ArticleLiterature Review

Cannabis arteritis: A new case report and a review of literature

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Abstract

Cannabis arteritis manifests in cannabis users, independently of tobacco consumption. Around 50 cases were reported in the literature since the first description of this entity in 1960. We report the case of a 36-year-old man, cannabis user, without vascular risk factor who developed digital necrosis on the right foot. The pedal pulses were not palpable. He had no abnormal laboratory findings. Arteriography revealed distal segmental lesions and occlusion of popliteal artery. This arteritis was linked to cannabis use, but the patient did not stop cannabis consumption. His symptoms became even worse and he eventually developed sub-acute ischaemia in his left leg despite vascular treatments. Amputation of the right second toe and of the left leg finally became necessary. Cannabis arteritis is relatively similar to thromboangiitis obliterans in its clinical and arteriographical presentation. A parallelism can be made between the role of tobacco in thromboangiitis obliterans pathogenesis and the role of cannabis in cannabis arteritis. Cannabis use must be searched in young patients presenting with arteriopathy. Cannabis arteritis may indeed represent a frequent cause of juvenile peripheral obstructive arterial disease, but is probably under-diagnosed.

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... Par rapport à l'artériopathie tabagique, les patients présentant une artériopathie liée au cannabis seraient souvent plus jeunes au début des symptômes ou au moment du diagnostic et présenteraient plus souvent des douleurs unilatérales, au repos, sans manifestations ulcéreuses ischémiques [84]. En cas de consommation persistante du cannabis, et ce, même après l'arrêt, voire absence de consommation de tabac, l'évolution de la pathologie est souvent sévère, avec, à terme, la nécessité d'une amputation (58 % des 80 patients) [70,77,85]. Par contre, un arrêt total d'exposition au cannabis, malgré une consommation de tabac maintenue, associé à un traitement médical et/ou chirurgical (iloprost, anti-aggrégant plaquettaire, sympatholyse, pontage, thrombolyse in situ) pourrait permettre, dans certains cas, une régression, voire guérison des lésions [77,78]. ...
... La revascularisation chirurgicale est rarement possible compte tenu de l'absence de lit d'aval. Les rechutes ou récidives des symptômes ont systématiquement été corrélées avec une reprise de la consommation de cannabis [69,70,[73][74][75]77,85]. ...
... La seconde, réalisée dans la série de Disdier et al., montrait une thrombose et une artérite, associées à un infiltrat de cellules mononucléaires et neutrophiles au niveau de la média, avec fragmentation de la limitante élastique interne [75]. Il est fort probable que l'aspect des lésions vasculaires secondaires au cannabis soit différent selon le stade de l'atteinte, tout comme dans la TAO [85]. Cependant, l'absence d'athérosclérose permet la distinction entre l'artérite liée au cannabis et les autres atteintes vasculaires périphérique chez les adultes de moins de 50 ans. ...
Article
Les complications vasculaires du cannabis sont encore largement discutées et leur incidence paraît faible en regard de la fréquence de l’exposition au cannabis dans la population générale. Les trois sphères qui sont potentiellement impliquées sont la sphère cardiaque, avec les syndromes coronariens aigus (SCA) et les arythmies, la sphère artérielle périphérique, avec l’artériopathie de type thromboangéite oblitérante (TAO), et la sphère cérébrale, avec les accidents vasculaires cérébraux (AVC). Les données épidémiologiques convergent pour une augmentation du risque de SCA ou d’AVC après exposition au cannabis. L’argument principal est une relation temporelle étroite entre l’exposition et la complication vasculaire, ainsi que l’exclusion habituelle d’autres étiologies. On note également un taux significatif de récidive en cas de ré-exposition. Cette association ne démontre cependant pas l’existence d’un lien causal. Il est par ailleurs difficile de faire ressortir des études le cannabis comme facteur de risque indépendant, car la majorité des patients a également des habitudes tabagiques. Tant pour les SCA que pour les AVC, le mécanisme physiopathologique le plus probable est celui d’un vasospasme artériel, tel qu’illustré dans les récentes observations de syndrome de vasoconstriction cérébrale réversible. En ce qui concerne les lésions artérielles périphériques, l’artériopathie associée au cannabis partage plusieurs caractéristiques épidémiologiques, cliniques et radiologiques avec la maladie de Buerger ou TAO. Le lien de cette maladie avec le tabagisme est bien établi. On peut imaginer que le cannabis jouerait un rôle de facteur précipitant en anticipant le début de la symptomatologie. Le décours de la maladie périphérique est influencé par l’arrêt ou la reprise de la consommation de cannabis.
... Vasculitis secondary to cannabis abuse, termed cannabis arteritis, was first described in the 1960's, and subsequently, there have been 70 reported cases in the literature. 3 It has been found to manifest in cannabis users independent of their tobacco or other drug use 4 ; a distinguishing feature being inflammation of the large proximal peripheral arteries. 5 Cannabis arteritis is a serious condition that can cause claudication, severe pain and necrosis and can lead to limb amputation. ...
... There are reported cases of symptomatic improvement when patients stopped using cannabis but did not discontinue their tobacco use. 4 Both heavy and lighter cannabis users can develop cannabis arteritis, and it is more common in young males. 11 The walls of the femoral and popliteal arteries were thickened in this case study and resulted in occlusive thrombosis of the vessel lumen. ...
... Thrombectomy, thrombolysis or arterial bypass are not effective without stopping cannabis use. 4 In this case, there were multiple investigations performed with no clear cause found for the vasculitis. The computed tomography angiography and positron emission tomography scans were suggestive of large vessel vasculitis, although this was not conclusive. ...
... Buerger's disease is a progressive, nonatherosclerotic, segmental infl ammatory vasoocclusive disease of unknown aetiology [1][2][3][4][5][6][7][8][9] , aff ecting the small and medium sized arteries, veins and nerves and is oft en bilateral 5,7 where infl ammatory thrombi may aff ect both the arteries and veins 5 . Th is disorder has been described as an autoimmune response, however the precise triggering antigen has not been discovered 10,11 . ...
... Th e disease has a high prevalence in people of low socioeconomic class who smoke bidis (homemade cigarettes with raw tobacco found in India) 5,12 . More recently, cannabis use has been attributed to the development of a form of vasculitis with very similar features to Buerger's disease 8,9 . ...
... Buerger's disease is a progressive, non-atherosclerotic, segmental infl ammatory vaso-occlusive disease of unknown aetiology [1][2][3][4][5][6][7][8][9] , affecting the small and medium sized arteries, veins and nerves and is often bilateral [5][6][7] . The normal structure of the vessel wall is usually preserved, including the internal elastic lamina and media. ...
Article
Buerger's disease is a progressive, nonatherosclerotic, segmental inflammatory vasoocclusive disease of unknown aetiology¹–⁹, affecting the small and medium sized arteries, veins and nerves and is often bilateral⁵–⁷. The normal structure of the vessel wall is usually preserved, including the internal elastic lamina and media. Buerger's disease predominantly affects male cigarette smokers¹–³,⁸ with 11%–23% of disease distribution in females⁶–⁷. Buerger's disease remains largely a clinicopathologic entity highlighting the importance of the sonographer's role to obtain a comprehensive clinical history and clinical examination. The combination of clinical assessment and the distinctive appearance of vessels affected by Bueger's disease on colour duplex ultrasound provide a useful tool for correct diagnosis.
... The pathophysiology is extremely similar to thromboangitis obliterans (Buerger's disease), an inflammatory and thrombotic disease of the small and medium arteries and veins of the hands and feet associated with tobacco use. [17][18][19][20] Additionally, cannabis usage has also been associated with claudication, Raynaud's phenomenon, ischemic ulcers, and digital necrosis. ...
... 26 In 2005 and 2007, Combermale and Peyrot et al., respectively, reported cases of vascular inflammation among cannabis users. 18,27 Combermale et al. reported a 38-year old chronic marijuana smoker who presented with dry necrotic lesions on the left big toe. 27 Imaging revealed proximal arteriopathy of the lower limbs. ...
... The necrotic lesions secondary to arterial insufficiency were successfully treated with hyperbaric oxygen therapy. 27 Peyrot et al. reported of a 30-year-old habitual cannabis smoker without any significant medical history, including no vasculopathies, who presented with digital necrosis of the right toe. 18 Arteriography revealed distal segmental arterial lesions that occluded the popliteal artery. After ruling out other causes, the vasculopathy was attributed to cannabis use. ...
