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Cannabis arteritis: Australian man diagnosed with marijuana-related disease that can cause loss of limb

Man will have to take aspirin as a blood thinner for the rest of his life

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An Australian man who smokes up to a gram of cannabis per day has narrowly escaped amputation after becoming the first in the country to be diagnosed with a rare disease linked to cannabis use.

After an ulcer on his toe failed to heal, the man consulted Frankston Hospital in Melbourne, where he was diagnosed with cannabis arteritis, an extremely rare disease which causes a build-up of plaque around the arteries, thereby decreasing blood flow to the limbs.

The patient, who has not been identified, was treated with a balloon angioplasty, where a collapsed balloon, known as a balloon catheter, is placed in the area which is constricted in order to inflate it to a healthy size.

Where cannabis is and isn’t legal

1 /10 Where cannabis is and isn’t legal

Where cannabis is and isn’t legal

Where cannabis is and isn’t legal

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Where cannabis is and isn’t legal

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Where cannabis is and isn’t legal

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He will also have to take aspirin, a blood thinner, for the rest of his life, according to reports in the Sunday Morning Herald.

Smoking cannabis can cause blood vessels to tighten, which increases resistance and contributes to an increasing amount of plaque building up around the arteries, thereby narrowing the artery itself.

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Cannabis arteritis occurs when the constriction of arteries reduces blood flow to the affected limbs, which can lead to death of cells, called necrosis. Severe cases of necrosis can lead to necessary amputation.

Very similar symptoms can be seen in patients suffering from Bueger’s disease, which is strongly linked to tobacco use.

Although fewer than 100 cases of the disease have ever been recorded, Dr Soon, of the Royal College of Australasian Surgeons, said medical professionals should still remain alert.

“Due to the increase in cannabis usage and the legalisation of medicinal cannabis, awareness of the condition is important and may become a growing problem in the future,” he told the Annual Scientific Congress.

1 /1 Man treated for cannabis-related disease that can lead to amputation

Man treated for cannabis-related disease that can lead to amputation

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Man will have to take aspirin as a blood thinner for the rest of his life

Journal of Rheumatology and Arthritic Diseases

Author Name: Dr. Ingo Schmidt

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Marijuana is the 3 rd most popular recreational drug and the use of recreational and medical marijuana has been legalized in several states. Knowledge of both acute and chronic adverse effects of cannabis is essential when counseling the public. We report 2 cases who developed arteritis and Raynaud’s as a squeal of long term cannabis use and provide a literature review.

Key words: Cannabis, Vasculitis, Raynauds, Thromboangiitis obliterans, Connective tissue disease.

A man in his 50’s, was admitted with a six week history of cool, painful, purplish fingertips of both hands. He was diagnosed with presumed new onset Reynaud’s one month previously which did not respond to nifedipine. Subsequently he was hospitalized with progressive symptoms, and tissue necrosis affecting the tips of digits 2-5 of both hands as well as new purplish discoloration of two of his toes. Preceding symptoms included decreased appetite and a several pound weight loss. He had forty pack year history of tobacco and had quit 8 years previously. At the time of admission, he had been smoking marijuana on a daily basis for several years, up to ten joints a day, and reported a recent increase in use due to hand pain. He denied other illicit drugs. Nifedipine was his only medication.

Physical examination revealed a middle aged man who appeared well. His vital signs were stable. The tips of fingers 2-5 bilaterally were cool and tender to palpation. Eschar formation was present on all digits distal to the DIP joints sparing the right fourth finger and bilateral thumbs with purplish discoloration extending proximal to the eschar. Radial pulses were strong, but ulnar pulses were absent bilaterally with positive Allen’s test. The patient also had tenderness and purplish discoloration of his right fourth and fifth toes. No neurologic deficits or synovitis was appreciated.

A complete blood cell count was only notable for platelets of 456,000. His serum creatinine and urinalysis were normal. Liver studies were significant for a mildly elevated ALT of 39 and his ESR was 31. Urine drug screen was positive for cannabinoid. Serum complements were slightly elevated with a C3 of 175 and C4 of 56. Studies for hepatitis B, hepatitis C, rheumatoid factor, anti-neutrophil cytoplasmic antibodies, antinuclear antibody, cryoglobulins, fasting glucose, serum protein electrophoresis, HIV, anticardiolipin antibodies, lupus anticoagulant, beta2-glycoprotein, factor V Leiden, and prothrombin gene were normal.

A chest radiograph revealed hyperexpanded lungs compatible with chronic obstructive pulmonary disease. Electrocardiogram and transthoracic echocardiogram, electromyography and nerve conduction studies were all normal. Angiography revealed loss of contrast flow to both ulnar arteries at the wrist level, poor filling of the superficial palmar arches, and no contrast flow to the left fifth and right second, third, and fourth digit arteries. Arteries supplying the thumbs were relatively spared. Subclavian, axillary, and brachial arteries were patent. In the right lower extremity there was no visible plantar arch and absent filling of distal arches. There were no corkscrew-like collateral vessels noted.

