Can cannabis hyperemesis (cannabis-induced hyperemesis) be associated with fever?

Cannabis Hyperemesis Syndrome and Fever

Cannabis hyperemesis syndrome (CHS) is not typically associated with fever as a primary symptom, and the presence of fever should prompt investigation for alternative or additional diagnoses. 1

Clinical Presentation of CHS

CHS is characterized by specific symptoms that help distinguish it from other conditions:

• Stereotypical episodic vomiting
• History of prolonged cannabis use (typically >1 year before symptom onset)
• Frequent cannabis use (>4 times per week)
• Relief with hot showers/baths
• Resolution of symptoms after cannabis cessation

The American Gastroenterological Association recognizes CHS as a distinct clinical entity with these characteristic features 1. The syndrome typically progresses through prodromal, hyperemetic, and recovery phases 2.

Fever and Differential Diagnosis

When a patient with suspected CHS presents with fever, clinicians should:

• Consider alternative diagnoses or complications
• Perform a comprehensive workup including complete blood count, electrolytes, liver function tests, and other relevant tests 1
• Rule out life-threatening conditions that may present with similar symptoms

Potential Complications That May Cause Fever

Some complications of CHS that might present with fever include:

• Burns from excessive hot water exposure (a compensatory behavior in CHS) that become infected 3
• Dehydration leading to complications
• Sepsis in severe cases 3

Diagnostic Approach

When evaluating a patient with suspected CHS who also has fever:

1. Confirm cannabis use pattern (>1.5 g/day of smoked cannabis or equivalent)
2. Document characteristic symptoms (cyclic vomiting, relief with hot showers)
3. Perform thorough evaluation to rule out infectious causes of symptoms
4. Consider that fever suggests an alternative or additional diagnosis

Management Considerations

The definitive management for CHS is complete cessation of cannabis use for at least 3-6 months 1. However, for acute symptom management:

• IV fluid rehydration is essential
• First-line pharmacological interventions include:
  • Haloperidol (0.5-2 mg IV or PO every 4-6 hours, maximum 8 mg/24 hours)
  • Metoclopramide
  • Topical capsaicin cream
• Second-line options include serotonin receptor antagonists, benzodiazepines, and olanzapine

Clinical Pearls and Pitfalls

• Key pitfall: Attributing fever to CHS alone may lead to missed diagnoses of serious conditions
• Patients often remain skeptical about cannabis as the cause of their symptoms 1
• CHS is becoming increasingly prevalent as cannabis use increases 4
• Compulsive hot bathing is a characteristic feature that can lead to complications including burns 3

Special Considerations

• Monitor for potential neurological complications in patients with significant adverse effects from cannabis use 1
• Patients with preexisting cardiovascular disease require special caution when managing adverse effects of marijuana use 1
• Consider drug interactions, particularly with medications metabolized by cytochrome P450 enzymes 1