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LACTIC ACIDOSIS: A RARE MANIFESTATION OF SYNTHETIC MARIJUANA INTOXICATION.

INTRODUCTION
Synthetic cannabinoids are designer drugs that mimic the effect of cannabis, which has become popular with young drug users. These drugs have a similar chemical structure and pharmacologic effects as marijuana, but seem to be more potent. These substances have been banned by the US Drug Enforcement Agency in 2010. Prior to 2010, these drugs were perceived as "safer" by the general population. Synthetic cannabinoids cause effects similar to marijuana making the subjects euphoric. However, they act as full, rather than partial, agonist at the receptor sites causing more severe side effects such as severe agitation, seizures, acute renal failure, and lactic acidosis.


CASE
An 18 year old man was brought to the emergency department after his friends found him unconscious at home. He was found to be lethargic with shallow and rapid breathing. The patient had metabolic acidosis with an anion gap of 26 and lactic acid levels were high at 10.6. He also had a generalized tonic clonic type seizure after admission however lactic acid levels were drawn before the seizure occurred. Urine drug screen was negative; blood alcohol did not show high levels of alcohol. The patient was intubated, mechanically ventilated and, started on a bicarbonate drip. After the patient was extubated, a thorough history was significant for synthetic marijuana use only.


DISCUSSION
Limited literature with few reported cases of lactic acidosis exist, and none to the degree we saw in our patient. Even though synthetic cannabinoids were added to schedule I controlled substance they are still sold legally as incense herbal products with package insert saying not for human consumption. At present, detection test are not readily available for rapid identification, and the literature on treating these patients is thin. Synthetic cannabinoid use should be kept in the differential during management of young patients who present with seizures and lactic acidosis. Further research is needed to identify rapid identification test and good treatment protocols for improved patient therapy.