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A Case of Toxicity from Cannabidiol Gummy Ingestion

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

A 56-year-old male with no known history of substance abuse and no known prior medical conditions presented via ambulance to the emergency department after being found by coworkers with bizarre behavior, vomiting, and slurred speech. He had legally purchased cannabidiol (CBD) gummies marketed for pain and anxiety relief at a gas station several hours prior. Vitals upon arrival were temperature 36.8 Celsius, heart rate (HR) 79, respiratory rate (RR) 12, blood pressure (BP) 113/60, and oxygen saturation (O2) of 84% on room air that improved upon arousal. Physical exam showed an obese man in no acute distress with a depressed level of consciousness but who awoke to painful stimuli. Neuro exam was significant for dysarthric, hypophonic speech. Labs were significant for a primary respiratory acidosis with concomitant mild lactic acid elevation, normal bicarbonate, and normal anion gap. A comprehensive urine toxicology screen including cannabis was negative. Vital signs three hours after presentation deteriorated, showing: HR 47, RR 8-12, BP 88/52, O2 78%. Electrocardiogram (EKG) revealed sinus bradycardia. The patient progressively became more obtunded and required constant stimuli in order to maintain a patent airway. Non-invasive positive pressure ventilation was not administered due to persistent emesis.

The patient underwent supportive care with intravenous fluids, oxygen, anti-emetics, continuous stimulation, and close neurologic monitoring with full recovery by the following morning. Further, patient history revealed that he had consumed two packages of CBD gummies, totaling 370 mg total of CBD (serving size on the package was 30 mg). He felt the products were healthy and safe based on packaging and therefore did not believe they would have any adverse effects.

CBD is one of many cannabinoids found in marijuana and marijuana-derived products. It is generally considered safe unlike its more psychoactive counterpart, tetrahydrocannabinol (THC), which has been linked to seizures, respiratory depression, and cardiovascular complications. CBD has surged in popularity recently, being marketed in oils, capsules, and candies as a health supplement, claiming to treat a wide variety of medical conditions such as glaucoma, pain, and even having beneficial effects on cancer prevention. Most currently available studies do not look at isolated CBD nor their synthetic equivalents, and purity is not guaranteed, thus leading to unforeseen side effects and toxicities. Moreover, these compounds do not show on traditional toxicology screens, posing a diagnostic dilemma for physicians. This case of respiratory depression and cardiovascular compromise in a relatively healthy man is just one example of the importance of considering synthetic CBD toxicity in the differential diagnosis, as there is little data available for recognizing and treating this condition.

Introduction

Cannabidiol (CBD) is a rising trend in pop-culture. It can now be found in baked goods and candies, infused into coffees, and on the shelves of stores in cosmetics and oils. Benefits have been found for specific seizure disorders such as Lennox-Gastaut syndrome and Dravet syndrome; it is also being studied for its role in neuropathic pain [1-2]. The excitement over these treatments has spurred the production of a multitude of CBD-containing products that advertise a broad spectrum of clinical benefits such as improving arthritis-related pain, potential curative effects on cancers, to an overall improvement in well-being. While these claims are unfounded, the general consensus from the World Health Organization is that CBD is well-tolerated with a good safety profile [3]. This is a case report of a 56-year-old male who experienced significant neurologic, cardiovascular, and respiratory depression due to CBD product intoxication.

Case presentation

A 56-year-old male on no medications with no known history of substance abuse presented via ambulance to the emergency department after being found by coworkers with bizarre behavior, vomiting, and slurred speech. He had legally purchased “CBD gummies” marketed for pain and anxiety relief three hours prior to his presenting to the emergency department, hoping they would help relieve pain from a recent back injury (Figures ​ (Figures1, 1 , ​ ,2 2 ).

Bag of CBD gummies consumed by patient marketed as a healthy solution for pain relief. Per packaging, each gummy contained 15 mg CBD.

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A second bag of CBD Gummies consumed by the patient and scanned into the chart upon arrival. Product reportedly contained 50 mg CBD, 44 mg B12, and 400 IU D3 per gummy.

Upon arrival, vital signs (VS) were significant for hypoxia which did improve upon arousal. [Table ​ [Table1 1 ]

Table 1

Initial Vital Signs
Temperature 36.8 degrees Celsius
Heart Rate 78 beats per minute
Respiratory Rate 12 breaths per minute
Blood Pressure 113/60
Oxygen Saturation 84% on room air

Physical exam showed an obese male in no acute distress with a depressed level of consciousness, but who awoke to painful stimuli. Neuro exam was significant for dysarthric, hypophonic speech. He was also noted to have non-bilious, non-bloody emesis intermittently. Arterial blood gas at that time showed a mild acute respiratory acidosis with normal anion gap, normal bicarbonate, and a mild lactic acid elevation (Table ​ (Table2 2 ).

