S4501 Vomiting and Vitamin Deficient: A Case of Wernicke's Encephalopathy Secondary to Cannabinoid Hyperemesis Syndrome

Introduction: Cannabinoid hyperemesis syndrome (CHS) can have multisystem consequences and can present in varying ways. Here we present a 55-year-old patient with CHS who presented for care due to new onset symptoms of Wernicke’s encephalopathy (WE). Case Description: A 55-year-old woman with medical history significant for migraines, gastroesophageal reflux disease, marijuana use, and several months of chronic nausea and emesis resulting in a recent 20 lb weight loss presented to the emergency department (ED) for altered mental status and aphasia. Serologic testing revealed a thiamine level of 45 nmol/L. A magnetic resonance imaging (MRI) showed bilateral thalamic changes suggestive of WE. The patient was admitted to the hospital and treated with fluid resuscitation, adequate oral intake, and 3 days of intravenous thiamine, after which she returned to her cognitive baseline and was discharged appropriately. Due to a history of chronic abdominal pain, diarrhea, and constipation, the patient had undergone both an esophagogastroduodenoscopy and colonoscopy the year before which were both negative. After discharge, she was seen again by gastroenterology. At this time, she endorsed daily use of marijuana in the months preceding her hospitalization for self-treatment of migraines. When prompted, she admitted to spending significant time taking hot showers to ease her nausea and vomiting prior to the ED presentation. After discharge, she had discontinued marijuana use and was no longer having daily nausea. In subsequent months, she had continued improvement of symptoms through optimization of medical management and total abstinence from marijuana. Subsequent MRI showed resolution of thalamic abnormalities. Discussion: Gastroenterologists are often involved in the care of patients with nausea and vomiting of unclear etiology. Despite its classic signs and symptoms, CHS poses challenges to diagnosis including limited patient understanding of the emetic potential of cannabinoids and varying disclosure of marijuana usage. WE has been increasingly linked to conditions beyond heavy alcohol use, but current literature shows minimal reports of WE secondary to CHS. A progression of WE can result in irreversible neuropsychiatric symptoms collectively known as Korsakoff syndrome, yet many cases of WE will go undiagnosed. In this patient, prompt administration of thiamine was likely a key factor in her symptomatic improvement and highlights the importance of considering CHS not only as a cause of chronic nausea and vomiting, but also as a provocative factor for WE and its dangerous sequelae.