Citation

Coble N, Mulay P, Funk A, Arnold J, Wiese M. MMWR Morb. Mortal. Wkly. Rep. 2022; 71(40): 1288-1290.

Copyright

(Copyright © 2022, (in public domain), Publisher U.S. Centers for Disease Control and Prevention)

DOI

10.15585/mmwr.mm7140a5

PMID

36201387

Abstract

On December 4, 2021, the Florida Department of Health in Hillsborough County was notified by the Florida Poison Information Center Tampa about three patients with unexplained bleeding and a history of synthetic cannabinoid (SCB) use. These patients resembled those from the nationwide incident of coagulopathy associated with SCB use that occurred in 2018, which included five patients from Florida who displayed similar signs, symptoms, and high-risk behaviors (1). An epidemiologic investigation was conducted to establish exposure links and provide guidance to hospitals and health care providers. On December 7, 2021, epidemiology program managers at county health departments in the region including Pasco County, Pinellas County, and Polk County, and emergency department physicians as well as medical examiners at Advent Health, St. Joseph Hospital, and Tampa General Hospital were informed about these three patients and asked to report any suspected cases. A press release was issued to the public for awareness. Florida's syndromic surveillance database, Electronic Surveillance System for the Early Notification of Community-based Epidemics, was used to monitor Florida Poison Information Center, emergency department, and urgent care data for potential new cases. Case definitions were established based on the nationwide 2018 incident (1). Patients were interviewed, and medical records were reviewed to collect information on patient demographics; signs and symptoms; SCB, marijuana, or other drug use; product purchase locations; and exposure to prescription vitamin K oxidoreductase antagonists.

A total of 52 cases were identified; 43 (82.7%) were confirmed and nine (17.3%) probable. A total of 38 (73.1%) cases were distributed throughout north and east Tampa; the other cases occurred sporadically throughout Hillsborough County. One patient was identified in neighboring Pinellas County. All patients except one were admitted to hospitals in Hillsborough County. The mean patient age was 36 years (range = 16-63 years); 40 (76.9%) were male. A total of 47 (87.0%) reported using SCBs with similar purchase locations before symptom onset. Five patients had both elevated international normalized ratios (INRs) and positive brodifacoum tests but did not report SCB use.* Symptom onset occurred during November 24-December 19, 2021 (Figure). The most common symptoms were hematuria (36; 69.2%), abdominal pain (33; 63.5%), and hematemesis (16; 30.8%). INR measurements were elevated in all patients; the median INR was 12.8 (range = 3.9 to >15) (2). Four (7.7%) patients died; the mean age of deceased patients was 34 years.



* INR is a laboratory measurement of how long blood takes to form a clot. INR is used to determine the effects of oral anticoagulants on the clotting system.

† Brodifacoum is a vitamin K epoxide cycle antagonist with a long half-life resulting in prolonged symptoms and treatment. Clinical coagulopathy is caused by a depletion of functional (vitamin K-dependent) clotting factors as a result of vitamin K oxidoreductase inhibition caused by brodifacoum.

§ In addition to oral vitamin K1, treatment with cholestyramine was also considered. However, this treatment was not used because of concerns regarding patient compliance to take several medications timed appropriately and potential adverse events from long-term cholestyramine use. Cholestyramine can affect oral absorption of vitamin K1 if taken concurrently, which would reduce absorption of oral vitamin K1 for therapeutic purposes.

Language: en