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When A Patient Presents With Forefoot Pain And Ulceration Complicated By Cannabis Arteritis
Mindful of the increasing legalization of marijuana, this author details the diagnosis and treatment of a patient who smoked marijuana and presented with forefoot pain and ulceration complicated by cannabis arteritis, a rare variant of Buerger’s disease.
Cannabis arteritis is an underdiagnosed cause of peripheral vascular disease in young patients. A 30-year-old man presented to the emergency department at our institution with redness, pain and swelling to his right hallux and fifth toe. The patient denied tobacco and alcohol use, but reported a 10-year history of smoking marijuana for management of attention deficit hyperactivity disorder (ADHD). He denied other illicit drug use.
An exam indicated the patient had erythema and edema to the affected digits as well as a stable eschar to the distal fifth toe. The patient had trace palpable pulses. The emergency room physician placed the patient on a 10-day course of cephalexin and instructed him to follow up with his primary care provider.
The patient presented to the emergency department three weeks later with persistent redness, pain and swelling to his toes as well as progressive wound development to his hallux and fifth toes. He noted no improvement with antibiotic treatment. In regard to the exam, the patient had monophasic dopplerable dorsalis pedis and posterior tibial pulses as well as normal ankle brachial indices (ABIs). The patient had cold digits with rubor to the forefoot as well as ulcerations with necrotic eschars present on both digits. A computed tomography (CT) angiogram showed no evidence of acute occlusion. The patient got a rererral to podiatry and interventional cardiology/vascular services.
Further workup included inflammatory and rheumatology laboratory studies as well as non-invasive vascular studies. Laboratory studies included erythrocyte sedimentation rate, C-reactive protein, lipids, complete blood count, chemistry panel, uric acid, complement (C3, C4), antinuclear antibody, rheumatoid factor, thyroid-stimulating hormone, 25-hydroxy vitamin D, antineutrophil cytoplasmic antibody (ANCA) vasculitis profile, anti-scleroderma antibody, antiphospholipid syndrome panel, antithrombin panel, factor V Leiden, homocysteine and D-dimer. All laboratory values were within normal limits with the exception of slightly elevated HDL cholesterol (64 mg/dL) and low 25-hydroxy vitamin D (20 ng/mL). Non-invasive vascular studies showed a mildly abnormal right ABI (0.88), a severely abnormal right tibial brachial index (TBI) (0.29), a right great toe pressures of 33 mmHg and severely abnormal right toe photoplethysmogram waveforms that suggested mild disease at the level of the ankle and severe disease of the right lower extremity microcirculation.
Radiographs and magnetic resonance imaging (MRI) of the right foot were negative for osteomyelitis. Lower extremity angiography with runoff showed normal femoral and popliteal vessels, but also revealed total occlusion of the right distal anterior tibial, distal posterior tibial and distal peroneal arteries with no evidence of atherosclerotic disease. Collateralization was present but there was poor filling of the vessels beyond the ankle. There were multiple attempts at percutaneous revascularization but the vascular surgeon was not able to achieve connection to a true distal lumen.
Given his continued ischemic pain and wound decline, the patient subsequently went back to the cardiac lab for a further attempt at peripheral revascularization. This procedure attained improved flow to the anterior tibial vessel. Following this procedure, the patient’s ABI improved to 0.85, the TBI improved to 0.59 and toe pressures improved to 69 mmHg.
The patient received counseling on the cessation of cannabis use and started on cilostazol, aspirin, clopidogrel and topical nitroglycerin (bid). He received local wound care and offloading for management of his ischemic wounds. Subsequent repeat vascular studies showed significant improvement in his ABI and TBI on the affected extremity. The patient did not require amputation and was progressing to wound healing at the last follow-up visit. Unfortunately, the patient was lost to follow-up prior to complete wound healing and resolution of his ischemic symptoms.