Table 2

Arterial Blood Gas
pH 7.30
pCO2 50.4
pO2 83.3
Lactic Acid 2.4

Labs were obtained and were notable for leukocytosis and mildly elevated creatinine kinase (CK) and CKMB (Table ​ (Table3). 3 ). A comprehensive toxicology screen including cannabis was negative (Table ​ (Table4 4 ).

Table 3

WBC, white blood cell count; RBC, red blood cell count; Hb, hemoglobin; Hct: hematocrit; Na: sodium; K: potassium; Cl, chloride; CO2, bicarbonate; CK, creatinine kinase; CKMB, creatinine kinase-MB

(H) indicates an elevated level, (L) indicates a low level

Initial Laboratory Values
WBC (H) 17.8
RBC 4.65
Hb 14
Hct (L) 41.7
Platelets 208
Na 139
K 4.5
Cl 107
CO2 25
Anion Gap 7
CK (H) 341
Ca (L) 8.4
Serum Alcohol
Troponin
CKMB (H) 4.4

Table 4

AMPX, amphetamines; BAR20: barbiturates; BEN, benzodiazepines; CAN 50, cannabinoids; OPI, opioids; PCP, phencyclidine; COC, cocaine; METH, methamphetamine

Urine Drug Screen
AMPX Negative
BAR200 Negative
BEN Negative
CAN 50 Negative
OPI Negative
PCP Negative
COC Negative
METH Negative

He was admitted to the medical floor, and VS 3 hours after presentation deteriorated, showing bradycardia with a nadir HR of 47, bradypnea as low as 8, blood pressure of 88/52 mmHg, and oxygen saturation as low as 78%. EKG revealed sinus bradycardia (Figure ​ (Figure3). 3 ). Narcan was given multiple times without improvement. The patient progressively became more obtunded but was able to maintain a patent airway with intermittent, aggressive stimuli. He was transferred to the intensive care unit (ICU) for close monitoring and possible intubation. Non-invasive positive pressure ventilation was not administered due to continued emesis.

The patient underwent supportive care with intravenous fluids, anti-emetics, oxygen via nasal cannula, and continuous aggressive stimuli. The following day, 18 hours after admission, the patient was fully alert, oriented, and VS showed signs of improvement (Figures ​ (Figures4 4 – ​ -6). 6 ). The patient recalled consuming 2 entire packages of CBD gummies, totaling 370 mg of CBD (serving size on the package was 30mg). He felt the products were safe based on packaging and ate them as he would eat any other candy, not believing they would have any adverse effects.

Significant bradycardia observed at approximately 3 hours after initial presentation with spontaneous recovery at approximately 26 hours.

Patient became hypotensive almost immediately after presentation which remained persistent until spontaneous recovery began to be seen at approximately 17 hours post-presentation with full recovery seen by the 26-hour period.

Upon presentation, the patient demonstrated some bradypnea which became more pronounced and persistent in the 9-21 hours after initial presentation. Again, spontaneous recovery occurred at approximately the 26-hour mark.

Discussion

This patient suffered neurologic and cardiopulmonary depression as a result of acute CBD intoxication. He was in his usual state of health prior to consuming two packs of CBD gummies. His heart rate, respiratory rate, and blood pressure dropped abruptly shortly after presentation and then experienced spontaneous recovery around 18-26 hours later without any intervention other than supportive care. This pattern of onset and recovery is consistent with toxin ingestion presumably from the CBD gummies which was the only known variable compared with the patient’s typical routine. Due to the report given by his coworkers, it was initially suspected that CBD overdose was the cause for this intoxication, of which there are no known published cases. However, given the lack of regulation and heterogeneity of over-the-counter CBD products, it is unclear which substance or substances were to blame in this patient. Similar cases are likely to be seen as these products become more commercially available.

One such case published in the literature is that of a 9-year-old boy with history of medically refractory epilepsy, diabetes insipidus, hypothyroidism, hemiplegic cerebral palsy, arachnoid cyst resection, and hypothalamic hamartoma resection who experienced profound neurologic and respiratory depression after CBD oil ingestion. The patient was being administered 1 drop of CBD oil to the gums daily but had incidental ingestion of 5 mL on the day of presentation. Upon arrival to the emergency department, he was noted to by hypothermic with depressed mental status and Glasgow coma score of 4-5 as well as decreased respiratory drive, leading to intubation. Urine screening was notable for a metabolite of THC, but testing was not readily available for CBD nor for synthetic cannabinoids. Mass spectrometry analysis of samples of the CBD oil from the same batch showed differing amounts of both CBD and THC. While the patient recovered, the exact constituent which caused the clinical findings mentioned was not able to be established due to lack of consistent formulations, purity, and potency of the commercially available products [4].