Article
Marijuana is the most commonly abused illicit drug in the United States (US) and much of the Westernized World with a steadily increasing prevalence in usage and abuse over the past decade, especially among adolescents. Much of the available data on 9-tetrahydrocannabinol (THC), the main psychoactive ingredient in marijuana, relates to its neurological effects and anti-emetic properties, with very little on the cardiovascular (CV) effects of THC. Available literature shows that THC has three major effects on the CV and the peripheral vasculature in the form of "cannabis arteritis," cannabis-induced vasospasms, and platelet aggregation, with an unknown verdict on the relationship between marijuana use and atherosclerosis progression. This manuscript reviews these effects and possible mechanisms of action. Moreover, limitations on current views of marijuana and indirect causes of CV toxicity will be investigated, such as concurrent drug use, lifestyle, and mental health. The effects of marijuana on the CV system are extremely worrisome and likely need more attention due to the growing legalization of cannabis for medicinal and recreational use across the US. As a result, awareness among health care professionals about potential side effects and toxicities associated with acute and chronic exposure of cannabis will increase in importance.
... Cannabis arteritis is a rare vascular disorder, which was first described by Sterne and Ducastaingt in the 1960s [3]. only above fifty cases have been reported in the litterature (4). ...
... In the literature, we found 55 cases of cannabis arteritis [4]. Most are young males, and only 3 female cases have been reported [6,7]. ...
... The different symptoms reported in cannabis arteritis are: claudication [7], Raynaud's phenomenon [6], sub-acute distal ischemia of the lower limbs [9], distal necrosis or gangrene of lower limbs [3][4][5][6], absence of distal pulses (all cases) and venous thrombosis [9]. ...
Article
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Introduction Cannabis is commonly misused psychoactive drug which is known to be associated with a number of psychotic and somatic side-effects. Cannabis arteritis is a rare vascular disorder, since only about fifty cases have been reported in the literature. Case presentation We report a case of a 40-year-old chronic cannabis user male, who was admitted for painful necrosis of the fifth toe of the right foot. The etiological investigation ruled out the main causes of juvenile arterial disease. Therefore cannabis was the only causative factor found in this patient. An amputation of the fifth toe was performed 20 days later of administrating Prostacyclin (Iloprost) , with a good postoperative improvement. Discussion The main causes of juvenile arterial disease are: atheromatous arterial disease, thromboangiitis obliterans (Buerger's disease) , systemic or autoimmune diseases. The diagnosis of cannabis arteritis remains a diagnosis of exclusion. it remains a rare phenomenon which is responsible for various symptoms, which can go as far as the amputation of the limb. Several authors have classified cannabis arteritis as a clinical form of Buerger's disease, due to similar clinical semiology and similar appearance at arteriography. Nowadays, we don't know exactly the histopathologic patterns of this pathology. Conclusion Although several therapeutic options exist, Cannabis weaning still the main part of cannabis arteritis treatment.
... Dado que el cannabis es percibido como inofensivo por el público en general y la legalización de su uso está en debate, los datos acerca de su peligro deben ser ampliamente difundidos. La arteriopatía por marihuana fue descripta por primera vez en 1960 y desde ese momento se han publicado alrededor de 100 casos en la literatura [3][4][5][6][7][8][9][10][11] . Se presentan dos casos clínicos de arteriopatía por marihuana internados en el Hospital Británico de Buenos Aires. ...
... Las recaídas vasculares siempre estuvieron relacionadas al consumo de marihuana, y las remisiones se asociaron a su suspensión (aun sin la suspensión del tabaco). La arteriopatía por marihuana tiene mal pronóstico si no se suspende su consumo, ya que 56 pacientes (58%) requirieron algún tipo de amputación [4][5][6][7][8][9][10][11] . ...
... Además, está claramente demostrado el efecto tóxico sinérgico del tabaco más la marihuana. Finalmente se ha especulado que la mutación de tres genes (stromolysin 1 5A/6A, eNOS T786C, MTHFR C677T A1298C) podría disminuir el óxido nítrico y los vasodilatadores derivados del endotelio promoviendo a su vez un estado protrombótico 4,5,10,15 . ...
Article
Full-text available
Resumen La arteriopatía por marihuana debe ser considerada en pacientes jóvenes con arteriopatía peri-férica sin factores de riesgo para ateroesclerosis. Se ha descrito por primera vez en 1960 y existen más de 100 casos en la literatura. Si bien se tiende a considerar como una entidad independiente de la trom-boangeítis obliterante o enfermedad de Leo Buerger, debido a los hallazgos la consideramos dentro del espectro de esta última. Presentamos dos casos de pacientes jóvenes con enfermedad vascular periférica asociada al consumo de marihuana, luego de excluir otras enfermedades. El tratamiento es el cese del consumo. Es indispensable valorar el uso de drogas en pacientes jóvenes que se presentan con arteriopatía periférica.
... When peripheral arterial disease is found in a young individual, the main causes for juvenile arteritis should be considered: atherosclerotic disease, systemic and autoimmune diseases and thromboangiitis obliterans (or Buerger's disease). 5 In our patient, there was no cardiovascular risk factor other than smoking and the screening for systemic and autoimmune diseases was negative. Our patient met the criteria for thromboangiitis obliterans as he was <45 years old, presented peripheral ischaemia without other cause of arterial disease, was a tobacco smoker and presented compatible arteriographic findings. ...
... 7 Clinically, CA manifests with claudication, acral pain, subacute distal ischaemia ( predominantly but non-exclusively of the lower limbs) and early disappearance of distal pulses. 5 Doppler ultrasonography and arteriography are the imagiological exams of choice to study peripheral arterial diseases. Unlike atherosclerosis, typical calcified plaques of atherosclerosis along proximal arteries are usually not seen in CA. 3 Arteriography reveals distal segmental stenosis that are often bilateral, a poor distal vascularisation and a weakly developed collateral vessels network. ...
... Other medical treatments have been proposed with various results like vasodilator drugs ( prostaglandins), 3 platelet aggregation inhibitors (acetylsalicylic acid) 3 or anticoagulant drugs (heparin). 5 Hyperbaric oxygen therapy has been used for severe cases. However, without cessation of the abuse, none of these therapeutic options are sufficient. ...
Article
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Cannabis arteritis (CA) is a major and underdiagnosed cause of peripheral arterial disease in young patients. A 34-year-old man, daily smoker of 20 cigarettes and two cannabis cigarettes for 14 years, presented with a necrotic plaque of left hallux for 3 weeks. The Doppler ultrasound and angiography were compatible with severe Buerger's disease. Submitted to a revascularisation procedure and hypocoagulation with rivaroxaban. He had ceased smoking but maintained consumption of cannabis. Owing to the persistence of distal necrosis, amputation of the hallux was performed with good evolution. CA is a subtype of Buerger's disease. It is poorly known but increasingly prevalent and manifests in cannabis users regardless of tobacco use. The drug is considered at least a cofactor of the arteriopathy. The most effective treatment is cessation of consumption. Being cannabis one of the most consumed drugs, its mandatory to ask about its use in all young patients with arteriopathy.
... Patients in both conditions are often young men who present with claudication and painful distal ischemia. Angiograms show circulatory abnormalities very similar to those of Buerger's disease, with distal segmental narrowing of the arteries [89]. In contrast to Buerger's disease, the collateral arterial network is less developed in cannabis arteritis and proximal atheromatous lesions are sometimes seen [87]. ...
... In contrast to Buerger's disease, the collateral arterial network is less developed in cannabis arteritis and proximal atheromatous lesions are sometimes seen [87]. An arterial biopsy in one case report found thrombosis with endarteritis associated with inflammation and fragmentation of the internal elastic lamina [89]. ...
Article
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With the expanded legalization of marijuana, its medical and recreational use have sharply increased over the past decade. A wide array of new forms of cannabis is available on the market today, and the potencies are ten times those of forms previously tested, meaning that the true impact of marijuana on the cardiovascular system remains unclear. Cannabis mainly exerts its effects via the sympathetic and parasympathetic nervous systems, with different doses affecting different cannabinoids receptors. Studies have shown that marijuana plays a role in thrombosis, inflammation, and atherosclerosis. Case reports have linked marijuana use to myocardial infarction, cardiac arrythmias, cardiomyopathies, stroke, and arteritis. Most patients are young, healthy men with no cardiovascular risk factors; however, the patient population is expected to change to include older individuals in the future. The widespread public perception of safety accompanying marijuana use has contributed to its increased use among the elderly, who are the most at risk population for acute cardiovascular events. In this review, we aim to provide a basic understanding of the physiological effects of marijuana on the cardiovascular system and to review the current literature regarding cardiovascular diseases linked to marijuana use in adults.
