Synthetic Cannabinoid‐Associated Multiple Organ Failure: Case Series and Literature Review

Abstract

Objective We describe a multicenter descriptive case series of six patients admitted with synthetic cannabinoid (SC) intoxication displaying similar symptoms and sequelae, all resulting in multiple organ failure. Methods Patients were included in this report if they presented with known SC use and experienced multiple organ failure between March 1, 2016, and July 19, 2016, to the intensive care units of three hospitals in Maryland. Patients were followed to either discharge or death, and complications related to SC were documented. Results All six patients presented with altered mental status and severe rhabdomyolysis, with a peak creatine phosphokinase ranging from 4000 to >320,000 units/L. The majority of patients (five of six) presented with acute kidney injury, with most (four of six) requiring continuous renal replacement therapy. Most patients experienced fever (five of six) and myocardial injury, as evidenced by a troponin elevation (three of six). Seizures occurred in half of patients (three of six patients). Two patients required emergent fasciotomies of the bilateral lower extremities for acute compartment syndrome. Two patients developed fulminant hepatic failure that necessitated liver transplant evaluation, one requiring Molecular Adsorbent Recirculating System (MARS) therapy as a bridge to successful transplant, while the patient without it did not survive. Delirium, severe rhabdomyolysis, acute kidney injury, and fever are common in patients with synthetic cannabinoid intoxication. Conclusions Given the growing abuse of these substances, clinicians should consider their use in the differential of such patient presentations. To our knowledge, only a few published case reports discuss multiple organ failure associated with SC toxicity, and only two have described an associated acute liver failure. Our report describes the first case of SC‐associated acute liver failure requiring organ transplantation. Clinicians should be aware of life‐threatening complications and consider SC ingestion in the differential diagnosis of patients presenting with multiple organ failure.

Designer drugs: mechanism of action and adverse effects

“…However, many of these cases were attributed to synthetic cannabinoid use based solely on statements by patients or witnesses, without analytical confirmation of the identity and amount of substances in bodily fluids or remaining drug products. Severe clinical complications that have been reported to be associated with synthetic cannabinoid use include convulsions and seizures (Adamowicz et al 2017;Bäckberg et al 2017;Bebarta et al 2012 Yirgin et al 2018), pneumonia and pulmonary infiltrates (Alhadi et al 2013;Alon and Saint-Fleur 2017;Berkowitz et al 2015;Chinnadurai et al 2016;Ö cal et al 2016), respiratory depression (Alon and Saint-Fleur 2017; Jinwala and Gupta 2012), supraventricular and ventricular arrhythmias (Davis and Boddington 2015;Ibrahim et al 2014;Ozturk et al 2019;Young et al 2012), myocardial ischemia and infarction (Clark et al 2015;Hamilton et al 2017;Hirapara and Aggarwal 2015;McIlroy et al 2016;McKeever et al 2015;Mehta et al 2017;Mills et al 2018;Mir et al 2011;Ozturk et al 2019;Shah et al 2016;Sherpa et al 2015;Tse et al 2014), takotsubo cardiomyopathy (Mohammed 2019), liver injury (Shahbaz et al 2018), acute kidney injury (Argamany et al 2016;Armstrong et al 2019;Bhanushali et al 2013;Buser et al 2014;El Zahran et al 2019;Gudsoorkar and Perez 2015;Kamel and Thajudeen 2015;Katz et al 2016b;…”

Adding more “spice” to the pot: A review of the chemistry and pharmacology of newly emerging heterocyclic synthetic cannabinoid receptor agonists

“…Similarly, 18 individuals showing signs of reduced levels of consciousness were transferred to local medical centers for emergency care in July 2016 in New York, following the consumption of the indazole SCRA, AMB‐FUBINACA ( 8 ) (Figure ) . SCRA consumption has also been linked with several adverse health effects, including seizures, acute respiratory distress syndrome (ARDS), acute kidney injury, myocardial infarction, pulmonary oedema, ischemic stroke, and multiple organ failure . Importantly, the aforementioned adverse effects associated with SCRA use are not typically observed following cannabis consumption .…”

Synthetic cannabinoid-associated coagulopathy secondary to long-acting anticoagulant rodenticides

“…There are notable differences between the two published geographic case series of synthetic cannabinoid-induced coagulopathy. [25,26] Kelkar et al [25] described a single tertiary care hospital's experience with managing 34 cases of LAAR-toxicity secondary to synthetic cannabinoid use. Most bleeding events were mild in both series, though the types of bleeding presentations differed slightly; intracerebral hemorrhage, bruising, melena, and menorrhagia were more frequent in the Illinois outbreak.…”

“…Another recent case series published by Armstrong et al [26] discusses the clinical course of 6 patients presenting with multi-organ failure from synthetic cannabinoids exposure. Psychological disturbance, acute kidney injury, severe rhabdomyolysis, compartment syndrome, shock, and liver failure were observed in this cohort, highlighting the wide variability in symptoms and severity after use of synthetic cannabinoids.…”