Cannabinoid Hyperemesis Syndrome (CHS): A Parisian Case Series

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To the Editors
In 2014, cannabis was the most widely used illicit psychoactive substance (PAS) around the world with 183 million users.1 In France, 17 million people have reported trying it at least one time in their life and 700,000 declared a daily use, even if according to the French Public Health Code, the illicit use of cannabis is punishable for 1-year detention and a fine of 3750 euros.2,3 Nevertheless, one pharmaceutical preparation of synthetic tetrahydrocannabinol (THC; dronabinol) is permitted in compassionate use: against nausea and vomiting induced by anticancer chemotherapy. Those antiemetic properties can be linked to the CB1 receptors localized in the central nervous system and the enteric plexus.4 Cannabis spray called Sativex® was granted marketing authorization in 2015 but is not yet commercialized. Worldwide, other pharmaceutical cannabinoids exist or are tested for similar indications or not.
Cardiovascular toxicity (acute coronary syndrome, peripheral arteriopathies) and bronchopulmonary toxicity associated with cannabis have already been reported in the literature.5 Cognitive and psychiatric toxicity such as panic disorder, mood disorder, and substance use disorder (SUD) are still being discussed.6 Meanwhile, a clinical picture seems to be more and more described. This addresses the issue of cannabinoid hyperemesis syndrome (CHS). First described in 2004, it concerned chronic cannabis abusers presenting cyclical vomiting and abdominal pain relieved by a hot shower/bath.7 The pathogenesis remains unclear, but CHS is usually defined by a prodromal phase followed by a phase of intensifying symptoms before a spontaneous and complete disappearance of the clinical signs after the cessation of cannabis use. In 2009, Sontineni et al8 defined clinical criteria, which were taken back and completed afterward by Simonetto et al9 in 2012.
Currently, cases of CHS reported in the literature are rare, and we propose to describe a case series evaluated based on the Simonetto CHS criteria to highlight potential specific characteristics of consumption. The other aim of this publication was to raise awareness of this syndrome to allow health professionals to take care of their patients properly and avoid costly and unnecessary investigations. Epidemiologic data should be improved and clinical aspects should be furthermore studied, particularly in consideration with the current decriminalization worldwide, which could generate a bigger use of cannabis and consequently put users at risk. We report a series of 19 clinical cases collected between 2012 and 2016 in the Ile de France region.
All cases were notified to the CEIP-A. a from addictologic units (12 cases), clinical departments (3 cases), and ADALISb (4 cases). All patients have a SUD.
Simonetto et al proposed major and supportive criteria for the diagnosis of CHS: Essential for diagnosis: long-term cannabis use; major features: severe cyclical nausea and vomiting, resolution of symptoms with cannabis cessation, relief of symptoms with hot showers or baths, abdominal pain, epigastric or periumbilical, weekly use of marijuana; and supportive features: age younger than 50 years, weight loss of more than 5 kg, morning predominance of symptoms, normal bowel habits, negative laboratory, radiographic, and endoscopic test results.
Our cases are compared on these precise criteria.
Ninety-nine cases of CHS were collected between 2012 and 2016. Patients are predominantly male (n = 16), between 20 and 48 years old with a mean age of 29.8 years. Medical history is reported for 15 patients among whom 5 declared psychiatric disorders and 2 a history of vomiting and migraine in their childhood. All patients are regular and current users of cannabis; the average amount is 10 joints a day (minimum, 2; maximum, 20). Polyintoxication is mentioned with nicotine (all cases), alcohol (4 cases), other illicit drugs (2 cases), and therapeutic treatments (antidepressant, neuroleptic, anxiolytic) in 3 cases.
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