A Case of Acute Liver Failure Associated With Synthetic Cannabis Use: Presidential Poster

Abstract

Introduction: A previously healthy 27-year-old man was transferred to our institution with concerns for acute liver failure. He presented after 2-3 days of fatigue, anorexia, nausea, and vomiting. At the local hospital, he was found to have transaminases in the 10,000s, creatinine of 2.2, INR 6.5, and a lactic acid of >15, prompting transfer to our ICU. On arrival, the patient was alert but acutely ill-appearing. He denied use of any IV drugs, alcohol, or prescription medications. He admitted to current marijuana, synthetic cannabis, and tobacco use. He denied any OTC medications or supplements other than <2 gm of APAP used in the last 2 days since becoming ill. An infectious work-up was negative. An extensive liver evaluation showed no signs of autoimmune hepatitis, viral hepatitis, or toxin exposure. Tests for alpha-1-antitrypsin and Wilson’s disease were negative. Acetaminophen levels were low. Shortly after admission, the patient became obtunded, requiring intubation for airway protection. His acidosis worsened, and CVVH was initiated. Overnight, he developed significant hypoxia and hypotension. His clinical status continued to decline despite maximal intervention, and he was made DNR. He died a few hours later; less than 24 hours after admission. Autopsy revealed fulminant liver failure with massive (80-90%) acute hepatocellular necrosis. The patient was also found to have diffuse alveolar damage, consistent with ARDS, and ATN of the kidneys. Toxicology screen was positive for marijuana and 5F-PB-22, a synthetic cannabinoid. No other causes of the acute liver failure were identified. Although marketed as a harmless, legal alternative to marijuana, synthetic cannabinoids have been associated with cases of respiratory distress, acute kidney injury, psychosis, and death. Since this “synthetic marijuana” first appeared on the market in the early 2000s, the DEA has banned several chemical forms; however, the law has been unable to keep up with the influx of new formulations. 5F-PB-22 is a newer generation of synthetic cannabis and the first to contain an ester backbone in its chemical structure. This alteration appears to be associated with increased toxicity, with 5 deaths attributed to its use in less than a year. The constantly evolving structure of synthetic cannabinoids makes it difficult to predict associated complications. To our knowledge, this patient is the first to have acute liver failure associated with synthetic cannabis use. This case illustrates that new health problems continue to be identified and that all physicians should be familiar with these compounds. A complete history and high index of suspicion may help bring to light more conditions associated with synthetic cannabis use.