Cannabinoid Hyperemesis Syndrome in an Athlete

Case Report

A 19-year-old Black male Division I football player with no significant past medical history presented to the emergency department (ED) with 2 days of severe abdominal pain, nausea, and vomiting. The patient presented to student health the day prior and was diagnosed with unspecified nausea and vomiting and prescribed ondansetron. He did not recall any known sick contacts or recent travel history. He answered “never” to screening questions of smoking, alcohol, and drug use. On physical examination in the ED, he was reported pacing inside the room, breathing rapidly, and unable to follow simple commands from the nursing staff. Vital signs included temperature 98.4°F, blood pressure 142/73 mmHg, and heart rate 48 BPM. He received intravenous (IV) 2 doses of haloperidol and IV fluids. His diagnostic workup, including complete blood count (CBC), comprehensive metabolic panel (CMP), lipase, and computed tomography of the abdomen and pelvis with contrast were normal. Urinalysis showed specific gravity >1.030 but otherwise negative. A urine drug screen was not obtained. He was prescribed ondansetron for presumed viral gastroenteritis and discharged. The next day, the symptoms persisted. He presented again to student health and received the same unspecified diagnosis as with the prior visit. He again responded “No” to the use of tobacco, alcohol, and recreational drugs. Ondansetron was switched to promethazine, and he was recommended to adhere to a clear liquid diet.

The primary care team physician later saw him in the athletic training room to discuss symptoms that had been occurring for 6 days. The patient recently transferred from an out-of-state Division I football program and was not well known to the sports medicine staff. Symptoms were not improving with antiemetics but were briefly alleviated by taking hot showers. He was vomiting multiple times per day and had lost 10 kg since his initial preparticipation physical examination 2 weeks prior. On a directed history, he reported using a Tetrahydrocannabinol (THC) edible before his initial ED visit, which made his symptoms significantly worse. He reported daily cannabis use in the form of edibles and smoking since the age of 12. Vital signs included temperature 97.3°F, blood pressure 166/105 mmHg, and heart rate 52 BPM. On physical examination, the patient was in mild emotional distress but speaking full sentences and following commands. He was hypovolemic with a capillary refill of 4 seconds, delayed skin turgor, and dry oral mucosa. Lung sounds were clear but mildly labored. He was bradycardic, but no murmurs or friction rub auscultated. The abdomen was soft, nondistended, and had diffuse mild tenderness without rebound. Special tests including obturator test, iliopsoas test, Rovsing's sign, and Murphy's sign were negative.

Based on the patient's history and normal workup, the athlete was diagnosed with Cannabinoid Hyperemesis Syndrome (CHS) in the training room. The team physician discussed supportive treatment measures focusing on oral hydration and refraining from cannabis use in any form. He was advised to start applying topical capsaicin cream to his abdomen for symptom relief, and his promethazine was switched to suppository form. IV access for fluid resuscitation in the training room was unsuccessful. The patient was sent to the ED, where IV fluids were administered. Repeat laboratory workup, including CBC, CMP, and lipase, were normal. A urine drug screen was not completed. He was discharged.

Nine days after symptom onset, the patient had complete resolution of his symptoms. He was counseled on addiction and the risk of recurrence if he resumed cannabis use. He remained asymptomatic and abstinent from cannabis for the subsequent 3 weeks, but he was then suspended from the football team due to unrelated off-campus issues and lost to follow up.