... However, total cessation of cannabis exposure, despite continued tobacco use, combined with medical and/or surgical treatment (iloprost, anti-platelet aggregation, sympatholysis, bypass, in situ thrombolysis) could, in some cases, allow regression or even healing of the lesions [9,11]. Surgical revascularization is rarely possible due to the absence of a downstream. ...
... To conclude probably under-diagnosed, cannabis-related arteritis is one of the most common peripheral vascular disorders in patients under 50 years of age. Clinical, arteriographic and epidemiological approaches to OAT, or Buerger's syndrome, attempt to consider cannabis-related arteritis as a subtype of OAT [11]. Before setting the diagnosis, it is essential to exclude other etiologies (absence of cardiovascular risk, hyperviscosity, thrombophilia or other embolic pathology, elastic tissue disease, autoimmune pathology, systemic vasculitis) [19]. ...
... 8 Most cases occurred in concomitant tobacco users without other traditional cardiovascular or prothrombotic risk factors. 9 Manifestations mostly involve signs of distal extremity ischemia and necrosis, more commonly along the feet. Other features include Raynaud phenomenon and venous thrombosis. ...
... 10 In most cases, cannabis cessation resulted in the halting of disease progression, whereas continued use was associated with disease advancement despite aggressive medical and surgical treatments. 9 Exact pathogenesis remains unclear with few arterial biopsies to rely upon and with their findings varying. Thrombosis both in the presence and absence of inflammation of the internal lamina has been described. ...
... Een angiografie toont typisch zowel proximale als distale segmentaire letsels met een slechte acrale circulatie en schaarse onderontwikkelde collateralen. De pathofysiologie van beide aandoeningen is nog onvoldoende opgehelderd, maar houdt vermoedelijk verband met de aanwezigheid van arseen in de geïnhaleerde rook (41). Deze aandoening kan veelal onder controle gebracht worden mits een cannabisstop (40)(41)(42). ...
... De pathofysiologie van beide aandoeningen is nog onvoldoende opgehelderd, maar houdt vermoedelijk verband met de aanwezigheid van arseen in de geïnhaleerde rook (41). Deze aandoening kan veelal onder controle gebracht worden mits een cannabisstop (40)(41)(42). ...
Article
Marijuana is the most commonly used illicit drug in Western civilisation. Its use is particularly widespread among adolescents in their late teens and early twenties. Although smoking marijuana is perceived as harmless, daily practice as well as literature tend to display the opposite. Series of elaborate studies performed in the twentieth century have consistently demonstrated important effects of marijuana on cardiovascular parameters. Through a myriad of hemodynamic effects, this drug can evoke acute cardiovascular adversities within the first hour of its use, including tachyarrhythmias, acute coronary syndrome and vascular complications. The risk is particularly high in users with pre-existing cardiovascular disease. Until now, the impact of chronic cannabis smoking on the heart and blood vessels remains unclear. In view of the increasing incidence of the metabolic syndrome (and its associated cardiovascular morbidity), a concurrent increase in the number of victims of marijuana abuse can also be expected. The most important challenge for primary and preventive health care organisations is to increase the awareness of the youth for cardiovascular risk factors, and to invest in further research in order to identify the exact mechanisms of action of this widespread drug of abuse.
... 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. ...
... 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. ...
Article
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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. We report 2 cases who developed arteritis and Raynaud’s as a squeal of long term cannabis use and provide a literature review
... Ki67 × 400 Case Reports in Vascular Medicine thrombosis (Peyrot et al. [23]). The most effective treatment of cannabis arteritis is the complete withdrawal of cannabis consumption, halting the progression [23,24]. ...
... Ki67 × 400 Case Reports in Vascular Medicine thrombosis (Peyrot et al. [23]). The most effective treatment of cannabis arteritis is the complete withdrawal of cannabis consumption, halting the progression [23,24]. As previously mentioned, our patient had no history of Raynaud's phenomenon, and the digital gangrene involved both upper and lower limbs. ...
Article
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Background: Non-Hodgkin lymphomas (NHLs) comprise a group of haematologic malignancies with different histologic subtypes. The clinical picture varies from indolent to aggressive presentation and nodal (lymphadenopathy) to extranodal (central nervous system, gastrointestinal, cutaneous plaque, or ulcer) involvement. Digital gangrene is seldom reported. Here, we describe a patient with pain and blackening of all fingers and toes as presenting symptoms of NHL. Case Presentation. A 32-year-old male weaver had been smoking three to five cannabis-containing cigarettes daily for about ten years and methamphetamine four to five tablets daily for five years. He had no history of Raynaud's phenomenon, fever, cough, weight loss, skin rash, joint pain, and atherogenic or thrombogenic risk factors. We found normal blood pressure and absent peripheral pulses in arms and legs, dry gangrene of all fingers and toes, generalized lymphadenopathy, and hepatomegaly with ascites. The chest X-ray was normal, as were blood sugar, lipid profile, and hepatic and renal function. Rheumatoid factor, antinuclear and antiphospholipid antibodies, C-ANCA and P-ANCA, hepatitis B and C, and HIV were negative. CT abdomen revealed hepatosplenomegaly with multiple intra-abdominal lymphadenopathies. The peripheral angiogram showed 90-99% stenosis of radial and dorsalis pedis arteries with normal proximal vessels. Diagnosis of non-Hodgkin lymphoma was confirmed by histopathology of cervical lymph node (diffuse type), immunohistochemically subtyped as peripheral T cell lymphoma (not otherwise specified). The digital ischemia worsened despite cessation of cannabis and methamphetamine and starting CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisolone) treatment, making amputation necessary. Conclusion: We present, to our knowledge, the first report of peripheral T cell lymphoma, NOS presenting with gangrene in all digits complicated by methamphetamine and cannabis abuse. This uncommon vascular manifestation of non-Hodgkin lymphoma may cause a diagnostic dilemma and delayed initiation of treatment.
... It is presented as a peripheral necrosis most often of the lower limbs [2,3]. Only about 50 confirmed cases between 1960 and 2008 were published in literature and most of them was men with CA in the lower limbs [4]. In this work, we report a case of a young women cannabis smoker with digital necrosis. ...
Article
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Cannabis is the most consumed psychoactive substance by young people. Chronic use of cannabis can lead to cannabis arteritis, which is a very rare peripheral vascular disease similar to Buerger's disease. It is affecting young adults, especially men, consuming cannabis. A 27-year old woman, with no particular past medical history except for long-term use of cannabis and tobacco developed a digital necrosis in the left hand. She denied using other illicit drugs. Doppler ultrasound examination of the upper limbs was unremarkable. Toxicological analysis revealed the presence of cannabis in both biological fluid and hair strand. Despite medical treatment, cessation of the cannabis and tobacco consumption and hyperbaric oxygen therapy, an amputation of necrotic parts was then required. This case shows the prolonged use of cannabis could be a risk factor for young adult arteritis. Faced with a rapidly progressive arteritis occurring in young adult, the physician should consider the history of use of cannabis. Hair analysis can be useful for confirmation of the chronic consumption of drugs.
... Usystematyzowanie i poszerzenie wiedzy na temat powiązań między paleniem marihuany a procesami hemostazy wydaje się konieczne, tym bardziej że obserwacje kliniczne pacjentów palących marihuanę potwierdzają hipotezę o roli fitokannabinoidów w wywoływaniu incydentów zakrzepowo-zatorowych. Opisano przypadki wystąpienia incydentów sercowo-naczyniowych (w tym zawału mięśnia sercowego, stenozy naczyń tętniczych kończyn dolnych czy zatorowości płucnej) u młodych osób (19-36 lat), bez rodzinnej historii choroby sercowo--naczyniowej, deklarujących palenie marihuany od dłuższego czasu [3,7,18,29,73,80]. Także w retrospektywnych i prospektywnych obserwacjach klinicznych, w grupach pacjentów hospitalizowanych z powodu zawału mięśnia sercowego i palących marihuanę stwierdzono prawie 5-krotny wzrost ryzyka wystąpienia zawału mięśnia sercowego w ciągu godziny od wypalenia marihuany, wzrost śmiertelności sercowo-naczyniowej w obserwacji długoterminowej, zakrzepowo-zarostowe zapalenie naczyń kończyn dolnych oraz zmiany przepływu w naczyniach mózgowych [36,45,52,72,90]. ...
