDICINE

Pneumomediastinum in a Patient with Cannabinoid Hyperemesis Syndrome

MARC J. VECCHIO, MD; WILLIAM D. BINDER, MD, FACEP

48 49 EN CASE PRESENTATION Figure 1. (A) Red arrows illustrating extensive pneumomediastinum and pneumo- A 23-year-old man with a past medical retroperitoneum; (B) illustrating air extending into the neck and spinal canal. history of cannabinoid hyperemesis syn- drome presented to the emergency depart- A B ment with 1 week of nausea, emesis and poor oral intake. Prior to presentation, the patient had been treated in the emer- gency department several times for intrac- table vomiting. The patient reported he was a daily long-term user of marijuana cigarettes. On presentation, the patient was afebrile with a pulse of 117 beats per minute, res- pirations of 20 per minute, blood pressure of 111/79 and oxygen saturation of 99% on room air. Physical examination revealed a thin man with eructation and subcutane- ous crepitation over the neck and thorax. Lung sounds were clear to auscultation bilaterally. Laboratory testing revealed a pH of 7.26, of 33, blood-urea nitrogen of 107 mg/dL and a newly ele- vated of 13.01 mg/dL. Nota- bly, the patient had normal labs with a creatinine of 0.84 mg/dL during a similar presentation for intractable vomiting one month prior to presentation. Chest X-ray showed evidence of subcutaneous gas and pneumomediastinum. Computed tomog- raphy (CT) of the chest and abdomen with intravenous contrast revealed pneu- momediastinum and pneumoretroperito- neum with extension into the spinal canal (Figure 1). Repeat CT imaging of the chest with oral contrast was performed and did not show extraluminal oral contrast extravasation into the (Figure 2). The patient was subsequently discharged without mediastinum. The patient was evaluated by cardiothoracic further complication. surgery, who recommended conservative management with Two months after discharge, the patient presented with close monitoring of symptoms. Urinalysis demonstrated a subsequent episode of intractable vomiting from can- muddy brown casts and renal tubular epithelial cells, sug- nabinoid hyperemesis syndrome. CT of the chest with gesting pre-renal secondary to volume depletion. intravenous contrast revealed complete resolution of Treatment with 3 days of intravenous fluids and anti-emet- the patient’s prior findings of pneumomediastinum and ics resulted in normalization of the patient’s creatinine pneumoretroperitoneum.

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Figure 2. Laboratory evaluation revealing patient’s basic metabolic panel References prior to, during and following presentation for cannabinoid hyperemesis 1. Galli JA, Sawaya RA, Friedenberg FK. Cannabinoid hyperemesis syndrome. syndrome. Curr Drug Abuse Rev. 2011;4(4):241-249. 2. DeVuono MV, Parker LA. Cannabinoid Hyperemesis Syndrome: 1 Month prior Presentation 1 week after A Review of Potential Mechanisms. Cannabis and Cannabinoid Research. 2020;5:1132-144. to presentation discharge 3. Sorensen CJ, DeSanto K, Borgelt L, Phillips KT, Monte AA. 144 mEq/L 152 mEq/L 136 mEq/L Cannabinoid Hyperemesis Syndrome: Diagnosis, Pathophys- 3.7 mEq/L 4.7 mEq/L 3.2 mEq/L iology, and Treatment – a Systematic Review. J Med Toxicol. 2017;13(1):71-87. Chloride 111 mEq/L 102 mEq/L 101 mEq/L 4. Lapoint J, Meyer S, Yu CK, Koenig KL, et al. Cannabinoid Hy- 21 mEq/L 17 mEq/L 28 mEq/L peremesis Syndrome: Public Health Implications and a Nov- el Model Treatment Guideline. West J Emerg Med. 2018;19: BUN 14 mg/dL 107 mg/dL 10 mg/dL 380-386. Creatinine 0.84 mg/dL 13.01 mg/dL 0.87 mg/dL 5. Gajendran M, Sifuentes J, Bashashati M, McCallum R. Can- nabinoid hyperemesis syndrome: definition, , clinical spectrum, insights into acute and long-term man- DISCUSSION agement. Journal of Investigative Medicine. 2020;68:1309-1316. Definitive diagnosis of cannabinoid hyperemesis syndrome 6. Nourbakhsh M, Miller A, Gofton J, Jones G, Adeagbo B. Can- nabinoid Hyperemesis Syndrome: Reports of Fatal Cases. (CHS) has proven to be challenging, as there is no stan- J Forensic Sci. 2019;64(1):270-274. dardized diagnostic criteria. This is likely due to the elu- sive nature of the syndrome’s pathophysiology. It has been Authors hypothesized to involve a complex interaction between the Marc J. Vecchio, MD, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI. endogenous CB and CB cannabinoid receptors (with CB 1 2 1 William D. Binder, MD, FACEP, Department of Emergency responsible for the majority of deleterious clinical effects) Medicine, Warren Alpert Medical School of Brown University, 1,2 and tetrahydrocannabinol (THC) in marijuana. In an effort Providence, RI. to increase the sensitivity for diagnosis, a recent systematic review evaluated several case reports to determine which Correspondence symptoms were most frequently encountered in patients Marc J. Vecchio, MD Rhode Island Hospital with CHS. The symptoms with the highest sensitivity 593 Eddy St. included severe nausea and vomiting in a cyclical pattern Providence, RI 02903 over several months, a minimum of weekly cannabis use for 401-444-4000 longer than 1 year, symptom relief with hot baths or showers [email protected] and resolution of symptoms after cessation of cannabis use.3 There is a male predominance and episodes usually last 1–2 days, but can extend up to 10 days.4 While the symptoms of CHS may appear benign, intractable vomiting from CHS can result in severe complications including acute renal fail- ure, esophageal perforation, severe derangement, pneumomediastinum, and death.5,6 While our patient did not end up having esophageal perforation, his acute renal failure, electrolyte derangements and pneumomediastinum demonstrate the potential life-threatening complications of CHS. This case illustrates the importance of monitoring for these complications in patients who present with intractable vomiting as a manifestation of CHS.

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