When comparing the two cases, there are certain similarities and differences which are worth mentioning. The pediatric patient consumed CBD oil, whereas the 56-year-old man ingested CBD gummies. In both scenarios, more of the CBD-labeled product was consumed than was recommended, and both patients required short-term hospitalization. In the case of the pediatric patient, testing for urine THC metabolites was also available. Neither patient had access to point-of-care testing for CBD or synthetic cannabinoids.

The CBD industry is projected to reach sales of $23 billion by 2023 [5]. This surge is likely due to the excitement behind potentially new medical breakthroughs and the desire as a culture to shift towards therapies that are more “natural.” However, most products, such as the one purchased by this patient are unregulated. Products can contain varying amounts of CBD in addition to unstudied cannabinoids, THC, or toxins such as pesticides and heavy metals. A recent study found that only 31% of 84 CBD products sold online from 31 companies were labeled correctly regarding the concentration of CBD. Additionally, THC was found in 21% of samples among other cannabinoids [6].

With the lack of a known blood level at which CBD exhibits toxic effects and the possible contamination of the product with other cannabinoids and toxins, it is difficult to know whether this is a true CBD intoxication versus toxicity from one of the constituents found in the product. Contributing to this diagnostic dilemma is the fact that the majority of these products are synthetic which allows for a larger spectrum of cannabinoids and much higher concentrations than would be found in natural sources. Additionally, synthetic products do not appear on standard toxicology screening, as was the case in this patient [7] (Oral Presentation: Bass, DO, Jessica, Linz, MD, David. Hashing Out the Unknowns of the CBD Craze. 2019 SGIM Annual Meeting; 5/11/2019).

Conclusions

This is a case of profound neurologic, cardiac, and respiratory depression secondary to acute CBD product intoxication resulting in ICU admission. The patient’s lack of substance abuse history and unintentional overdose should raise concern for physicians as more people are consuming such products. The aggressive marketing of these products paired with the lack of regulation and quality control has the potential to cause a significant negative impact on public health. Clinicians should be aware of this when prompted for advice from patients as well as when treating patients with potential intoxication. Further research into these compounds is certainly indicated and regulation may be warranted for consumer protection.

Notes

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

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Because Huaxia has no pillar industries of its own at all, the https://greenlotushemp.com/ biggest benefit of the lord s mansion is only the taxation of agriculture. Just now they watched the performance of the first batch of magicians, and they were so excited. The Potter family actually betrayed the kingdom, benefits of cbd you should immediately send someone to arrest him and inform His Majesty the King. The right phase looked at the departing back, and there was laced cbd gummies a hint of ruthlessness in his eyes.

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Just as he would challenge Darren and Barron if he had enough power, He stood up with a chuckle: laced cbd gummies Of course you want to be laced cbd gummies in the ring, I don t think you will give me this position directly. Mickey has agreed that the Guardian of Light will notify the three kingdoms of the cooperation with Tianmu, and let the three kingdoms inform the whole country. I don t know what the three adults are coming here this time? We have some things to discuss with Tianmu, which may disturb the lord for a few days. If Lieyang Kingdom used these two giant dragons to throw boulders to laced cbd gummies attack ordinary soldiers, how many would they kill at one time? It would take at least a few minutes for them to fly back and forth, and even if they laced cbd gummies hit them for a day, it wouldn t cause much damage. Even if this shadow is wonderful cbd pills not at the level of the snack merchant, his strength must be above the peak 8 gummies of ordinary legends. After that, he didn t give Galen and others a chance to laced cbd gummies complain again, and left quickly.

After a lot of fun, the three of them put the magic locomotive into their space ring and entered the arena. The next selection will cost 150,000 gold coins, and a half-price discount will be randomly selected. Everyone at the banquet looked up one after another, cheap effective cbd gummies In the distant sky, a huge flying dragon was flying from far to near, towards Nice City. benefits of cbd oil Buck has no choice but to compress the strength of the herb gummies clone to the twelfth Laced Cbd Gummies level. Promoted him laced cbd gummies cbd gummies to the hereditary marquis of the kingdom, and changed his territory from Nice City to Rota City. Although he is not the culprit, he is no different from the culprit! coldly. Looking innocently at the Right Prime Minister: Master Right gummy Prime Minister, I laced cbd gummies have already dispatched troops. He did not treat them badly, and immediately appointed cbd cream Alvin, the patriarch of the Connie family, as the administrative minister of Nice City, responsible for the government affairs of Nice City.