Article
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Elements of the endocannabinoid system (cannabinoid receptors CB1, CB2, CBPT and CBED, endocannabinoids, enzymes involved in the synthesis and metabolism of endocannabinoids) are located on the structures involved in the process of hemostasis. An increasing level of endocannabinoids was also observed in some pathological conditions, which may occur in disorders of hemostasis. At the same time, disconcertingly, there is an increased number of reports about incidents of cardiovascular events in smokers of marijuana. Experimental and clinical studies demonstrated multidirectional, often contradictory, effects of cannabinoids on hemostasis, including effects of the compounds on platelets, vascular endothelium, fibrinolysis and plasma coagulation systems. The mechanisms of action of cannabinoids on homeostasis depend on the cannabinoid receptors CB1, CB2, CBPT and CBED, receptors of other systems stimulated by endocannabinoids, as well as metabolites of endocannabinoids and nitrogen oxide. The range of biological functions of endo- and plant cannabinoids, expanded to include the process of hemostasis, may constitute a condition for their recognition as a new factor responsible for thromboembolism in smokers of marijuana, in pathological disorders with increased levels of endocannabinoids and in individuals with polymorphisms of FAAH C385A and A385A. On the other hand, there are compelling reasons for anti‑hemostatic action of cannabinoids.
... Le tabac est un facteur confondant majeur ; mais l'association tabac-cannabis parait potentialiser les dommages, en particulier le risque de thrombo-angéite oblitérante, de nécroses distales, d'ischémie des membres supérieurs et inférieurs chez des patients jeunes [12]. En 2007, Peyrot et al. [40] comptabilisent environ 50 cas d'« artérite cannabique » publiés depuis les années 1960. ...
... Levophed (norepinephrine bitartrate) has been implicated as a cause for toe necrosis in multiple reports. 2 Cannabis consumption even without vascular risk factors may lead to digital necrosis. 4 Large cell lung cancer was recorded as a potential root cause of fifth right toe necrosis in an individual who was originally admitted to a hospital for a painful left hand. Blue toe syndrome has been reported to occur as an uncommon complication of acute pancreatitis and other case related to using intra-arterial chemotherapy. ...
Article
Toe necrosis may have vast different etiologies. These include ischemia, embolus, and others. (1) The most common etiology is ischemia. It is a reduction in blood supply to a viable tissue that can lead to susceptibility to infection and tissue death. Peripheral ischemia, which is rooted in the lower limbs, is a major risk factor for toe necrosis because the basal metabolic requirements of tissue are not being sufficiently met. As a result, pain, ulcers, and gangrene commonly occur. (2) Other causes of direct and indirect toe necrosis and related lower limb gangrene include mechanical trauma, infectious, pharmacological sensitivity, cancer, blue toe syndrome, and other granulomatous diseases, such as Churg-Strauss syndrome. We present a case series of toes necrosis which resulted from different etiologies and their management.
... Two published cases of cannabis-associated vascular events have suggested cannabis-induced arteritis as a possible cause. Peyrot et al. reported the case of a 36-year-old cannabis user with no conventional cardiovascular risk factors who developed rapidly progressive peripheral vascular disease in his legs (17). Angiography demonstrated widespread bilateral lesions suggestive of arteritis, although inflammatory markers, autoantibody, and thrombophilia screens were normal. ...
Article
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Background: The use of cannabis is not usually regarded as a risk factor for acute coronary syndrome. However, several cases of myocardial infarction (MI) associated with cannabis use have been reported in the scientific literature. The etiology of this phenomenon is not known. Objectives: To present a case of cannabis-associated MI in which atherosclerotic coronary disease was excluded as a potential etiology by intravascular ultrasound examination, and briefly review the other possible mechanisms by which this effect may be mediated. Case report: We present the case of a previously healthy 21-year-old man who regularly smoked cannabis and presented to the Emergency Department with ST-elevation myocardial infarction after participating in a sport. He was also a cigarette smoker, but had no other conventional cardiovascular risk factors. At coronary angiography, a large amount of thrombus was found in the left anterior descending coronary artery. He recovered with medical treatment, and subsequent intravascular ultrasound examination showed no evidence of atherosclerosis at the site of the thrombus. Conclusion: Cannabis-associated MI is increasingly recognized. The etiology is unclear, but we believe this is the first report of the phenomenon where atherosclerotic plaque rupture has been excluded as the cause with a high degree of confidence.
... Since then, a large number of cases [116][117][118][119] and two comprehensive reviews [120,121] have appeared in the literature. The disease is clinically indistinguishable from thromboangiitis obliterans [122][123][124][125][126][127], but tends to occur at an earlier age in those who use both cannabis and tobacco [128]. The typical angiographic appearance is that of segmental narrowing of distal arteries with minimal if any collateral vessels [127][128][129]. ...
Article
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The recreational use of cannabis has sharply increased in recent years in parallel with its legalization and decriminalization in several countries. Commonly, the traditional cannabis has been replaced by potent synthetic cannabinoids and cannabimimetics in various forms. Despite overwhelming public perception of the safety of these substances, an increasing number of serious cardiovascular adverse events have been reported in temporal relation to recreational cannabis use. These have included sudden cardiac death, vascular (coronary, cerebral and peripheral) events, arrhythmias and stress cardiomyopathy among others. Many of the victims of these events are relatively young men with few if any cardiovascular risk factors. However, there are reasons to believe that older individuals and those with risk factors for or established cardiovascular disease are at even higher danger of such events following exposure to cannabis. The pathophysiological basis of these events is not fully understood and likely encompasses a complex interaction between the active ingredients (particularly the major cannabinoid, Δ⁹-tetrahydrocannabinol), and the endo-cannabinoid system, autonomic nervous system, as well as other receptor and non-receptor mediated pathways. Other complicating factors include opposing physiologic effects of other cannabinoids (predominantly cannabidiol), presence of regulatory proteins that act as metabolizing enzymes, binding molecules, or ligands, as well as functional polymorphisms of target receptors. Tolerance to the effects of cannabis may also develop on repeated exposures at least in part due to receptor downregulation or desensitization. Moreover, effects of cannabis may be enhanced or altered by concomitant use of other illicit drugs or medications used for treatment of established cardiovascular diseases. Regardless of these considerations, it is expected that the current cannabis epidemic would add significantly to the universal burden of cardiovascular diseases. Electronic supplementary material The online version of this article (10.1007/s40119-017-0102-x) contains supplementary material, which is available to authorized users.
... A disease similar to thromboangitis obliterans (Buerger's disease) has been reported with use of cannabis [86][87][88][89]; however, the frequent concomitant use of tobacco makes the association difficult for some cases [90]. Others believe that cannabis arteritis is a subtype of Buerger's disease, it manifests in cannabis users regardless of tobacco use, or the drug is considered at least a cofactor of the arteriopathy [91]. ...
Article
Background: Cannabis use has increased over the past several years as some countries have legalized its use for treatment of certain medical conditions and/or for recreational use. Thus, concerns have risen about potential adverse health effects. Increasing number of reports have associated cannabis use with serious cardiovascular (CV) complications. Furthermore, there appears to be a likeness in the harmful health effects, especially on the CV and respiratory systems, of cannabis smoking to those of tobacco smoking. Objective: to review the CV effects of cannabis use and compare them with those of tobacco use. Methods: Articles were reviewed that were published in the English literature reporting on cannabis and cannabinoid pharmacology and their effects on the CV system and their attendant consequences. Emphasis was also placed on articles reporting on cannabis use in adolescents, exposure to secondhand smoke, its effect on exercise and finally its inter-relationship and similarities with tobacco use. Results: With growing cannabis use, increasing number of reports have emerged associating marijuana use with serious and life-threatening CV complications, including acute coronary syndromes, potentially lethal cardiac arrhythmias and ischemic strokes. There are certain similarities of the deleterious CV and respiratory effects of cannabis smoking with those of tobacco smoking. Despite the difference in the active ingredients (tetrahydrocannabinol vs nicotine), each substance produces a plethora of chemicals when smoked and these are largely identical; furthermore, due to different modes of smoking, cannabis chemicals are retained in the body for a longer time. Of course, concomitant tobacco and cannabis smoking is a perplexing factor in isolating damages specifically pertaining to cannabis use, while the health risk is additive. Although the mechanisms producing CV harm may be somewhat different between these two substances, the outcome appears similar, or even worse, as the effects may emerge at a younger age. Conclusion: There is an increasing concern that, apart from the mental health problem with cannabis smoking, societies may be facing another wave of a déjà vu / déjà vécu phenomenon similar to the tobacco smoking story.
