Management of Rodenticide Poisoning Associated with Synthetic Cannabinoids Patrick O
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CASE IN POINT Management of Rodenticide Poisoning Associated with Synthetic Cannabinoids Patrick O. Godwin, MD, MBA; Sarah Unterman, MD; Zane Z. Elfessi, PharmD; Jaimmie D. Bhagat, PharmD; and Kevin Kolman, PharmD Synthetic cannabinoids may be adulterated with potent vitamin K antagonists, which should be considered if a patient presents with unexplained coagulopathy, widespread bleeding, and a history of synthetic cannabinoid use. etween March 7, 2018, and May 9, dyspnea, headache, fevers, chills, or dysuria. Patrick Godwin is Chief of Hospital Medicine, Sarah 2018, at least 164 people in Illinois The patient’s past medical history in- Unterman is Chief of Bwere sickened by synthetic cannabi- cluded hypertension, dyslipidemia, chronic Emergency Medicine, noids laced with rodenticides. The Illinois lower back pain, and vitamin D deficiency. Zane Elfessi, Jaimmie Department of Public Health has reported His past surgical history was notable for an Bhagat, and Kevin Kolman are Clinical 4 deaths connected with the use of synthetic exploratory laparotomy after a stab wound Pharmacy Specialists, cannabinoids (sold under names such as to the abdomen. The patient reported tak- all at Jesse Brown VA Spice, K2, Legal Weed, etc).1 Synthetic can- ing the following medications: morphine SA Medical Center in Chicago, nabinoids are mind-altering chemicals that 30 mg bid, meloxicam 15 mg daily, amitrip- Illinois. Patrick Godwin is an Associate Professor of are sprayed on dried plant material and often tyline 100 mg qhs, amlodipine 5 mg daily, Clinical Medicine and sold at convenience stores. Some users have hydrocodone/acetaminophen 5/325 mg q12h Sarah Unterman is a reported smoking these substances because prn, atorvastatin 20 mg qhs, omeprazole Clinical Assistant Professor of Emergency Medicine, they are generally not detected by standard 20 mg qam, senna 187 mg daily prn, psyl- both at the University of urine toxicology tests. lium 1 packet dissolved in water daily prn, Illinois College of Medicine Recreational use of synthetic cannabinoids and cholecalciferol 1,000 IU daily. in Chicago. Zane Elfessi can lead to serious and, at times, deadly com- The patient’s temperature was 98o F, blood and Jaimmie Bhagat are Clinical Assistant plications. Chemicals found in rat poison pressure, 144/80 mm Hg; pulse, 131 beats per Professors, both at the have contaminated batches of synthetic can- minute; respiratory rate, 18 breaths per min- University of Illinois College of Pharmacy in nabinoids, leading to coagulopathy and se- ute; and O2 saturation, 98% (ambient air). A vere bleeding. Affected patients have reported Chicago. physical examination revealed no acute dis- Correspondence: hemoptysis, hematuria, severe epistaxis, tress; he was coughing up blood; clear lungs; Patrick Godwin bleeding gums, conjunctival hemorrhages, heart sounds were tachycardic and irregu- ([email protected]) and gastrointestinal bleeding. The follow- larly irregular; soft, nondistended, mild gen- ing case is of a patient who presented to an eralized tenderness in the abdomen with emergency department (ED) with severe co- no guarding and no rebound. The pertinent agulopathy and cardiotoxicity after using an laboratory tests were international normal- adulterated synthetic cannabinoid product. ized ratio (INR), > 20; prothrombin time, > 150 seconds; prothrombin thrombo- CASE PRESENTATION plastin time, 157 seconds; hemoglobin, A 65-year-old man presented to the ED re- 13.3 g/dL; platelet count, 195 k/uL; porting hematochezia, hematuria, and he- white blood count, 11.3 k/uL; creatinine, moptysis. He reported that these symptoms 0.57mg/dL; potassium, 3.8 mmol/L, D-dimer began about 1 day after he had smoked a test, 0.87 ug/mL fibrinogen equivalent units; synthetic cannabinoid called K2. The pa- fibrinogen level, 624 mg/dL; troponin, tient stated that some of his friends who used < 0.04 ng/mL; lactic acid, 1.3 mmol/L; total the same product were experiencing simi- bilirubin, 0.8 mg/dL; alanine aminotrans- lar symptoms. He reported mild generalized ferase, 22 U/L, aspartate aminotransferase, abdominal pain but reported no chest pain, 22 U/L; alkaline phosphatase, 89 U/L; mdedge.com/fedprac MAY 2019 • FEDERAL PRACTITIONER • 237 Synthetic Cannabinoid Poisoning FIGURE 1 Electrocardiogram Showing Atrial Fibrillation With Rapid coagulopathy due to concern Ventricular Response for possible rodenticide poi- soning associated with very long half-life. This dose was then decreased to 50 mg bid. He was given IV fluid resus- citation with normal saline and started on rate control for AF with oral metopro- lol. His heart rate improved. An echocardiogram showed new cardiomyopathy with an ejection fraction of 25% to 30%. Given basilar infil- trates and 1 episode of low- grade fever, he was started on ceftriaxone for possible community-acquired pneu- monia. The patient was urinalysis with > 50 red blood cells/high