A Case Report of Cannabis Abuse: A Surprising Etiology of Elevated Troponin - Cureus

A 21-year-old pistillate diligent with a past aesculapian past of asthma presented with acute onset of thorax pain. She localized the symptom implicit the thorax and epigastric area. It was mean to severe, non-radiating and non-exertional symptom relieved by sitting upright and leaning forward. It was associated with aggregate episodes of nausea and vomiting with yellow-colored non-bloody vomitus containing ingested nutrient particles. She denied immoderate past of fever, cough, shortness of breath, palpitation, abdominal pain, oregon little urinary tract symptoms. She besides denied immoderate illicit cause maltreatment connected presentation.

On examination, humor unit was 147/89 mmHg with a pulse complaint of 64 per minute, respiratory complaint of 18 per minute, a somesthesia of 36.9 degrees C, and saturation of 99% connected country air. Auscultation of the thorax revealed bilateral adjacent aerial introduction with nary added enactment dependable and mean bosom sounds. The abdominal introspection was uneventful, and determination was nary edema successful the extremities. The archetypal electrocardiogram (EKG) showed mean sinus bushed with a bosom complaint of 73 beats per minute, PR interval of 172 ms, and QRS duration of 90 sclerosis with QTc of 453 sclerosis (Figure 1).

The archetypal laboratory tests showed achromatic compartment counts of 5800/mm3, hemoglobin 13.3 g/dl, and hematocrit 42%. The d-dimer was precocious astatine 663 ng/ml. The urine toxicology surface was affirmative for cannabinoids and opioids. However, urine toxicology affirmative for opioids tin beryllium justifiable arsenic the urine illustration was collected aft she received morphine successful the exigency section for pain, and the urine illustration was collected subsequently. Furthermore, precocious sensitivity troponin astatine the clip of admittance was 190.9 ng/ml, which aboriginal trended to a maximum worth of 1234.2 ng/ml connected time 2 of admission. Figure 2 depicts the graphical practice of troponin levels connected the time of admission.

The computed tomography angiogram (CTA) of the thorax was ordered to regularisation retired pulmonary embolism, which showed nary definite grounds of pulmonary embolism with nary acute pleural oregon parenchymal illness (Figure 3).

Bedside echocardiography showed an ejection fraction of 60% with nary determination partition question abnormalities with nary signs of effusion. We offered the diligent coronary angiography to regularisation retired immoderate coronary artery disease, but she refused the process aft discussing its risks and benefits. 

She was managed with aspirin 324 mg stat, atorvastatin 80 mg, intravenous morphine sulfate 4 mg, intravenous ondansetron, and sublingual nitroglycerine 0.4 mg. She was admitted to the telemetry portion for continuous cardiac monitoring. Her symptoms resolved eventually, with implicit betterment connected time 4 of admission. She received continued attraction with aspirin 81 mg regular and atorvastatin 40 mg daily. Repeat EKG (Figure 4) showed mean sinus bushed with a bosom complaint of 64 bpm, PR interval of 170 ms, QRS interval of 90 ms, and QTc interval of 455 ms. 

The diligent was discharged connected time 4 of admittance with the discharge diagnosis of thorax symptom with elevated troponin, apt owed to accent request secondary to cannabis use. Aspirin 81 mg chewable tablets and atorvastatin 40 mg tablets were continued arsenic discharge medicine with proposal to travel up successful the cardiology session successful 1 week.

Cannabis is 1 of the wide utilized psychoactive substances with euphoric effects chiefly via the progressive compound tetrahydrocannabinol (THC) and inflammatory effects via cannabidiol (CBD) [1, 2]. Its effects are mediated via CB1 and CB2 receptors, distributed implicit the cardinal tense system, cardiovascular system, and immune cells [3].

In this lawsuit report, we discussed the elevated troponin levels successful a 21-year-old nonsmoker pistillate with nary past of benignant 2 diabetes mellitus, hypertension, hyperlipidemia, oregon chronic kidney disease. However, the diligent refused percutaneous coronary involution to visualize the coronary arteries, a mean EKG successful a diligent without immoderate established cardiovascular hazard factors for coronary artery illness (CAD) points toward a debased pretest probability of CAD arsenic a origin of troponin elevation. On the different hand, elevated troponin, apt owed to accent request owed to cannabis use, is simply a genuine possibility. Jouanjus et al. and Mittleman et al., successful large-scale retrospective studies, reported the incidence of cardiovascular events arsenic 2.6 per 1000 successful regular cannabis users, on with an yearly acute cardiovascular lawsuit hazard of 1.5 to 3% per twelvemonth [4, 5]. There has been lit proving a cannabis-induced summation successful myocardial oxygen demand. The projected mechanisms for the summation successful myocardial oxygen request are from tachycardia owed to the activation of the CB1 receptor-mediated sympathetic tense system, the inhibition of the cardiac parasympathetic tense system, and reflex tachycardia from cannabis-induced vasodilation [6-8].

Furthermore, an summation successful myocardial oxygen request is besides attributed to reduced oxygen transportation owed to carboxyhemoglobin accumulation successful radical smoking cannabis [9]. In addition, cannabis induced endothelial dysfunction and platelet aggregation could besides pb to compromised myocardial vasculature impairing oxygen transportation to myocardial tissues [10-12]. In our case, the circumstantial grounds of having nary hazard factors for acute coronary syndrome, the emergence of troponin with the symptoms, and the solution of the symptoms afterward tin beryllium proved by the accrued myocardial oxygen request apt from vasospasm.