|Year : 2016 | Volume
| Issue : 6 | Page : 256-258
Acute rhabdomyolysis following synthetic cannabinoid ingestion
Demilade A Adedinsewo1, Oluwaseun Odewole2, Taylor Todd3
1 Department of Internal Medicine, Morehouse School of Medicine, Atlanta, GA; Grady Memorial Hospital, Atlanta, GA, USA
2 Grady Memorial Hospital, Atlanta, GA; Department of Family Medicine, Morehouse School of Medicine, Atlanta, GA, USA
3 Grady Memorial Hospital, Atlanta, GA; Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
|Date of Web Publication||30-Jun-2016|
Dr. Demilade A Adedinsewo
80 Jesse Hill Jr. Dr. SE, Atlanta, GA 30303
Source of Support: None, Conflict of Interest: None
Context: Novel psychoactive substances, including synthetic cannabinoids, are becoming increasingly popular, with more patients being seen in the emergency room following acute ingestion. These substances have been associated with a wide range of adverse effects. However, identification of complications, clinical toxicity, and management remain challenging. Case Report: We present the case of a young African-American male who developed severe agitation and bizarre behavior following acute K2 ingestion. Laboratory studies revealed markedly elevated serum creatine phosphokinase (CPK) with normal renal function. The patient was managed with aggressive intravenous (IV) fluid hydration and treatment of underlying psychiatric illness. Conclusion: We recommend the routine evaluation of renal function and CPK levels with early initiation of IV hydration among patients who present to the emergency department following acute ingestion of synthetic cannabinoids to identify potential complications early as well as institute early supportive therapy.
Keywords: K2, rhabdomyolysis, stimulant drugs, synthetic cannabinoids
|How to cite this article:|
Adedinsewo DA, Odewole O, Todd T. Acute rhabdomyolysis following synthetic cannabinoid ingestion. North Am J Med Sci 2016;8:256-8
|How to cite this URL:|
Adedinsewo DA, Odewole O, Todd T. Acute rhabdomyolysis following synthetic cannabinoid ingestion. North Am J Med Sci [serial online] 2016 [cited 2019 Nov 18];8:256-8. Available from: http://www.najms.org/text.asp?2016/8/6/256/185038
| Introduction|| |
Novel psychoactive substances and stimulants including synthetic cannabinoids aka "spice" or "K2" and synthetic cathinones aka "bath salts" add a layer of complexity with regards to correctly identifying and managing acute substance ingestion and toxicity in the emergency department (ED). Identification of synthetic cannabinoids in biological specimens continues to be challenging  given metabolites are not currently included in routine drug screening tests.  This likely adds to their appeal among those who ingest these substances as they would be difficult or almost impossible to identify. Studies have shown that the use of these new psychoactive substances is prevalent among adolescents and young adults. ,,, Very little is known about the acute adverse effects following the use of these synthetic compounds or its long-term effects, more so, given the chemical composition of these drugs are constantly being changed by clandestine manufacturers.  Some reported effects include seizures, chest pain, vomiting, breathing problems, and psychiatric manifestations such as panic, anxiety, paranoia, hallucinations, agitation, violent behavior, psychosis, and possible dependence. ,,, Case reports have also identified the additional complications of synthetic cannabinoid use including acute renal failure,  rhabdomyolysis,  acute delirium, , myocardial infarction,  QT prolongation,  stroke,  acute gastric dilation,  and leukodystrophy.  Benzodiazepines and haloperidol have been suggested to be helpful in the management of symptoms. However, there are no antidotes for these substances and guidelines for management currently do not exist.
| Case Report|| |
A 27-year-old man was brought to the emergency room on account of agitation and bizarre behavior shortly after ingestion of K2. The patient arrived in the ED 2 h post ingestion. He had received 2 mg of lorazepam and 2 mg of midazolam before arrival in the ED with a resolution of behavioral symptoms. While in the ED, he denied any complaints and was unable to remember the events surrounding the reported episode. He denied syncope, seizures, or trauma to the head but said: "I felt like I was dying at the time." He also denied co-ingestion of any other recreational drug or other medications. He denied suicidal intent, saying, "I was just trying to get high. It is embarrassing." He noted a similar incident 3 months prior, also after ingesting K2 and said eyewitnesses told him that he had a seizure, but he never presented to the hospital. The medical history was significant for bipolar affective disorder (on fluoxetine and risperidone) and exploratory laparotomy 5 years ago for bowel obstruction. He was a current smoker, smoking one to two packs of cigarettes per day for the last 8 years but denied any other illicit drug use.