started on cholestyramine to help with wash- power field; large blood, negative leukocyte out of the possible rodenticide. No endo- esterase, negative nitrite. The patient’s urine scopic interventions were performed. toxicology was negative for cannabinoids, The patient was transferred to an inpa- methadone, amphetamines, cocaine, and ben- tient telemetry floor 24 hours after admission zodiazepines; but was positive for opiates. An to the ICU once his tachycardia and bleed- anticoagulant poisoning panel also was ordered. ing improved. He did not require transfu- An electrocardiogram (ECG) and imaging sion of packed red blood cells. In the ICU studies were ordered. The ECG showed atrial his INR had ranged between 1.62 and fibrillation (AF) with rapid ventricular re- 2.46 (down from > 20 in the ED). His hemo- sponse (Figure 1). A chest X-ray indicated bi- globin dropped from 13.3 g/dL on admission basilar consolidations that were worse on the to 12 g/dL on transfer from the ICU, before right side. A noncontrast computed tomogra- stabilizing around 11 g/dL on the floor. The phy (CT) of the head did not show intracra- patient’s heart rate required better control, nial bleeding. An abdomen/pelvis CT showed so metoprolol was increased to a total daily bilateral diffuse patchy peribronchovascular dose of 200 mg on the telemetry floor. Oral ground-glass opacities in the lung bases that digoxin was then added after a digoxin load could represent pulmonary hemorrhage, but for additional rate control, as the patient re- no peritoneal or retroperitoneal bleeding. mained tachycardic. Twice a day the patient continued to take 50 mg vitamin K. Cho- Treatment lestyramine and ceftriaxone were initially In the ED, the case was discussed with the continued, but when the INR started increas- Illinois Poison Control Center. The patient ing again, the cholestyramine was stopped was diagnosed with coagulopathy likely due to allow for an increase to more frequent to anticoagulant poisoning. He was imme- 3-times daily vitamin 50 mg K adminis- diately treated with 10 mg of IV vitamin K, tration (cholestyramine can interfere with a fixed dose of 2,000 units of 4-factor pro- vitamin K absorption). According to the toxi- thrombin complex concentrate, and 4 units cology service, there was only weak evidence of fresh frozen plasma. His INR improved to to support use of cholestyramine in this 1.42 within several hours. He received 5 mg setting. of IV metoprolol for uncontrolled AF and Given his ongoing mild hemoptysis, was admitted to the intensive care unit (ICU) the patient received first 1 unit, and then for further care. another 4 units of FFP when the INR in- In the ICU the patient was started on oral creased to 3.96 despite oral vitamin K. vitamin K 50 mg tid for ongoing treatment of After FFP, the INR decreased to 1.93 and 238 • FEDERAL PRACTITIONER • MAY 2019 mdedge.com/fedprac Synthetic Cannabinoid Poisoning subsequently to 1.52. A CT of the chest FIGURE 2 Computed Tomography of the Chest Showing showed patchy ground-glass densities Patchy Ground-Glass Densities Representing Pulmonary throughout the lungs, predominantly at Hemorrhage the lung bases and to a lesser extent in the upper lobes. The findings were felt to rep- resent pulmonary hemorrhage given the patient’s history of hemoptysis (Figure 2). Antibiotics were stopped. The patient re- mained afebrile and without leukocytosis. The patient’s heart rate control improved, and he remained hemodynamically stable. A thyroid function test was within normal limits. Lisinopril was added to metoprolol and digoxin given his newly diagnosed car- diomyopathy. The patient was observed for a total of 4 days on the inpatient floor and discharged after his INR stabilized around 1.5 on twice daily 50 mg vitamin K. The pa- tient’s hematuria and hematochezia com- pletely resolved, and hemoptysis was much improved at the time of discharge. His hemoglobin remained stable. The an- ticoagulant poisoning panel came back positive for difenacoum and brodifa- coum. Given the long half-lives of these cardioversion; however, he did not remain in 2 substances, the patient required ongoing sinus rhythm, and is being continued on an- high-dose vitamin K therapy. The patient ticoagulation and rate control for his AF. was seen 2 days and 9 days after hospital discharge by his primary care physi- DISCUSSION cian. He had no recurrence of bleeding. Users generally smoke synthetic cannabi- His INR had a slight upward trend from noids, which produce cannabis-like effects. 1.50 to 1.70, so his vitamin K dose was in- However, atypical intoxication effects with creased to twice daily 60 mg vitamin K. A worse complications often occur.2 These subsequent visit documented a follow-up products typically contain dried shredded INR of 1.28 on this higher dose. Six weeks plant material that is soaked in or sprayed after hospital discharge a repeat echocar- with several synthetic cannabinoids, vary- diogram showed a recovered ejection frac- ing in dosage and combination.3 Synthetic tion of 50% to 55%.