SPICE GOT US IN A PICKLE: A CASE OF SYNTHETIC MARIJUANA-INDUCED CARDIOMYOPATHY AND RHABDOMYOLYSIS

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Spice is a commonly used name for synthetic cannabinoids (SCs) which are chemical analogs of naturally occurring cannabinoids. They are increasingly used for their hallucinogenic effects, low cost and ease of availability. They are not detected in routine urine assays and their detection requires specialized urine drug screens making them an attractive option for young adults. There are case reports of cardiomyopathies associated with their overdose. We discuss the case of a young male who presents with rhabdomyolysis and cardiomyopathy after an intentional overdose of Spice. CASE PRESENTATION: A 21-year-old male with a past medical history of major depressive disorder and substance abuse (heroin, marijuana, spice) was brought in by emergency medical services after being found unresponsive. His vital signs were BP 78/46 mmHg, HR 97 beats per minute, RR 20 times a minute, temperature 100F, saturating 93% on room air. On physical exam, his pupils were pinpoint and he had a Glasgow Coma Scale of 8 (eye 2, verbal 2, motor 4) with decerebrate posturing. Labs showed pH of 6.94, bicarbonate of 12, Urine Drug Screen was positive for opiates and cannabinoids, lactate of 16.4, Creatinine of 2.3, a creatinine kinase of >22,000 and a troponin of 3.35. An EKG on admission showed sinus rhythm with short PR interval and J point elevation most noticeable in lead 1. Bedside ultrasound showed bi-ventricular failure with severe global hypokinesis. He was intubated and started on Dobutamine and Norepinephrine drips. On day 3, pressors were weaned off, he was extubated and Echo showed improved Left Ventricular function off pressors. His acute kidney injury resolved with hemodynamic support and Creatinine of 0.8 on discharge. He admitted to sniffing Heroin and smoking Spice prior to admission and he was discharged home. It was suspected he had spice induced cardiomyopathy and AKI. The patient had no history of coronary artery disease or alcohol use, no evidence of valvular abnormality and no signs of sepsis and the cardiomyopathy was attributed to Spice. He did not have prolonged hypotension, nephrotoxic medication use and his kidney injury was attributed to rhabdomyolysis. DISCUSSION: There are case reports of ST-elevation myocardial infarctions triggered by SC use; most of these have been young patients with normal-appearing coronary arteries on angiography. SCs bind to CBR1 receptors with a higher affinity than natural cannabinoids leading to direct negative inotropic effect on cardiomyocytes. While most case reports of SC-induced nephropathy involve acute tubular necrosis, our patient presented with rhabdomyolysis-induced nephropathy. CONCLUSIONS: SCs are far more dangerous than their natural counterparts and as they require special assays for detection, health care providers should be cognizant of their use and effects. Reference #1: Ting JYS. Reversible cardiomyopathy associated with acute inhaled marijuana use in a young adult. Clin Toxicol (Phila) 2007;45:432–4. https://doi.org/10.1080/15563650601073587. Reference #2: Bhanushali GK, Jain G, Fatima H, Leisch LJ. Thornley-Brown D. AKI associated with synthetic cannabinoids: A case series. Clin J Am Soc Nephrol. 2013;8:5236. https://doi.org/10.2215/CJN.05690612 DISCLOSURES: No relevant relationships by Iman Khan, source=Web Response