A review of systems was positive for sore throat, constipation, and headaches. Physical examination revealed a young male, who was calm, comfortable alert and oriented to time, place, and person. He was initially, tachycardic on presentation with a heart rate of 106, which improved to 75 after 30 min. Blood pressure on arrival was 119/84, and oxygen saturation was 98-100% on room air. The rest of his physical examination was unremarkable. Laboratory results revealed markedly elevated serum creatine phosphokinase (CPK): 18,812 (laboratory ref range: 49-397 U/L) and mildly elevated aspartate aminotransferase: 160 (laboratory ref range: 10-42 U/L). The remainder of his metabolic profile, complete blood cell count, urinalysis, serum ethanol, acetaminophen and salicylate levels were essentially normal. A urine toxicology screen was positive only for benzodiazepines. An electrocardiogram (EKG) showed a sinus rhythm with concave ST elevations and J point notch in leads I, V4, V5, V6, a pattern considered a normal variant or commonly described as early repolarization without evidence of the left ventricular hypertrophy and normal QTc = 386.
He was diagnosed with synthetic cannabinoid intoxication and rhabdomyolysis and managed with aggressive intravenous (IV) hydration with normal saline, receiving 5 L of fluid while in the emergency department (ED). He was subsequently admitted to the medicine service for further management of rhabdomyolysis. Intravenous fluid hydration was continued at 250 ml/h and psychiatric medications were resumed. Over the next 2 days, CPK levels trended down from 18,812 to 8414, and renal function remained within normal limits.
He was discharged from the hospital after 3 days and counseled to avoid illicit drugs and synthetic stimulant ingestion.
| Discussion|| |
We describe a patient with acute ingestion of K2 and resultant severe rhabdomyolysis with normal renal function while remaining clinically and hemodynamically stable. Rhabdomyolysis is a rare complication of synthetic cannabinoid use and requires a high index of suspicion and laboratory evaluation for early identification. Elevated CPK levels, in our patient, may have been potentiated by severe agitation prior to arrival in the ER. Given K2 ingestion has been associated with seizures and agitation these features are likely to be contributing factors for the marked elevation of CPK.
Benzodiazepines, as monotherapy, are the main-stay of therapy for the management of seizures and agitation having a toxicologic cause while phenytoin and levetiracetam are not recommended. 
K2 and other synthetic stimulants are being marketed under false advertising schemes and often labeled as "not for human consumption" to avoid regulatory agencies. In addition, the chemical compositions of these agents are constantly being changed, taking advantage of a loophole, in order to market them as legal alternatives to marijuana.
Several states have reported an outbreak of life-threatening symptoms and deaths among patients presenting to the emergency room following synthetic cannabinoid exposure. , This re-emphasizes the need for a thorough evaluation of patients presenting to the ED with unknown etiology for behavioral disturbance with suspected ingestion of synthetic cannabinoids.
The pathophysiology of the associated adverse effects of these new drugs is still poorly understood, and a comprehensive list of related complications does not exist at this time. Given, the constantly changing chemical composition of these designer drugs, studies attempting to identify antidotes or treatments face a challenging task. In addition, we were unable to obtain biologic confirmation of exposure to "K2" in the serum although we ordered a serum test for synthetic cannabinoids. This is not surprising, as standard drug tests are limited and cannot easily detect many of the chemicals used in these products  given the constantly changing chemical composition of these substances; there is a high likelihood of false negatives.
We recommend a high index of suspicion for synthetic stimulant use among young person's presenting to the ED with behavioral symptoms of unknown etiology and comprehensive testing to identify potential complications early should be performed, i.e., a complete metabolic profile, CPK, lactic acid, toxicology screen to identify co-ingestion of other substances, EKG, and a complete blood count. We also recommend the early institution of IV hydration in patients without contraindications to IV fluids pending the availability of results; given patients with potentially life-threatening complications such as rhabdomyolysis may appear clinically well.
There is paucity of scientific evidence regarding the treatment of synthetic cannabinoid toxicity and supportive care and management of clinical symptoms are the current main-stay of therapy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Davies BB, Bayard C, Larson SJ, Zarwell LW, Mitchell RA. Retrospective analysis of synthetic cannabinoid metabolites in urine of individuals suspected of driving impaired. J Anal Toxicol 2016;40:89-96.
Patrick ME, O′Malley PM, Kloska DD, Schulenberg JE, Johnston LD, Miech RA, et al.