... bei dieser Klientel Myokardinfarkte und Hirninfarkte unter exzessivem Cannabiskonsum beschrieben [36]. Vereinzelt wurden eine der Thrombangiitis obliterans ähnelnde Arteriitis [37], Pankreatitis [38] und membranöse Glomerulonephritis [39] auf den Cannabiskonsum zurückgeführt. Etwas häufiger finden sich Gynäkomastien und negative, aber reversible Effekte auf Fertilität und Spermatogenese [40]. ...
... In addition, case studies have also associated cannabis use to increased risk of arrhythmia [35] (including ventricular tachycardia and potentially sudden death); ischemic stroke [141], particularly among healthy young patients [52]; recurrent [129] or acute coronary syndrome with elevated ST segment [49]; and myocardial infarction (MI), immediately or soon after smoking cannabis [24,37,94,100,142]. Cannabis use has also been reported to be associated with peripheral atherosclerotic disease, sometimes referred to as cannabis arteritis [118,131], a condition that is indistinguishable from thromboangiitis obliterans (Buerger's disease) [74,126] that has also been causally linked to tobacco smoking [53]. ...
Chapter
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Consumed by an estimated 2.5% of the world’s population, cannabis is the most popular illicit drug. Depending on age of onset, frequency, duration, and other variables, cannabis use can be associated with a broad spectrum of medical consequences, the range of which mirrors the physiological ubiquity and versatility of the endocannabinoid system. Importantly, the adverse consequences of cannabis use can progress to become overt clinical conditions, independently of the development of a cannabis use disorder. The purpose of this chapter is to present an updated overview of these adverse health effects of cannabis use and the implications of our current understanding vis-á-vis public health and research agendas moving forward.
... Studies have shown that >90% of the stroke burden is attributable to modifiable risk factors, such as tobacco smoking, alcohol consumption, poor diet, low physical activity, and hypertension [3][4][5]. Despite its widespread abuse, cannabis-associated cerebrovascular disease is only infrequently reported [6]. The objective of this study was to describe the characteristic of stroke associated to alcohol, tobacco and cannabis in a tertiary hospital in Burkina Faso. ...
... 69,70 Further, severe arteritis has been seen in cases of long-standing cannabis consumption, with claudication, acral pain, Raynaud syndrome, distal necrosis, and venous thrombosis. 71 Calciphylaxis Calciphylaxis, also known as calcific uremic arteriolopathy, and Martorell hypertensive ischemic leg ulcer (HYTILU) are two other important differential diagnoses for microthrombotic ulcers. Both ulcers are attributable to blood vessel wall calcification. ...
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General purpose: To discuss the pathogenesis and clinical features of wounds caused by microthrombi formation under the following categories of systemic diseases: cold-related and immune-complex deposition diseases, coagulopathies, abnormalities in red blood cell structure, emboli, and vasospasm. Target audience: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. Learning objectives/outcomes: After participating in this educational activity, the participant should be better able to:1. Recall the etiology, risk factors, and pathophysiology of the various types of microthrombotic wounds.2. Describe the clinical manifestations and treatment of the various types of microthrombotic wounds. Abstract: Typical wounds such as diabetic foot ulcers, venous leg ulcers, pressure ulcers, and arterial ulcers are responsible for more than 70% of chronic wounds. Atypical wounds have broad differential diagnoses and can sometimes develop as a combination of different conditions. Regardless of the etiology, impaired blood circulation is characteristic of all chronic and acute wounds. Chronic wounds associated with microthrombi formation are an important group of atypical wounds commonly linked to an underlying systemic disease. In this perspective article, the pathogenesis and clinical features of wounds caused by microthrombi formation are discussed under the following categories of systemic diseases: cold-related and immune-complex deposition diseases, coagulopathies, abnormalities in red blood cell structure, emboli, and vasospasm.
... In contrast, a strong activation of TRPV2 leading to the afore mentioned cell swelling is likely to impair the capillary flow, where the RBC diameter exceeds the vessel diameter (Kihm et al., 2021). The cannabinoid induced increase in RBC volume could very well-contribute to the thrombotic events, frequently reported to occur after cannabis consumption especially in combination with vasoconstriction that is also related to cannabis consumption (Disdier et al., 2001;Mittleman et al., 2001;Peyrot et al., 2007;Wolff et al., 2011). ...
Article
With the advent of legalization of marijuana for medicinal and recreational purposes, and the increase use of marijuana, healthcare providers will be increasingly confronted with marijuana users as patients in clinical environments. While there is vast literature regarding the societal and mental health harms associated with marijuana use, there is a paucity of reviews of the potential consequences of marijuana use on physical health or medical conditions. We examine the recent literature on the physical harms associated with illicit and legal marijuana administration. We surveyed the peer-reviewed medical literature from 1998 to 2013 of studies assessing the association of marijuana use and physical diseases. We conclude that healthcare providers should be cognizant that the existing literature suggests that marijuana use can cause physical harm. However, evidence is needed, and further research should be considered, to prove causal associations of marijuana with many physical health conditions.
Article
Increasingly, the identification, assessment and treatment of unhealthy use of alcohol and other drugs often occur within general medical settings. Within this climate, there is a growing awareness of the physical effects connected to acute or chronic use of substances of abuse. By examining these associations and their purported biological causative mechanisms, greater clinical attention-in the form of screening, identification and treatment-to co-occurring medical conditions as well as to the use of illicit substances itself may be possible. In this review, we examine recent peer-reviewed literature regarding three substances of abuse (cocaine, marijuana and opioids) and their direct associations with physical disorders. We group the association of diseases based on organ systems and critically examine the literature regarding the evidence to supporting those associations and causative mechanisms. There is good evidence to support the association of cocaine, marijuana and opioid use with a variety of physical health conditions. Unfortunately, while the causative evidence of these associations is preliminary, we could conclude that the use of these substances can incite a host of medical illnesses or complicate their treatment. When combined with societal, mental health and public health harms associated with the use of illicit substances, co-occurring or incident physical health conditions associated with substance use may present a substantial healthcare cost to the individual as well as to the healthcare system at large, resulting in a debilitating strain on often limited time and resources.
Article
Marijuana is the most widely used illicit drug, with approximately 200 million users worldwide. Once illegal throughout the United States, cannabis is now legal for medicinal purposes in several states and for recreational use in 3 states. The current wave of decriminalization may lead to more widespread use, and it is important that cardiologists be made aware of the potential for marijuana-associated adverse cardiovascular effects that may begin to occur in the population at a greater frequency. In this report, the investigators focus on the known cardiovascular, cerebrovascular, and peripheral effects of marijuana inhalation. Temporal associations between marijuana use and serious adverse events, including myocardial infarction, sudden cardiac death, cardiomyopathy, stroke, transient ischemic attack, and cannabis arteritis have been described. In conclusion, the potential for increased use of marijuana in the changing legal landscape suggests the need for the community to intensify research regarding the safety of marijuana use and for cardiologists to maintain an awareness of the potential for adverse effects.
Thesis
Nous avons montré : a) qu’il existe un lien entre la consommation de cannabis et la présence de sténoses artérielles intracrâniennes multifocales chez le jeune adulte victime d’infarctus cérébral, b) que la prévalence des sténoses artérielles intracrâniennes atteint un tiers des cas dans une cohorte de 159 infarctus cérébraux du jeune adulte, c) que 13% des infarctus cérébraux dans cette série répondent aux critères angiographiques du syndrome de vasoconstriction cérébrale réversible déclenché majoritairement par la consommation de cannabis, d) que le tétrahydrocannabinol (THC, le principal produit actif du cannabis) inhibe in vitro la chaîne respiratoire mitochondriale de cerveau de rat, et induit une génération significative de peroxyde d’hydrogène. La génération de radicaux libres pourrait être un des mécanismes possibles de toxicité cérébrale du THC en jeu lors d’un infarctus cérébral.