What You Should Know About Cannabis Arteritis
Cannabis arteritis is a proposed subtype of Buerger’s disease (thromboangiitis obliterans). Buerger’s disease is an inflammatory occlusive vascular disorder characterized by inflammatory endarteritis, a prothrombotic state and subsequent vaso-occlusive disorder affecting the small to medium-sized vessels of the lower and upper extremities. This disorder most commonly affects men 20 to 40 years old. Cannabis arteritis occurs with cannabis use, independently of tobacco use. This disorder is poorly understood and research can be difficult, owing to the frequent concomitant use of marijuana and tobacco products. Cannabis arteritis is becoming increasingly prevalent with the increasing use and legalization of cannabis in many states.
Clinical features of cannabis arteritis are identical to Buerger’s disease and include claudication, rest pain, ischemic ulcerations and gangrene.1 The development of “corkscrew” collateral vessels is a hallmark feature of Buerger’s disease but several authors have reported that the collateral vessels in cannabis arteritis are less developed.2,3 Cannabis arteritis can affect both the upper and lower extremity, but most commonly affects the digits of the lower extremity.4 Unlike the high amount and prolonged use of tobacco that is associated with Buerger’s disease, cannabis arteritis occurs earlier and with lower amounts of cannabis use.5
Cessation of cannabis use is the most effective treatment of cannabis arteritis.6,7 Similar to tobacco use in Buerger’s disease, disease progression and amputation risk in cannabis arteritis are closely associated with higher amounts and continuity of cannabis use.4 Additional treatment modalities that researchers have reported in the management of cannabis arteritis include peripheral revascularization procedures, anticoagulation, vasodilator treatment and hyperbaric oxygen.6–9 Progression of cannabis arteritis to non-healing wounds and tissue necrosis often necessitates amputation.4,7,8
In Conclusion
This report highlights a case of cannabis arteritis, a variant of Buerger’s disease, in a young man who did not use tobacco products. Similar to outcomes clinicians see with Buerger’s disease, the patient was able to avoid amputation by discontinuing cannabis use and undergoing peripheral revascularization.
Further research is needed to examine the pathophysiology as well as the epidemiology of this disorder, and to determine optimal treatment modalities to aid in limb salvage and avoiding amputation. With the increasing legalization of marijuana, providers should maintain an index of suspicion for cannabis contributing to the development of inflammatory vaso-occlusive disorders similar to Buerger’s disease.
Dr. Hoffman is the Medical Director of the Orthopedic Clinic and an Attending Physician in the Department of Orthopedics at Denver Health Medical Center. She is an Assistant Professor in the Department of Orthopedics at the University of Colorado School of Medicine.
References
1. Abyshov NS, Zakirdzhaev EA, Aliev ZM. [Modern aspects of diagnostics and treatment for thromboangiitis obliterans]. Khirurgiia (Mosk). 2009(2):75-79.
2. Grotenhermen F. Cannabis-associated arteritis. Vasa. 2010;39(1):43-53.
3. Alexander J, Ciagne MX, Kong JH. Thromboangitis obliterans associated with cannabis use: a case report and literature review. Vasc Dis Manage. 2011;8(7):E124–E126.
4. Peyrot I, Garsaud AM, Saint-Cyr I, Quitman O, Sanchez B, Quist D. Cannabis arteritis: a new case report and a review of literature. J Eur Acad Dermatol Venereol. 2007;21(3):388-391.
5. Ducasse E, Chevalier J, Dasnoy D, Speziale F, Fiorani P, Puppinck P. Popliteal artery entrapment associated with cannabis arteritis. Eur J Vasc Endovasc Surg. 2004;27(3):327-332.
6. Santos RP, Resende CI, Vieira AP, Brito C. Cannabis arteritis: ever more important to consider. BMJ Case Rep. 2017;2017.
7. Combemale P, Consort T, Denis-Thelis L, Estival JL, Dupin M, Kanitakis J. Cannabis arteritis. Br J Dermatol. 2005;152(1):166-169.
8. El Omri N, Eljaoudi R, Mekouar F, et al. Cannabis arteritis. Pan Afr Med J. 2017;26:53.
9. Groger A, Aslani A, Wolter T, Noah EM, Pallua N. [A rare case of cannabis arteritis]. Vasa. 2003;32(2):95-97.