Novel psychoactive substance use by US adolescents: Characteristics associated with use of synthetic cannabinoids and synthetic cathinones. Drug Alcohol Rev 2015. DOI: 10.1111/dar.12372.
Gudsoorkar VS, Perez JA Jr. A new differential diagnosis: Synthetic Cannabinoids-associated acute renal failure. Methodist Debakey Cardiovasc J 2015;11:189-91.
Finkelstein Y, Goel G, Hutson JR, Armstrong J, Baum CR, Wax P, et al.
Drug misuse in adolescents presenting to the emergency department. Pediatr Emerg Care 2015. [Epub ahead of print]. DOI: 10.1097/PEC.0000000000000571.
Palamar JJ, Martins SS, Su MK, Ompad DC. Self-reported use of novel psychoactive substances in a US nationally representative survey: Prevalence, correlates, and a call for new survey methods to prevent underreporting. Drug Alcohol Depend 2015;156:112-9.
Kemp AM, Clark MS, Dobbs T, Galli R, Sherman J, Cox R. Top 10 facts you need to know about synthetic cannabinoids: Not so nice spice. Am J Med 2016;129:240-4.
Chase PB, Hawkins J, Mosier J, Jimenez E, Boesen K, Logan BK, et al.
Differential physiological and behavioral cues observed in individuals smoking botanical marijuana versus synthetic cannabinoid drugs. Clin Toxicol (Phila) 2016;54:14-9.
Müller HH, Kornhuber J, Sperling W. The behavioral profile of spice and synthetic cannabinoids in humans. Brain Res Bull 2015. pii: S0361-923030052-6.
Zhao A, Tan M, Maung A, Salifu M, Mallappallil M. Rhabdomyolysis and acute kidney injury requiring dialysis as a result of concomitant use of atypical neuroleptics and synthetic cannabinoids. Case Rep Nephrol 2015;2015:235982.
Tyndall JA, Gerona R, De Portu G, Trecki J, Elie MC, Lucas J, et al.
An outbreak of acute delirium from exposure to the synthetic cannabinoid AB-CHMINACA. Clin Toxicol (Phila) 2015;53:950-6.
Kasper AM, Ridpath AD, Arnold JK, Chatham-Stephens K, Morrison M, Olayinka O, et al.
Severe illness associated with reported use of synthetic cannabinoids - Mississippi, April 2015. MMWR Morb Mortal Wkly Rep 2015;64:1121-2.
Tait RJ, Caldicott D, Mountain D, Hill SL, Lenton S.
A systematic review of adverse events arising from the use of synthetic cannabinoids and their associated treatment. Clin Toxicol (Phila) 2016;54:1-13.
Von Der Haar J, Talebi S, Ghobadi F, Singh S, Chirurgi R, Rajeswari P, et al.
Synthetic cannabinoids and their effects on the cardiovascular system. J Emerg Med 2016;50:258-62.
Sevinc MM, Kinaci E, Bayrak S, Yardimci AH, Cakar E, Bektas H. Extraordinary cause of acute gastric dilatation and hepatic portal venous gas: Chronic use of synthetic cannabinoid. World J Gastroenterol 2015;21:10704-8.
Fellner A, Benninger F, Djaldetti R. Synthetic cannabinoids revealing adrenoleukodystrophy. J Clin Neurosci 2016;24:155-6.
Andrabi S, Greene S, Moukaddam N, Li B. New drugs of abuse and withdrawal syndromes. Emerg Med Clin North Am 2015;33:779-95.
|This article has been cited by|
||Synthetic Cannabinoid-Associated Multiple Organ Failure: Case Series and Literature Review
| ||Faith Armstrong,Michael T. McCurdy,Mojdeh S. Heavner |
| ||Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy. 2019; |
|[Pubmed] | [DOI]|
||Toxic by design? Formation of thermal degradants and cyanide from carboxamide-type synthetic cannabinoids CUMYL-PICA, 5F-CUMYL-PICA, AMB-FUBINACA, MDMB-FUBINACA, NNEI, and MN-18 during exposure to high temperatures
| ||Richard C. Kevin,Alexander L. Kovach,Timothy W. Lefever,Thomas F. Gamage,Jenny L. Wiley,Iain S. McGregor,Brian F. Thomas |
| ||Forensic Toxicology. 2018; |
|[Pubmed] | [DOI]|
||Rhabdomyolysis after exercise with an electrical muscle stimulator
| ||Mary Ellen Zator Estes |
| ||The Nurse Practitioner. 2018; 43(9): 8 |
|[Pubmed] | [DOI]|