A53-36 Esophageal Perforation and Pneumomediastinum Secondary to Cannabinoid Hyperemesis Syndrome

Abstract Introduction Cannabinoid hyperemesis syndrome (CHS) is a cyclic vomiting disorder in long-term, high-dose cannabis users, typically daily or near-daily. It features recurrent, severe vomiting every week to months and can cause dehydration, electrolyte imbalances, acute kidney injury, and complications of forceful retching, including pneumomediastinum, pneumothorax, pneumopericardium, and rare Boerhaave syndrome. Spontaneous pneumomediastinum (0.001-0.01% incidence) results from alveolar rupture with air tracking into the mediastinum (Macklin effect). In cannabis users, triggers include Valsalva during smoking, breath-holding barotrauma, and vomiting-related esophageal injury. Recognition is critical; definitive prevention is cannabis cessation, with supportive care during flares to manage complications and stabilize patients. Case report A 29-year-old Caucasian man with GERD, daily marijuana use, and active vaping presented to the emergency department with moderate to severe mid-back pain after two days of nausea and violent vomiting. A contrast-enhanced chest CT revealed pneumomediastinum most pronounced in the inferior mediastinum, a small amount of left pleural gas, and a moderate loculated left pleural effusion, raising concern for esophageal rupture. A CT esophagram showed oral contrast in the mid and distal esophagus with a suspected small posterior leak at the T7-T8 level. Additional imaging findings included residual pneumomediastinum, periesophageal air around the mid and distal esophagus, esophageal wall thickening, and multiloculated fluid collections with air-fluid levels along the left mediastinum and pleural surfaces, with adjacent atelectasis. Cardiothoracic surgery was consulted, and he underwent thoracotomy with decortication and washout, plus open gastrojejunostomy tube placement; he also had a left-sided loculated pleural effusion and is now status post decortication. Operative cultures grew Candida albicans, Streptococcus constellatus, Streptococcus anginosus, and Streptococcus mitis/oralis. He was initially treated with broad-spectrum antibiotics, then transitioned to piperacillin-tazobactam (Zosyn) and fluconazole for 6 to 8 weeks, with plans for close outpatient follow-up. Discussion Cannabinoid hyperemesis syndrome (CHS) is a form of cyclic vomiting linked to heavy, long-term cannabis use. In some patients, severe retching or inhalation techniques can cause air leaks into the chest (pneumomediastinum) by rupturing tiny air sacs or through small tears in the esophagus. These complications can be dangerous if not recognized quickly. Clinician,especially in primary care and emergency departments should think of CHS when frequent cannabis users arrive with chest or neck pain, swelling under the skin, or signs of esophageal injury. Prompt diagnosis, supportive care, and counseling on cannabis cessation can prevent serious harm and improve outcomes. This abstract is funded by: none