An 18-year-old woman came to the emergency department with nausea, abdominal pain, and vomiting that had lasted for four days. She also had some diarrhea, which had stopped. She had no fever or chills and had not been in contact with anyone who was sick. Since her symptoms began, she was unable to eat. She said that taking hot showers was the only thing that made her feel better.

As part of routine screening, a sexual health history was obtained. She said she was sexually active, did not use condoms, and had multiple partners. She was currently on her menstrual period.

Her entire abdomen was sore to the touch, but her physical examination was otherwise normal.

Despite intravenous fluids and medications for her pain and nausea, she was unable to keep any food or drink down. She was admitted to the hospital for fluids and further tests and after a few days felt better.

Similar episodes occurred over the next six months, requiring repeated hospital admissions.

Results of blood tests were all normal: Her pregnancy test was negative; her urine showed that she did not have a bladder or kidney infection.

A pelvic ultrasound showed a cyst, or fluid-filled sac, on her right ovary. Large ovarian cysts, more than about 2½ inches in diameter, can cause twisting (torsion) of the ovary, which is a very painful medical emergency. But our patient’s cyst was only an inch wide, most like the type that does not cause pain and usually resolves on its own.

We considered dysmenorrhea, or menstrual cramps, which can cause such intense lower abdominal pain that it can lead to nausea and vomiting. But our patient’s pain involved her whole abdomen, not just her lower abdomen, ruling out dysmenorrhea.

We were also concerned she might have pelvic inflammatory disease (PID), an infection of the ovaries, fallopian tubes, or uterus that can cause vomiting and abdominal pain. PID is usually caused by a sexually transmitted infection. Our patient tested positive for chlamydia (which condom use prevents). However, PID was ruled out because she did not have any pain on her gynecologic examination.

During these months, she lost 25 pounds, which she was happy with because she said her thighs and abdomen were “too big.” Her frequent vomiting and extreme weight loss, coupled with apparent body issues, led us to consider an eating disorder. However, her severe abdominal pain made this unlikely to be her main diagnosis.

Solution

During each hospital stay, she was observed to take multiple hot showers. That sparked another possible diagnosis.

Cannabinoid hyperemesis syndrome (CHS) is a rare condition characterized by daily marijuana use for prolonged periods and severe recurring nausea and vomiting that is temporarily relieved by taking hot showers.

Marijuana works by attaching to receptors in the brain and gastrointestinal (GI) tract. Although short-term use may relieve nausea, long-term use may result in changes in the GI tract receptors that lead to severe nausea and vomiting. Patients with CHS often become dehydrated, requiring hospitalization for intravenous fluids. There is no explanation for why hot showers help.

Our patient acknowledged she used marijuana frequently.

Based on the medical history, physical examination, and test results, we concluded that our patient had CHS.

According to one study, the prevalence of CHS nearly doubled after the legalization of medical marijuana in some states.

The only cure for CHS is to completely stop using marijuana.

Some people may need support from drug rehabilitation programs and therapy. A list of marijuana addiction hotlines can be found at drugrehab.com/addiction/drugs/marijuana/hotlines.

Rima Himelstein is an adolescent-medicine specialist and Sydney Jones is a third-year pediatric resident at Nemours/AI duPont Hospital for Children.