Case: A highly anxious and dehydrated adolescent came to a local emergency department with complaints of intractable emesis, weight loss, and abdominal pain. He stated that bathing and "guzzling water" ameliorated symptoms. He admitted to using marijuana socially. Efforts at palliation with benzodiazepines, atypical antipsychotics, and antiemetic medications were unable to soothe the patient. After thorough initial diagnostics and physical exam failed to elucidate etiology, the patient was referred to an inpatient psychiatric facility for further evaluation of potential psychosomatic or affective causes. During psychiatric evaluation and upon obtaining additional information from family and reviewing the work done by primary care providers, the patient was questioned stringently about his marijuana use patterns. Questioning revealed that the patient had previous chemical dependency treatment, legal charges related to drug use, and heavy daily marijuana use including "dabbing," ingestion of THC candy, and smoking up to several grams a day.
Discussion: Cannabinoid hyperemesis syndrome (CHS) consists of intractable emesis, abdominal pain, and weight loss. There is often a history of symptom amelioration with bathing and showering. These patients may or may not admit to heavy marijuana use. Cannabis effects vary and are dose dependent. Historically, CHS would require over a year of heavy daily use. In this day and age of higher THC potency marijuana and even higher THC potency "dabs," it is anticipated that more cases of cannabis related syndromes in general, and CHS in particular will be presenting more frequently to ambulatory and emergency room settings. The patients will potentially be younger and have a shorter duration of heavy cannabis use before symptoms start. A high index of suspicion will be required to prevent expensive and potentially invasive workups and thus delaying diagnosis and treatment.