Article
Introduction L'implication du cannabis dans la physiopathologie de l'artérite distale fait l'objet de controverses. Le but de cette étude était de déterminer si la co-exposition au cannabis influence le mode de présentation et l'évolution de la thromboangéite oblitérante (TAO) chez les patients tabagiques. Méthodes Tous les patients consécutifs présentant une TAO confirmée étaient rétrospectivement revus concernant leur consommation de tabac et de cannabis. Résultats Au total, 38 patients ayant une TAO confirmée étaient inclus dans cette étude. En tout, 10 patients (26%) prenaient du cannabis (δ9-trans-tetrahydrocannabinol [THC], THC+) en association au tabac, alors que 28 patients (74%) étaient uniquement fumeur de tabac (THC−). L'exposition au tabac était comparable dans les deux groupes (21,7 ± 12 vs. 26,7 ± 17 paquets-années). Les patients THC+ étaient plus jeunes que les patients THC− lorsque débutaient les symptômes (28,5 ± 7 ans vs. 36,6 ± 10,5 ans, p = 0,02) et avaient plus fréquemment une atteinte unilatérale des membres inférieurs (44% vs. 7%, p = 0,02). Si 66% des patients présentaient une ischémie critique des membres inférieurs, les patients THC+ présentaient plus souvent des douleurs de décubitus sans ulcère ischémique (50% vs. 5%, p = 0,048). Les membres supérieurs étaient atteints cliniquement chez 50% des patients THC+ et 32% des patients THC−. Des injections répétées d'iloprost étaient nécessaires chez 84% des patients. Les résultats et les taux d'amputations mineures et majeures (10%) ne différaient pas entre les deux groupes. Conclusion L'exposition au cannabis influence l'âge de début et le mode de présentation de la TAO, mais pas les résultats. Les résultats de l'étude actuelle suggèrent que le cannabis représente un cofacteur du tabagisme qui pourrait accélérer le début et le mode de présentation de la TAO.
Article
En France, un quart des accidents vasculaires cerebraux (AVC) survient chez des personnes de moins de 65 ans. Bien que le risque d’accidents ischemiques cerebraux (AIC) augmente avec l’âge, une hausse de 10 % a ete enregistree chez les moins de 65 ans entre 2002 et 2008. La plupart des facteurs de risque des sujets plus âges : hypertension arterielle, hypercholesterolemie, diabete, sont aussi des facteurs de risque chez le sujet jeune. Mais, bien qu’il y ait des facteurs de risque identiques entre les populations jeunes et plus âgees, certains facteurs de risque vasculaires sont plus specifiques au sujet jeune : la contraception orale, la migraine, la prise de drogue, la grossesse. En plus de l’examen neurologique classique, l’examen extra-neurologique a une importance cruciale pour orienter vers une cause rare d’AIC. Les examens dermatologique et ophtalmologique sont particulierement interessants ainsi que la discussion multidisciplinaire avec les specialistes de ces memes organes. Jusqu’a 40 % des AIC restent de cause inconnue. Nous detaillerons les causes frequentes d’AIC du sujet jeune : les causes inconnues associees a un foramen ovale permeable (FOP), la dissection arterielle, et des causes plus rares mais non exceptionnelles : le syndrome des antiphospholipides, la maladie de Fabry, les AIC en rapport avec la prise de cannabis.
Article
The aim of this study was to describe the different arterial complications reported in cannabis smokers. This study was a literature review. Cannabis use was found to be associated with stroke, myocardial infarction, and lower limb arteritis. Arterial disease involved especially young men. There was a very strong temporal link between arterial complications and cannabis use for stroke and myocardial infarction episodes. Patient outcome was closely correlated with cannabis withdrawal and relapses associated with cannabis rechallenge. Cannabis use was associated with particular characteristics of arterial disease. The increased risk of myocardial infarction onset occurred within 1 hour of smoking marijuana compared with periods of non-use. Strokes occurred mainly in the posterior cerebral circulation. Compared with cohorts of thromboangiitis obliterans patients, those with cannabis-associated limb arteritis were younger, more often male, and had more frequent unilateral involvement of the lower limbs at clinical presentation. Cannabis use is associated with arterial disease such as stroke, myocardial infarction, and limbs arteritis. It appears essential to investigate cannabis use in young patients presenting with such arterial manifestations, as outcome is closely correlated with cannabis withdrawal.
Article
Objectives Heavy cannabis use has been associated with the development of acute myocardial infarction and stroke. The objective of this study was to determine if heavy, chronic cannabis use is associated with the development of acute limb ischemia (ALI) or critical limb ischemia (CLI). Methods We conducted a retrospective cohort study within the National Inpatient Sample (2006–2015). Patients without cannabis use disorder (CUD) were matched to patients with CUD in a 2:1 ratio using propensity scores. Our primary outcomes were incidence of ALI and CLI. Secondary outcomes included incidence of acute mesenteric ischemia (AMI), chronic mesenteric ischemia (CMI), frequency of open or endovascular interventions, length of stay, and total costs. Sensitivity analyses were performed with alternative models, including in the entire unmatched cohort with regression models utilizing survey weights to account for sampling methodology. Results We identified a cohort of 46,297 857 unmatched patients. Patients with CUD in the unmatched cohort were younger, with less cardiovascular risk factors, but higher rates of smoking and substance abuse. The matched cohort included 824,856 patients with CUD and 1,610,497 controls. Those with CUD had a higher incidence of ALI (OR 1.20 95% CI: 1.04-1.38 P=.016). Following multiple sensitivity analyses, there was no robust association between CLI and CUD. We observed no robust association of CUD with AMI, CMI, procedures performed, frequency of amputation, costs, or total length of stay. Conclusions Cannabis use disorder was associated with a significantly higher incidence of admission for acute limb ischemia. CUD was not associated with an increased risk of critical limb ischemia following sensitivity analysis. Given CUD is often seen in younger, less co-morbid patients it provides an important target for intervention in this population.
Article
Objective: Susac syndrome, a rare disorder, is thought to be mediated by autoantibodies. One of the potential targets of these autoantibodies could be an antigen in the microvessels of the brain, the retina, and the inner ear leading to central nervous system (CNS) alterations, visual disturbances, and hearing deficits. Our aim is to expand clinicians' diagnostic options when facing psychosis due to medical conditions. Methods: A case report was conducted for this study. Results: This paper reports the case of a young male drug user who presented with psychosis, confusion and CNS vasculitis. First deemed to be drug-induced CNS vasculitis, it was finally diagnosed as Susac syndrome. Conclusions: Although an infrequent entity, Susac syndrome should remain an option in the differential diagnosis of several neurological and psychiatric presentations.
Article
Peripheral arterial disease (PAD) encompasses disease of all arteries of the body except the coronary arteries. The main etiology whatever the patient's age is atherosclerosis. Different etiologies can induce PAD especially when patients are younger than 50 years old and have no cardiovascular risk factors (smoking, hypertension, diabetes…). PAD that appears before 50 years old can be named juvenile PAD (JPAD) although there is no consensus about the definition. The aim of this work is to present the different etiologies of JPAD according to their hereditary, acquired or mixed origins. The following hereditary causes are addressed: Marfan syndrome, Ehlers-Danlos syndrome, homocystinuria, pseudoxanthoma elasticum, osteogenesis imperfecta "mid-aortic" syndrome. Among the acquired etiologies, inflammatory JPADs without extravascular signs such as atherosclerosis and Buerger's disease, inflammatory JPADs with extravascular signs as Takayasu's disease, Behçet's disease and Cogan's syndrome, JPADs like aortitis, embolic JPADs, iatrogenic JPADs, and mechanical or traumatic JPADs are described. Finally, mixed origins as thrombotic disease and fibromuscular dysplasia are presented. This work will assist clinicians in the diagnosis of JPAD. Copyright © 2016 Elsevier Masson SAS. All rights reserved.
Thesis
Thèse portant sur l'étude de trois plantes psychotropes consommées en Nouvelle-Calédonie : kava, cannabis et datura. L'étude porte plus spécifiquement sur les aspects médicaux et médico-légaux.
Chapter
Thromboangiitis obliterans (TAO) was first described in 1879, when Felix von Winiwarter, an Austrian surgeon who was an associate of Theodor Billroth, reported in the German Archives of Clinical Surgery a single case of what he described as presenile spontaneous gangrene (Lie et al., Mayo Clin Proc 54:802–807, 1979). In 1908, Leo Buerger, a physician at Mount Sinai Hospital (New York, NY, USA), noticed the same condition in 11 amputated limbs of patients of Jewish descent, describing the absence of large vessel involvement and termed the disease ‘thromboangiitis obliterans’ and in 1924 briefly reported a possible relationship with tobacco (Buerger, The circulatory disturbances of the extremities. Philadelphia, PA: WB Saunders; 1924). In 1922, Allen and Brown reported 200 cases of TAO from 1922 to 1926 and noticed that all were male smokers (Mills et al., Am J Surg 154:123–129, 1987). TAO or Buerger’s disease is a segmental inflammatory arteriopathy affecting mostly medium- and small-sized vessels both arterial and venous in the lower and upper extremity. In some Eastern countries, this vasculitis can represent up to 40–60 % of all peripheral vascular diseases (PVD) (Joviliano et al., Int J Angiol 18:119–125, 2009; Weinberg and Jaff, Circulation 126:213–222, 2012). The disease affects mostly young male smokers and tends to present with rest pain and tissue loss. Tobacco exposure is strongly associated with initiation and progression of the disease even if the real mechanism remains still unclear. Since atherosclerotic risk factors other than smoking are commonly absent, smoking cessation is the only way to stop the disease progression. Clinical features, patient’s history and angiographic findings are the basis of early diagnosis of TAO.
