Adherence to Long-Term Follow-Up of Patients with Life-Threatening, Inhaled Synthetic Cannabinoids-Associated Coagulopathy in Chicago

A Case of Brodifacoum-Induced Epiglottitis

This case report presents a 33-year-old woman who presented to the emergency department with abdominal pain and gingival and vaginal bleeding. She admitted to using synthetic cannabinoids, and contamination with brodifacoum was suspected, for which qualitative testing was positive. The patient was discharged with an improved international normalized ratio (INR) seven days later with oral vitamin K. Fourteen days after discharge, she re-presented with widespread ecchymosis, leg swelling, and intermittent gingival and vaginal bleeding. Her INR was again elevated. She was controlled with oral vitamin K therapy, stabilized, and discharged three days later. Twenty-eight days following the second discharge, the patient re-presented with oral swelling, right eye ecchymosis, and vaginal bleeding after abstaining from vitamin K therapy for two weeks. A bedside nasopharyngolaryngoscopy showed the base of the tongue, epiglottis, aryepiglottic (AE) folds, arytenoids, and false vocal folds were all edematous with ecchymosis. Due to the diffuse epiglottic and supraglottic edema, the patient was intubated to avoid further decompensation. After receiving IV and oral vitamin K, she was extubated two days later. Her INR fully normalized, and she was then discharged on day 4. Our case of epiglottitis could demonstrate thermal injury associated with smoking synthetic cannabinoids, but given diffuse ecchymosis and severe coagulopathy, hematoma associated with brodifacoum poisoning was considered the most likely etiology. The patient's coagulopathy was rapidly reversed, empiric antibiotic coverage was provided, and she rapidly improved. Brodifacoum exposure has been known to cause increased bleeding, as seen in this case. However, it should also be considered that exposure can lead to epiglottitis. If a similar patient is presented in the future, it is important to consider that coagulopathy may be caused by the adulteration of drugs of abuse, specifically brodifacoum with synthetic cannabinoids.

From Euphoria to Emergency: Exploring the Role of K2/Spice in Diffuse Alveolar Hemorrhage

Marijuana or cannabis has been one of the most widely used recreational drugs, in the United States. However, a sinister counterpart has emerged in recent times: K2/Spice, a synthetic rendition of tetrahydrocannabinol (THC), capturing increasing popularity. Alarming reports have linked this synthetic compound to a multitude of life-threatening complications, ranging from acute kidney injury (AKI) from direct nephrotoxicity to cardiac arrest. Here we present the case of a 34-year-old man who presented with hemoptysis, later found to have diffuse alveolar hemorrhage (DAH) on the investigation after smoking K2/Spice successfully treated with a course of intravenous steroids. The case presented underscores the urgent need for increased awareness about the potential complications associated with synthetic compounds like K2/Spice, such as diffuse alveolar hemorrhage, and the importance of developing effective treatment strategies.

Superwarfarin poisoning: challenges still remain

Superwarfarin (long-acting anticoagulant rodenticide) poisoning should be suspected in unexplained bleeding with prolonged prothrombin time, especially in the absence of another explanation. Diagnosis and treatment of this intoxication remain a challenge as the direct analysis of superwarfarin in serum is not always possible. Therefore, toxin bioavailability remains unknown and close monitoring and treatment for long periods are required to avoid serious bleeding complications. Here, we discuss a case of suspected superwarfarin poisoning to highlight the challenges in early diagnosis and the challenges we encountered in treatment management and ensuring compliance for long periods.

Cannabinoids in Neurology - Position paper from Scientific Departments from Brazilian Academy of Neurology

Cannabinoids comprehend endocannabinoids, phytocannabinoids, and synthetic cannabinoids, with actions both in the central and peripherical nervous systems. A considerable amount of publications have been made in recent years, although cannabis has been known for over a thousand years. Scientific Departments from the Brazilian Academy of Neurology described evidence for medical use in their areas. Literature is constantly changing, and possible new evidence can emerge in the next days or months. Prescription of these substances must be discussed with patients and their families, with knowledge about adverse events and their efficacy.