Upon admission, he was started on prednisone 1 mg/kg/day and low dose aspirin and continued on nifedipine. Patient was advised to stop smoking marijuana. His hand pain decreased and purplish discoloration to his hands began to regress. Prednisone was eventually tapered down to 5 mg per day. Nevertheless, patient still required amputation of his left third and right fifth digits. Repeat arteriogram nine months later revealed slight progression and exam revealed purplish discoloration to his left thumb. Patient admitted to a recent lapse of marijuana usage. His urine drug screen tested positive for cannabis.

A Caucasian man in his 20’s, presented with new onset of Reynaud’s, for 8 months, followed by diffuse pain, prolonged joint stiffness, and intermittent tingling in median nerve distribution of both hands.

Patient admitted to smoking marijuana on daily basis since starting his job about 12 months, in a marijuana farm. During that time he avoided direct contact with pesticide and denied other illicit drugs. His initial exam revealed mildly dilated nail fold capillary without dropouts. Rest of exam was unremarkable. His labs revealed negative ANA, scleroderma antibody, CCP, Rheumatoid factor, normal inflammatory markers, complete blood count, complete metabolic panel, and negative urinalysis. He later stopped both marijuana and working on farm. Despite this conservative treatment of avoidance, he continued to have arthralgia and Raynaud’s. Importantly with stopping of marijuana he did not progress with digital ulceration.

In our first case, several differential diagnoses were considered such as PolyarteritisNodosa (PAN), cryoglobulinemia, Buerger’s disease. The lack of vasculitic rash, lack of peripheral neuropathy, undetectable viral load, and normal complements and negative serologic work up made these unlikely. Patient was diagnosed with Marijuana induced arteritis becausecessation of marijuana immediately improved symptoms. When he relapsed and began to use marijuana again his symptoms returned.

In the second case, Raynaud’s occurred shortly after use of Marijuana. Although patient continued to have Raynaud’s however did not progress to digital ischemia after stopping the offending agent.

Cannabis Arteritis was first described in 1960 in young Moroccan males who smoked kif, an oriental variety of cannabis extract, and was largely forgotten in the literature until the 1990s [6]. Since then, over 50 cases have been reported, mainly in European publications; it is generally believed that there is a vast underestimation of the actual prevalence of this condition. Cannabis Arteritis closely resembles Buerger’s disease clinically and arteriographically and a correlation can be made between the role of tobacco in Buerger’s disease and cannabis in cannabis arteritis. A synergistic noxious effect of tobacco and cannabis has been postulated.

Cannabis Arteritis most commonly affects patients between the ages of 20 and 40, and typically presents with ischemic manifestation of the hands or feet. The lower extremities are more commonly affected. The review by Peyrot only identified 2 cases involving upper extremities and a review by Combemale likewise only identified 3 cases involving the upper extremities [7, 8]. Commonly reported symptoms of cannabis arteritis include claudication, acral pain, recent Reynaud’s phenomenon, and distal necrosis or gangrene of lower limbs. A history of cannabis use is always reported. There has been one case report of lower limb arteriopathy in a patient with significant amphetamine use and concomitant cannabis use as well, and the author has proposed that the arteriopathy was likely due to amphetamine via an inflammatory disturbance of the vasa vasorum, though the author also proposed a possible synergistic effect of amphetamine and cannabis [9]. Contaminants use of arsenic has been implicated in the Blackfoot disease, an endemic from of Buerger’s disease in Taiwan related to chronic arsenic poisoning from well water [10].

On exam, there may be weak or absent distal pulses, Allen’s maneuver can be positive with delay of filling of palmar arcades; acute phase reactants and autoantibodies are usually normal or negative. Laboratory tests for thrombophilic factors are often negative. In our case, lupus anticoagulant, anticardiolipin, and beta 2 glycoprotein were negative. Homocysteine was normal at 9.8 and Factor V Leiden and prothrombin G20210A were wildtype. In Disdier’s review of ten patients, three were noted to have slightly elevated homocysteine levels, though the levels were not specified. Most patients did not have other cardiovascular risk factors [11]. In Peyrot’s review of 55 patients, hypercholesterolemia was documented once and there were 4 cases of hypertriglyceridemia and one case of diabetes [7], though this was not observed in our patient.

Angiography often reveals distal segmental occlusions or skips lesions characterized by areas of diseased vessels interspersed with normal vessels. Both abrupt and smoothly tapered arterial occlusions can be found often with adjacent tortuous collaterals termed “corkscrews”. Compensatory networks have been found to be less well developed with less observation of corkscrews in patients with cannabis arteritis than in patients with Buerger’s Disease [12].

Histopathologic data is sparse and contradictory. Arterial biopsy is rarely performed as it may aggravate the condition. Sterne and Ducastaingt had reported that arterial biopsy in cannabis arteritis showed thrombosis, but no inflammation of the vascular wall. However, this histopathology analysis was made in late lesions and the author did not specify how many biopsies they found [13]. On the other hand, Disdier has reported thrombosis and endarteritis associated with mild inflammation involving the media, with fragmentation of the internal elastic lamina [11].

Marijuana is the 3rd most popular recreational drug and the use of recreational and medical marijuana has been legalized in several states. Knowledge of both acute and chronic adverse effects of cannabis is essential when counseling the public.