Article
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The growing popularity of medical and recreational consumption of cannabis, especially among the youth, raises immediate concerns regarding its safety and long-terms effects. The cardiovascular effects of cannabis are not well known. Cannabis consumption has been shown to cause arrhythmia including ventricular tachycardia, and potentially sudden death, and to increase the risk of myocardial infarction (MI). These effects appear to be compounded by cigarette smoking and precipitated by excessive physical activity, especially during the first few hours of consumption. Cannabinoids, or the active compounds of cannabis, have been shown to have heterogeneous effects on central and peripheral circulation. Acute cannabis consumption has been shown to cause an increase in blood pressure, specifically systolic blood pressure (SBP), and orthostatic hypotension. Cannabis use has been reported to increase risk of ischemic stroke, particularly in the healthy young patients. The endocannabinoid system (ECS) is currently considered as a promising therapeutic target in the management of several disease conditions. Synthetic cannabinoids (SCs) are being increasingly investigated for their therapeutic effects; however, the value of their benefits over possible complications remains controversial. Despite the considerable research in this field, the benefits of cannabis and its synthetic derivatives remains questionable even in the face of an increasingly tolerating attitude towards recreational consumption and promotion of the therapeutic complications. More efforts are needed to increase awareness among the public, especially youth, about the cardiovascular risks associated with cannabis use and to disseminate the accumulated knowledge regarding its ill effects.
Article
Cannabis (Cannabis sativa/indica), also known as marijuana, has been used for medicinal and recreational purposes for millennia. There has been a recent trend to legalize the use of cannabis, as illustrated by the recent legalization votes in numerous states in the United States and legislation in Canada to allow recreational cannabis use. With this increasing consumption of cannabis, dermatologists will see increased pressure to prescribe cannabis and will see the side effects of cannabis use with greater frequency. There are several approved medical indications for cannabis use, including psoriasis, lupus, nail-patella syndrome, and severe pain. In addition, very preliminary studies have suggested cannabis and its derivatives might have use in acne, dermatitis, pruritus, wound healing, and skin cancer. Further well-controlled studies are required to explore these potential uses. Conversely, the side effects of cannabis use are relatively well documented, and dermatologists should be aware of these presentations. Side effects of cannabis use include cannabis allergy manifesting as urticaria and pruritus, cannabis arteritis presenting with necrosis and ulcers, and oral cancers from cannabis smoke. In this review, we summarize some of the studies and reports regarding the medicinal uses of cannabis in the dermatology clinic and some of the side effects that might present more often to dermatologists as the use of cannabis increases.
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Synthetic cannabinoids have caused a large number of emergency presentations to hospitals for adverse cardiovascular events including numerous deaths, particularly for the more potent analogs acting on the CB 1 receptor. While smoked cannabis use is often associated with significant changes in heart rate and cardiac output, amongst other physiological changes, it has been rarely considered in the forensic literature as a significant contributory or causal factor in sudden unexpected death. A review of case reports of admissions to hospitals for cardiovascular events was undertaken together with a review of epidemiological studies, and case reports of sudden death attributed, at least in part, to use of this drug. These publications show that use of cannabis is not without its risks of occasional serious medical emergencies and sudden death, with reports of at least 35 persons presenting with significant cardiovascular emergencies who had recently smoked a cannabis preparation. At least 13 deaths from a cardiovascular mechanism have been reported from use of this drug which is very likely to be an under-estimate of the true incidence of its contribution to sudden death. In addition, many cases of stroke and vascular arteritis have also been reported with the latter often involving a limb amputation. While it is a drug with widespread usage among the community with relatively few deaths when faced with a circumstance of very recent use (within a few hours), a positive blood concentration of THC and a possible cardiac-related or cerebrovascular cause of death this drug should be considered, at least, a contributory cause of death in cases of sudden or unexpected death.
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Toe necrosis has many aetiologies. The most common one is ischaemia. In fact, both direct and indirect toe necrosis, as well as related lower limb gangrene, could be secondary to mechanical trauma, infections, pharmacological sensitivity, cancer, blue toe syndrome and other granulomatous diseases. We report a case of toes necrosis caused by an uncommon aetiology.
Article
For the first time in the history of the modern era smoking tobacco is not the most popular inhaled product. After a flurry of legislature, cannabis has come to the forefront of both medicinal and recreational drug use. A confluence of evidence suggests, however, that marijuana consumption may confer a particularly worrisome cardiovascular risk profile. While combustible forms still contain many of the same harmful chemicals found in tobacco such as aromatic amines, polycyclic aromatic hydrocarbons (PAHs), and nitric oxide, some in even greater concentrations than tobacco, edible preparations have been evidenced to cause more cardiovascular-related emergency department visits. Importantly, this body of evidence suggests that cannabis use may be placing a younger, healthier population at risk of suffering major cardiovascular accidents particularly in the moments immediately following consumption. With males in their 30’s apparently bearing the brunt of this burden, cannabis consumption has been associated with an increase in ischemic stroke—a blockage in the cerebral or cerebellar vasculature—and almost a fivefold increase in myocardial infarction. THC containing compounds have also been linked to vascular complications ranging from mild plaques to total arterial occlusion resulting in claudication, rest pain, ischemic ulceration and gangrene—recently termed cannabis arteritis. While this research remains in a nascent stage, marijuana consumption seems to be predisposing a youthful, traditionally low health risk cohort to a variety of major adverse cardiovascular events.
Article
University of Conneticut School of Medicine The public and health care providers are increasingly curious about the potential medical benefits of Cannabis. In vitro and in vivo studies of Cannabis have suggested it has favorable effects on regulating pain, pruritus, and inflammation, making it a potentially attractive therapeutic agent for many dermatologic conditions. The body of literature reporting on the role of cannabinoids in dermatology is in its infancy but growing. We review the current research, possible cutaneous adverse effects, and future directions for cannabinoids and their use in skin cancer, acne, psoriasis, pruritus, dermatitis, scleroderma, dermatomyositis, cutaneous lupus erythematous, epidermolysis bullosa, pain, and wound healing.
Chapter
A number of recreationally used drugs, licit and illicit, have been linked to ischemic and hemorrhagic stroke. In some cases, for example, ethanol and tobacco, epidemiologic data convincingly identify the agents as risk factors without implying direct temporal causality. In the case of psychostimulant drugs-including methamphetamine, 3,4-methylenedioxymetamphetamine ("ecstasy"), cathinone derivatives ("bath salts"), and cocaine, as well as cannabis products-linkage is based on case reports and limited epidemiologic data, but temporal association of use, plus biological plausibility, suggest direct causality. Recreational drug use should be considered in any patient with a stroke, regardless of age.
Article
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The main causes of arteriopathy in young patients include drugs, metabolic diseases, pseudoxanthoma elasticum and Buerger's disease. Arteritis due to Cannabis indica was first reported in 1960, and the role of this drug as a risk factor for arteritis was confirmed in several subsequent publications. A 38-year-old smoker with no previous contributory medical history except for long-standing cannabis abuse developed a dry necrotic lesion of the left big toe. Imaging examinations revealed proximal arteriopathy of the lower limbs that predominated on the left side. He had no atherogenic or thrombogenic risk factors, and no signs of pseudoxanthoma elasticum were found. Remarkably, the development of arteritis paralleled cannabis abuse. The course was slowly favourable after weaning from the drug, vasodilator treatment and hyperbaric oxygen therapy. Despite some subtle clinical differences (more proximal than distal involvement), cannabis arteritis may be considered as a particular form of Buerger's disease, where cannabis, along with tobacco, seems to cause arterial lesions. Along with the noxious effects of cannabis on vessels, a role for contaminating arsenic is also possible. Cannabis arteritis is not widely known, but may prove not to be so rare if one considers consumption of cannabis besides that of tobacco.