Unmet clinical laboratory need in patients hospitalized for acute poisoning from long-acting anticoagulant rodenticides

The importance of real-time, quantitative toxicology data available for physicians treating poisoned patients was illustrated during the 2018 outbreak in Illinois of severe coagulopathy caused by inhaling illicit synthetic cannabinoids products contaminated with commercially-available brodifacoum, difenacoum, and bromadiolone, three potent, long-acting anticoagulant rodenticides (LAARs). Identification and quantification of these life-threatening toxins in blood samples of hospitalized patients required toxicology testing with liquid chromatography-tandem mass spectrometry (LC-MS/MS) that was not available in clinical laboratories of hospitals at the time of the outbreak. This highly-sensitive, quantitative assay can provide critical information to guide patient care during and after hospitalization, including identification of offending LAARs, estimates of the ingested dose, and dosage and discontinuation of oral vitamin K1 therapy after hospital discharge once plasma LAARs concentrations decreased to a safe level (<10 ng/mL). Accordingly, we propose an action plan to enable treating physicians to quantify plasma concentrations of several LAARs simultaneously in poisoned patients. It involves rapid (<15 min), sensitive, and validated LC-MS/MS methods developed, tested and validated in our laboratory. This will allow treating physicians to request quantitative plasma LAARs testing, report test results in the patient's hospital discharge summary, and recommend regular monitoring of plasma LAARs concentrations in the outpatient setting.

Effects of vitamin K1 treatment on plasma concentrations of long-acting anticoagulant rodenticide enantiomers following inhalation of contaminated synthetic cannabinoids

Background: An outbreak of synthetic cannabinoid (SC)-associated coagulopathy and bleeding in Illinois, USA was determined to be due to inhalation of SC contaminated with brodifacoum (BDF), difenacoum (DiF), and bromadiolone (BDL), highly potent long-acting anticoagulant rodenticides (LAARs). Treatment with high-dose vitamin K1 (VK1) prevented mortality; however, plasma LAAR levels were not measured risking recurrence of coagulopathy and bleeding due to premature discontinuation. The goal of this study was to determine if plasma LAAR levels were reduced following standard of care treatment to normalize coagulopathy.Methods: Blood samples were collected from a cohort of 32 patients, and ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) analysis used to quantify plasma LAAR levels including enantiomers.Results: BDF was detected in 31 samples; 30 also contained DiF and 18 contained BDL. Initial plasma levels were 581 ± 87, 11.0 ± 1.9, and 14.9 ± 5.9 ng/mL for BDF, DiF, and BDL, respectively (mean ± SE). At discharge plasma, BDF levels remained elevated at 453 ± 68 ng/mL. Plasma half-lives for BDF, DiF, and BDL were 7.5 ± 1.3, 7.2 ± 1.9, and 1.8 ± 0.3 days, respectively. The half-life for trans-BDF enantiomers (5.7 ± 0.8 days) was shorter than for cis-enantiomers (7.6 ± 1.9 days). BDF half-lives were shorter, and coagulopathy normalized faster in patients receiving intravenous VK1 as compared to oral VK1. Patients prescribed VK1 at discharge had fewer re-admittances.Conclusions: These results demonstrate that plasma LAAR levels at discharge were elevated in poisoned patients despite normal coagulation, and that the route of VK1 administration affected LAAR pharmacokinetics and INR normalization. We propose plasma LAAR levels and coagulation be monitored concomitantly during follow-up of patients with LAAR poisoning. KEY POINTSIn patients treated with high-dose vitamin K1 for LAAR poisoning, plasma levels remained 40-fold above safe levels upon discharge from hospital.LAAR half-lives, normalization of coagulopathy, and readmittances were reduced by treatment with intravenous vitamin K1.