National Library of Medicine / National Institutes of Health:
Serotonin Syndrome versus Cannabis Toxicity in the Emergency Department
As more states legalize marijuana, the potential of marijuana abuse could lead to an increase in the number of emergency department (ED) visits. We describe two patients who presented to the ED with dilated pupils, rigidity in both lower extremities, and clonus in both feet after inhaling the vapor of a highly potent form of marijuana. Serotonin syndrome diagnosis was initially considered in the differential diagnosis. Ultimately, high-potency marijuana abuse was the final diagnosis. Therefore, marijuana toxicity should be considered in ED patients who present with signs and symptoms similar to that of serotonin syndrome.
As the legalization of cannabis becomes prevalent in the United States, effects from its abuse will result in an increase in emergency department (ED) visits.1 We have witnessed a growing trend in our community ED among adolescents abusing a highly potent form of marijuana, butane hash oil (BHO). BHO is a concentrated form of tetrahydrocannabinol (THC) that is created by using liquid butane as a solvent to extract THC from marijuana plants.
A 17-year-old female presented to a large community ED by emergency medical services (EMS) from her home for a possible seizure. EMS providers had witnessed agitation, altered mental status, tachycardia, muscle stiffness and tremors in the limbs, ….
Serotonin syndrome was considered in the differential diagnosis. After pediatric critical care and pediatric neurology consultation, one oral dose of cyprohepatidine 4 mg was administered. The patient was admitted to the pediatric intensive care unit. Magnetic resonance imaging of the brain was normal, and an electroencephalogram showed no epileptic activity. The patient rapidly improved and was discharged the following day. Prior to discharge, the patient admitted to “dabbing” about 30 minutes prior to arrival to the hospital. The same patient returned to the ED the following night with a similar presentation, once again associated with dabbing.
A 16-year-old male took “a hit from a dab pen” while on the bus to school. He developed altered mental status and was transported to the ED. On arrival he was mildly obtunded, Glasgow Coma Score was 13 (three for eye-opening response, four verbal response, and six motor response). Vital signs were recorded as blood pressure 152/86 mmHg, pulse 116 bpm, oral temperature 98.6° F and 100% pulse oximetry on room air. Physical exam showed dilated pupils to five mm, tachycardia, and rigidity of the lower extremities with non-sustained clonus in the legs bilaterally. Lab results were normal with the exception of a drug screen positive for THC. This patient slowly improved over six hours of observation in the ED and was discharged home.
The most striking exam finding in these two ED patients was the lower extremity rigidity with hyper-reflexivity. Animal studies have demonstrated that potent cannabinoid receptor agonists may activate the serotonin receptors (5-hydroxytryptamine1A and 5-hydroxytryptamine2A), and THC inhibits serotonin re-uptake.5, 8 Therefore, it is likely that emergency physicians may see some of the hallmarks of serotonin syndrome in “dabbing” users.