Choose the lottery, fortunately, this time the pointer did not select the small wooden laced cbd gummies box, but stopped on the scroll. The huge beam of light that suddenly appeared made the entire battlefield stunned. His face sank: If you want to take it, you can take it, this is an order. There are such smart people in the world? Weed grass can t believe it, He has been learning magic technology from the village chief since he was a child. Hearing the words, Galen and the laced cbd gummies others stepped back where can i buy harlequin cbd oil and looked at Mars opposite with a smile. It is absolutely a shame for cbd gummies for pain the kingdom to hand over Benedict, How long can the peace bought from the sale of dignity last. At the same time, in the high-end battle, Rutgers was injured by cbd store near me Carus, and the city lord s mansion was forced to give up the best cbd products best store thc gummies pursuit, saying Perhaps the City Lord s Mansion can achieve even more brilliant results. The shopping guide girl followed the stairs and went straight to the seventh floor. In the underground world, above the bloody legion, a space crack appeared out of thin air.

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He thought that these lords would be dissatisfied with the long-awaited arrival, but he did not expect this to be the case now. Riven independently, If the hero is successfully selected, the summoning will cost 150,000 gold coins.

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Blanche didn t want to stand here with Chesterton talking nonsense, she nodded and jumped back to distance herself from Chesterton. Once a member all natural cbd cream of the Shadow Eagle appears in Nice There is no amnesty in the city area! In this way, the Nice city area may be the most unlikely place for Shadow Eagle members to appear, and it is even safer than the king s capital.

It is impossible for us to mobilize such a large-scale force, Know, Moreover, compared with the strength of the Blue Shirt Army and our City Lord s Mansion today, the Blue Shirt Army has to deal with us and lead troops to attack directly, so why bother. After it is turned on, lloyds pharmacy cbd sleep gummies the time flow rate is doubled, and the lifespan of the creatures in the performance field is not affected by the time acceleration.

If you don t want to die, don t say anything, The boss stood behind the guard and said softly. It is his duty to make plans, and it is up to him to decide whether to adopt them or not. Light and shadow cbd gummies near me flashed, and Galen s image began to change, The original blue and gold-edged battle armor turned into a metallic edible gummies blue-black, and the breastplate cbd oil biotech 1000mg best results cbd store and hem were blood-red bright red. After the reception, he also invited a few nobles who could talk extra strength cbd oil dr phil to him or who had higher froggys cbd gummies titles to watch the performance with him on the main stage on the day of the celebration. They used to cbd for anxiety be a childhood sweetheart couple, but your grandson wanted to take love with a knife. The boss knew that if he wanted to get news of Swain, he had to go to Saint Zeil City.

Then, this cute cat was played by the clever little mouse in cbd gummies products various ways, It is indeed a very funny and funny scene, but it has half a cent dr oz cbd gummies to do with the construction of the territory.

After I leave, cbd gummies the Huaxia collar will be handed over to you, He took out a large iron box from the space ring, and the iron box contained the hundred coins he had just taken out of the system space. When I summoned a cbd oils famous ninja that day, I was overjoyed when I saw that the famous ninja randomly summoned were Madara royal cbd gummies and Itachi. In the City cbd gummies near me Lord s Mansion, in the council hall, Benedict sat at the top, Rutgers and the third young master Kret sat on either laced cbd gummies cost of cbd gummies to quit smoking side of him. It is the map of Nice city area, Glancing at everyone in the audience, Rutgers pointed to the location cbd gummies for tinnitus on shark tank of the rose collar: First of all, let s discuss the territory of the red rose collar. said loudly to Blanche, shaboink cbd gummies Blanche looked up at the third prince, did she still want to join the royal family in the end? In fact, in Blanche s heart, there is some resistance to the royal families of the three online shop benefits of cbd kingdoms.

wana brands cbd gummies It s not up to others to dictate laced cbd gummies how our Senlan family s territory should be. It s a pity that they are not legendary dragons, otherwise I can have some exchanges with them. Saint Zeer City, in the Lord s Mansion, Hearing the news that Huaxia led troops, Klaren s face was gloomy and abnormal, and the council hall was dead silent. the boss said, Can you do it alone? Swain asked, Daniel s power, he had seen gummies before, No problem, the boss replied. Alvin s words were unanimously approved by everyone in the house, except for Martha. Just this sentence, the lord is enough to be called a hero of the kingdom, and he will live forever. .

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