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Radiological findings in poisoning by synthetic cannabinoids adulterated with brodifacoum

  • Emergency Radiology
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A Commentary to this article was published on 22 December 2023

Abstract

Objectives

Severe coagulopathy due to consumption of synthetic cannabinoids adulterated with brodifacoum, a long-acting anticoagulant, is an emerging worldwide hazard. Here, we review the spectrum of imaging findings in adulterated cannabinoid poisoning.

Materials and methods

In this retrospective study, we used the Israeli Poison Information Center database to identify patients with cannabinoid-associated coagulopathy who presented to the Rambam Health Care Campus, where most patients were treated during an outbreak in northern Israel between September 2021 and June 2022. All relevant imaging studies for these patients were reviewed. We estimated the sensitivity of findings for cannabinoid-associated coagulopathy. Associations between a continuous variable and a dichotomous outcome were assessed with the Mann–Whitney U test.

Results

We identified 48 patients (mean age 40 years ± 9 [SD], 43 males) with 54 hospitalizations due to cannabinoid-associated coagulopathy. Symptomatic hemorrhage was documented in 50 (93%) cases at presentation, most of whom (78%) had hemorrhage from multiple systems. The most common bleeding site was the genitourinary collecting system, with a characteristic sign of suburothelial bleeding in 16/18 of performed abdominal CTs (sensitivity 89% [CI 65–99%] for cannabinoid-associated coagulopathy). Intramural bowel hematomas were noted in 70% (7/10) of CTs of patients with gastrointestinal bleeding. Incidental bleeding sites were identified on imaging in 24% of patients. An increased number of bleeding sites was associated with need for vasopressors (difference in bleeding sites 3.00 [95% CI 0.99–4.00], p = 0.026).

Conclusion

CT plays a key role in the diagnosis and work-up of adulterated cannabinoid-associated coagulopathy. Characteristic signs include suburothelial hemorrhage and intramural bowel hematomas.

Clinical relevance statement

Recognition of radiological signs of adulterated synthetic cannabinoid-associated coagulopathy is critical for optimizing outbreak control on the public health level and ensuring timely treatment on the individual patient level.

Key Points

• Severe coagulopathy due to consumption of synthetic cannabinoids adulterated with brodifacoum, a long-acting anticoagulant, is an emerging worldwide threat.

• Characteristic imaging signs include suburothelial bleeding, intramural bowel hematomas, and rare incidental bleeding sites.

• Imaging has a pivotal role in optimizing outbreak control and ensuring timely and appropriate treatment.

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Abbreviations

ED:

Emergency department

GIB:

Gastrointestinal bleeding (GIB)

HCC :

Health care campus

INR:

International normalized ratio

IPIC:

Israeli Poison Information Center

LAAR:

Long-acting anticoagulant rodenticide

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Funding

The authors state that this work has not received any funding.

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Authors and Affiliations

  1. Department of Radiology, Rambam Health Care Campus, Haifa, Israel

    Nitai Bar, Rebeca Lopez-Alonso, Goni Merhav, Maxim Leiderman, Anat Ilivitzki & Sobhi Abadi

  2. Department of Ophthalmology, Rambam Health Care Campus, Haifa, Israel

    Efrat Naaman

  3. Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel

    Anat Ilivitzki, Yael Lurie, Daniel Kurnik & Sobhi Abadi

  4. Israel Poison Information Center, Rambam Health Care Campus, Haifa, Israel

    Yael Lurie

  5. Section of Clinical Pharmacology and Toxicology, Rambam Health Care Campus, Haifa, Israel

    Yael Lurie & Daniel Kurnik

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  1. Nitai Bar
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Corresponding author

Correspondence to Nitai Bar.

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Guarantor

The scientific guarantor of this publication is Nitai Bar.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was waived by the Institutional Review Board on the condition of de-identified data analysis (0658–21-RMB-D).

Ethical approval

Institutional Review Board approval was obtained (0658–21-RMB-D).

Study subjects or cohorts overlap

Some study subjects or cohorts have been previously reported in https://doi.org/https://doi.org/10.1080/15563650.2023.2215402.

Methodology

• retrospective

• diagnostic or prognostic study

• performed at one institution

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Bar, N., Lopez-Alonso, R., Merhav, G. et al. Radiological findings in poisoning by synthetic cannabinoids adulterated with brodifacoum. Eur Radiol (2023). https://doi.org/10.1007/s00330-023-10496-4

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