Article
Introduction. – The responsibility of cannabis in juvenile thromboangeitis has been suggested for few years. We describe four new cases.Exegesis. – Young men presented with distal arteriopathy of the lower limbs in 3 cases, and of the left upper limb in the remaining patient. Symptoms occurred progressively, distal pulses had disappeared, and distal necrosis was constant. Three patients suffered from Raynaud phenomenon, none of them presented with venous thrombosis. Radiologic evaluation revealed distal abnormalities in all cases, and proximal arterial thrombosis in one case. The four patients were cannabis smokers for at least four years. With cannabis interruption and symptomatic treatment, lesions improved for three patients. For one of them, recurrence of arteriopathy occurred when he resumed to smoke cannabis. For the fourth one who never stopped cannabis, an amputation was necessary.Conclusion. – Search for cannabis use is important because interruption may improve prognosis.
Article
A 24-vear old woman, heavy cannabis smoker with progressive Raynauld's phenomenon and digital necrosis is presented. Systemic sclerosis and other connective tissue disorders as well as arteriosclerosis and arterial emboli were excluded with appropriate laboratory examinations. Arteriography revealed multiple forearm, palmar and digital occlusions with corkscrewshaped vessels. Based on these characteristic arteriography and clinical findings, the diagnosis of cannabis-arteritis was finally retained. With careful necrectomy, conservative wound dressings and secondary prostacyclin therapy a complete healing of digital necrosis was observed. There was no recurrence during the 6 month-follow-up. This observation demonstrates that cannabis may represent a possible cofactor in the pathogenesis of arteritis in young smokers. Early recognition is important to avoid irreversible complications such as loss of digits.
Article
Introduction Since the end of the nineteen-nineties, cannabis is not only incriminated in the onset of thromboangiitis obliterans but also in inducing artheromatous lesions in young subjects. Observation A young, Caucasian, 18 year-old man was referred for cannabis withdrawal in the treatment of arteritis of the left leg. Discussion Cannabis is by far the illicite psychoactive substance most consumed by the 15-25 year-olds. Data in the literature, notably since the end of the nineteen-nineties, show that cannabis is accused of provoking arterial disease similar to that which is found in Buerger's disease (or thromboangiitis obliterans) in young subjects of whichever sex.
Article
The causal effect of cannabis, associated or not with smoking, in juvenile thromboangiitis disorders such as Leo Buerger disease, has been suggested. We describe here a case of a 30-year-old woman who smoked cannabis and developed intermittent claudication of the lower limbs. Female sex and proximal localization of the lesions (external iliac artery) are not usually described in "cannabis arteritis". Cannabis would be involved not only in the pathogenesis of juvenile obstructive arteriopathy, but also in the development of atheromatous lesions in the young subject.
Article
The purpose of this paper was to revisit the old concept of cannabis arteritis first described in the 1960s and report 10 new cases. Ten male patients, with a median age of 23.7 years developed subacute distal ischemia of lower or upper limbs, leading to necrosis in the toes and/or fingers and sometimes to distal limb gangrene. Two of the patients also presented with venous thrombosis and three patients were suffering from a recent Raynaud's phenomenon. Biological test results did not show evidence of the classical vascular risk factors for thrombosis. Arteriographic evaluation in all cases revealed distal abnormalities in the arteries of feet, legs, forearms, and hands resembling those of Buerger's disease. A collateral circulation sometimes with opacification of the vasa nervorum was noted. In some cases, arterial proximal atherosclerotic lesions and venous thrombosis were observed. All patients were moderate tobacco smokers and regular cannabis users. Despite treatment with ilomedine and heparin in all cases, five amputations were necessary in four patients. The vasoconstrictor effect of cannabis on the vascular system has been known for a long time. It has been shown that delta-8- and delta-9-tetrahydrocanabinols may induce peripheral vasoconstrictor activity. Cannabis arteritis resembles Buerger's disease, but patients were moderate tobacco smokers and regular cannabis users. These cases show that prolonged use of cannabis could be an additive risk factor for juvenile and young adult arteritis. Cannabis arteritis is a forgotten and severe occlusive vascular disease occurring in young adults. Search for cannabis use may be an important tool for a better knowledge of arteritis in young smokers.
Article
Juvenile peripheral obstructive arterial diseases (POAD) have been poorly investigated but account for 1 to 7% of POAD. We analyzed retrospectively a cohort of patients with onset before the age of 50 years. Seventy-three patients (60 males and 13 females) were divided into 4 groups (Buerger's disease: TAO, atheromatous PAOD, auto-immune POAD, arteriopathy of undetermined origin). The first symptoms occurred at 38 +/- 8 years of age. Fourteen patients (20%) had TAO, 51 (70%) atheromatous POAD, 4 (5%) POAD with systemic or autoimmune disease, and 4 (5%) undetermined POAD. Age of onset was earlier in TAO (35 +/- 8 vs 40 +/- 8 years, p=0.046), smoking greater in the atheroma group (33 +/- 16 vs 24 +/- 14 pack-years, p=0.033). Fifty-three POAD patients had dyslipidaemia and 26% hypertension. Regular cannabis intake was more frequent in the TAO group (21 vs 8%). At the time of medical care, Fontaine's stage was more frequently stage II in atheroma patients (57 vs 14%) and stage IV in TAO patients (86 vs 35%). TAO was diagnosed in 43% cannabis users and in 19% non users. The main etiology of juvenile POAD is atheroma, followed by TAO. Cannabis users account for at least 10% of these patients. They are characterized by lower tobacco intake, more distal lesions, more frequent involvement of the upper limbs. They present more frequently as TAO.
Article
The Buerger's disease or thromboangiitis obliterants (TAO) is a non atheromatous inflammatory disease which alters medium and small-sized arteries and veins. It can be found world-wide, but it is more frequent in Eastern Europe, Middle East, Asia and Southeast Asia. Young men and smokers are the most affected. The incidence of this disease is increasing among women. The cause of this disease is unknown yet. The most striking fact is the relationship between TAO and tobacco. The diagnostic is most often late in front of a digital leg ischemia. Complementary exams help to its diagnostic and management but none of them are specific out of the pathology. The affection is evolving towards distal gangrene with amputation in 5 to 10% of cases. Prostacyclin demonstrated its efficiency. Revascularization surgery is difficult but sometimes possible. Sympathectomy, medular stimulation must be suggested. The patient survival is not at stake and the prognosis is above all functional. The most important element in the treatment is stop smoking definitively.
Article
The responsibility of cannabis in juvenile thromboangeitis has been suggested for few years. We describe four new cases. Young men presented with distal arteriopathy of the lower limbs in 3 cases, and of the left upper limb in the remaining patient. Symptoms occurred progressively, distal pulses had disappeared, and distal necrosis was constant. Three patients suffered from Raynaud phenomenon, none of them presented with venous thrombosis. Radiologic evaluation revealed distal abnormalities in all cases, and proximal arterial thrombosis in one case. The four patients were cannabis smokers for at least four years. With cannabis interruption and symptomatic treatment, lesions improved for three patients. For one of them, recurrence of arteriopathy occurred when he resumed to smoke cannabis. For the fourth one who never stopped cannabis, an amputation was necessary. Search for cannabis use is important because interruption may improve prognosis.
Article
A 24-year old woman, heavy cannabis smoker with progressive Raynauld's phenomenon and digital necrosis is presented. Systemic sclerosis and other connective tissue disorders as well as arteriosclerosis and arterial emboli were excluded with appropriate laboratory examinations. Arteriography revealed multiple forearm, palmar and digital occlusions with corkscrew-shaped vessels. Based on these characteristic arteriography and clinical findings, the diagnosis of cannabis-arteritis was finally retained. With careful necrectomy, conservative wound dressings and secondary prostacyclin therapy a complete healing of digital necrosis was observed. There was no recurrence during the 6 month-follow-up. This observation demonstrates that cannabis may represent a possible cofactor in the pathogenesis of arteritis in young smokers. Early recognition is important to avoid irreversible complications such as loss of digits.
Article
Since the end of the nineteen-nineties, cannabis is not only incriminated in the onset of thromboangiitis obliterans but also in inducing artheromatous lesions in young subjects. A young, Caucasian, 18 year-old man was referred for cannabis withdrawal in the treatment of arteritis of the left leg. Cannabis is by far the illicite psychoactive substance most consumed by the 15-25 year-olds. Data in the literature, notably since the end of the nineteen-nineties, show that cannabis is accused of provoking arterial disease similar to that which is found in Buerger's disease (or thromboangiitis obliterans) in young subjects of whichever sex.