The patient’s past medical history included Type 1 diabetes mellitus,gastroparesis, and hypertension. Her social history was significant for daily marijuana use, but she denied alcohol and tobacco. Upon the current admission, the patient denied chest pain, headaches, shortness of breath, back pain, and diarrhea. The patient also stated that nothing aggravated or relieved the symptoms. Vitals were as follows: Blood pressure 153/110mmHg, Pulse 95 beats/min, temperature 98.9°F, respiratory rate 15 breaths/min,and SpO2 100% on room air. A physical exam revealed an alert, awake, and oriented female with dry mucus membranes, diffuse abdominal pain, and bilateral mild tingling sensation in lower extremities. Her vomiting was bilious and sometimes mixed with blood. Cardiac and lung examinations were unremarkable.The patient’s social history, clinical presentation, vital signs, and labsat admission supported the diagnosis of CHS and are depicted in Table 1. The patient left the hospital against medical advice and was discharged on haloperidol5 mg by mouth every 8 hours. The patient was given instructions regarding the diagnosis, expectations, follow-up, and return precautions.
Unfortunately,despite counseling, the patient was not amenable to cannabis cessation at that time. She was also counseled on the importance of therapy adherence and following up with her primary care physician. Reports of CHS in patients have increased over the years, despite the syndrome’s increasing prevalence, many physicians are unfamiliar with its diagnosis and treatment . This under-recognition may be due to the paradoxical use for the treatment of nausea and vomiting, the stigma associated with cannabis use,and the illegal status of cannabis in some areas leading to under-reporting of use.The frequency of emergency department visits and high hospital admission rates for CHS exemplify the difficulty in symptom management . The lack of knowledge and treatment recommendations regarding CHS compounds this issue.We report the first case of recurrent acute cannabinoid hyperemesis syndrome successfully treated with haloperidol given both intramuscularly and orally. The Naranjo adverse drug reaction probability scale was utilized to assess the probability that the hyperemesis was related to cannabinoid use, and a total score of 6 was obtained.Diagnosis is determined through receiving a detailed medication history and a comprehensive physical examination.
In a recent systematic review conducted by Sorensen and colleagues, the following diagnostic characteristics and frequency of each were found: history of regular cannabis use for over one year, severe nausea and vomiting ,vomiting that recurs in a cyclic pattern over months, resolution of symptoms after stopping cannabis, compulsive hot baths/showers with symptom relief , male predominance, abdominal pain , at least weekly cannabis use, history of daily cannabis use , and age less than 50 at time of evaluation. With >10 years of self-reported cannabis use, our patient experienced the following symptoms: severe nausea and vomiting that has recurred over many months in a cyclic pattern.Haloperidol is a drug primarily used for sedation, behavioral agitation, and asan antipsychotic. However, haloperidol has been used as an antiemetic for years,particularly in the anesthesia, general surgery, and oncology literature .Haloperidolis a butyrophenone antipsychotic that non-selectively blocks postsynaptic dopaminergic D2 receptors in the chemoreceptor trigger zone. The CTZ is located in the medulla oblongata and is exposed to toxins in the blood stream,which triggers vomiting. The mechanism of action of haloperidol’s antiemetic effects in CHS is unknown. The medication may decrease nausea and vomiting by blocking the dopamine receptors in the CTZ, thus reducing input to the medullary vomiting center. Early administration of haloperidol in acute episodes of CHS may reduce symptoms, minimize the time in the emergency room,and reduce the rate of hospital admissions .
These reported cases have been summarized in Table 4. In 5 out of the 6 reportedcases,haloperidol was given intramuscularly only, and in one case, the route of administration was not provided . Also, interestingly only one of the cases was a woman and our case makes two. In a recent analysis synthesizing findings from case reports found that men were overwhelmingly more likely to be diagnosed with CHS relative to women. However, this sex discrepancy may reflect heavier cannabis use reported among men relative to women, rather than a sex-specific sensitivity to this adverse effect of cannabis. More studies are warranted to research these findings.The main point from these six cases was that patients continued to have refractorynausea and vomiting with standard antiemetics. However, once given doses of haloperidol, the patients experienced a clinically significant improvement in their symptoms. And like the other cases, our patient received a multitude of other antiemetics without the relief of symptoms and it was only when she was treated with IV haloperidol followed by oral did her symptoms subside.