[Progressive cannabis-induced arteritis: a clinical thromboangiitis obliterans sub-group?]

Cannabis arteritis: A case report and brief review of the literature

Introduction

Cannabis is commonly misused psychoactive drug which is known to be associated with a number of psychotic and somatic side-effects. Cannabis arteritis is a rare vascular disorder, since only about fifty cases have been reported in the literature.

Case presentation

We report a case of a 40-year-old chronic cannabis user male, who was admitted for painful necrosis of the fifth toe of the right foot. The etiological investigation ruled out the main causes of juvenile arterial disease. Therefore cannabis was the only causative factor found in this patient. An amputation of the fifth toe was performed 20 days later of administrating Prostacyclin (Iloprost) , with a good postoperative improvement.

Discussion

The main causes of juvenile arterial disease are: atheromatous arterial disease, thromboangiitis obliterans (Buerger's disease) , systemic or autoimmune diseases. The diagnosis of cannabis arteritis remains a diagnosis of exclusion. it remains a rare phenomenon which is responsible for various symptoms, which can go as far as the amputation of the limb. Several authors have classified cannabis arteritis as a clinical form of Buerger's disease, due to similar clinical semiology and similar appearance at arteriography. Nowadays, we don't know exactly the histopathologic patterns of this pathology.

Conclusion

Although several therapeutic options exist, Cannabis weaning still the main part of cannabis arteritis treatment.

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Cannabis arteritis is a rare vascular disorder, since only above fifty cases have been reported in the literature.

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The diagnosis of cannabis arteritis remains a diagnosis of exclusion. therefore the main causes of juvenile arterial disease must be ruled out.

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Nowadays, we don't know exactly the histopathologic patterns of this pathology.

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A number of therapeutic options exist. This case was successfully managed with an extended course of intravenous vasodilator therapy combined with amputation of the necrotic toe. Long term treatment consists of cessation of Cannabis use to prevent recurrence.

Cannabinoids in the Pathophysiology of Skin Inflammation

Cannabinoids are increasingly-used substances in the treatment of chronic pain, some neuropsychiatric disorders and more recently, skin disorders with an inflammatory component. However, various studies cite conflicting results concerning the cellular mechanisms involved, while others suggest that cannabinoids may even exert pro-inflammatory behaviors. This paper aims to detail and clarify the complex workings of cannabinoids in the molecular setting of the main dermatological inflammatory diseases, and their interactions with other substances with emerging applications in the treatment of these conditions. Also, the potential role of cannabinoids as antitumoral drugs is explored in relation to the inflammatory component of skin cancer. In vivo and in vitro studies that employed either phyto-, endo-, or synthetic cannabinoids were considered in this paper. Cannabinoids are regarded with growing interest as eligible drugs in the treatment of skin inflammatory conditions, with potential anticancer effects, and the readiness in monitoring of effects and the facility of topical application may contribute to the growing support of the use of these substances. Despite the promising early results, further controlled human studies are required to establish the definitive role of these products in the pathophysiology of skin inflammation and their usefulness in the clinical setting.

Cannabis arteritis: ever more important to consider

Cannabis arteritis (CA) is a major and underdiagnosed cause of peripheral arterial disease in young patients. A 34-year-old man, daily smoker of 20 cigarettes and two cannabis cigarettes for 14 years, presented with a necrotic plaque of left hallux for 3 weeks. The Doppler ultrasound and angiography were compatible with severe Buerger's disease. Submitted to a revascularisation procedure and hypocoagulation with rivaroxaban. He had ceased smoking but maintained consumption of cannabis. Owing to the persistence of distal necrosis, amputation of the hallux was performed with good evolution. CA is a subtype of Buerger's disease. It is poorly known but increasingly prevalent and manifests in cannabis users regardless of tobacco use. The drug is considered at least a cofactor of the arteriopathy. The most effective treatment is cessation of consumption. Being cannabis one of the most consumed drugs, its mandatory to ask about its use in all young patients with arteriopathy.

Stromelysin-1 5A/6A and eNOS T-786C Polymorphisms, MTHFR C677T and A1298C Mutations, and Cigarette-Cannabis Smoking: A Pilot, Hypothesis-Generating Study of Gene-Environment Pathophysiological Associations With Buerger’s Disease

Buerger’s disease (BD) etiologies are poorly understood. Beyond smoking cessation, medical-surgical treatments have limited success. We hypothesized that mutations associated with arterial vasospasm (stromelysin-1 5A/6A, eNOS T-786C) and C677T-A1298C methylene tetrahydrofolate reductase (MTHFR) interacted with cigarette-cannabis smoking, reducing vasodilatory nitric oxide (NO), promoting arterial spasm-thrombosis. Of 21 smoking BD patients (14 men [2 siblings], 7 women; 20 white, 1 African-American), compared to 21 age-gender-race matched healthy controls, 5A/6A stromelysin- 1 homozygosity was present in 7 of 21 (33%) BD cases versus 5 of 21 (24%) controls (risk ratio 1.4; 95% confidence interval [CI] 0.5-3.7), and eNOS T-786C homozygosity was present in 3 of 21 (14%) BD cases versus 1 of 21 (5%) controls (risk ratio 3.0; 95% CI 0.3-26.6). C677T MTHFR homozygosity or compound C677T-A1298C heterozygosity was present in 7 of 21 cases (33%) versus 11 of 21 controls (52%) (risk ratio 0.6; 95% CI 0.3-1.3). In 18 patients who stopped and 3 who continued smoking, all stromelysin-1 5A/6A and/or eNOS heterozygotes-homozygotes, superficial phlebitis, lower limb gangrenous ulcers, and intractable ischemic rest pain with arterial occlusion progressed despite conventional medical therapy, threatening amputation. In 15 patients, to increase vasodilatory NO via endothelial NO synthase, l-arginine (15 g/day) was given, along with folic acid (5 mg), vitamin B6 (100 mg), and B12 (2000 mg/day) to optimize homocysteine metabolism and reduce asymmetric dimethylarginine, a NO synthase inhibitor. Unexpectedly quickly and strikingly, within 8 weeks to 8 months receiving l-arginine-folic acid, 11 of 15 treated patients improved with uniform pain reduction, ulcer healing, and in 5, full recovery of previously absent peripheral pulses. In smokers homo/heterozygous for stromelysin-1 5A/6A and eNOS T-786C mutations, we speculate that the development and severity of BD are related to a gene-environment vasospastic interaction with reduced NO-mediated vasodilatation. Increasing NO production by l-arginine while optimizing homocysteine metabolism by folic acid-B6-B12 may have therapeutic benefit. Further blinded, placebo-controlled studies are needed to determine whether our observations can be generalized to larger BD cohorts.

[Cannabis use: what to do in general practice?]

Cannabis use is now more frequent than alcohol drinking or tobacco smoking among young people (15-34years), whereas it may induce numerous medical aftermaths. Identifying and assessing cannabis use in general practice have become a current public health issue. The two steps of screening consist in spotting risky use of cannabis, and then in checking criteria for cannabis use disorder (CUD). Risky use requires a "brief intervention" by the general practitioner (GP). In case of CUD, the new DSM-5 criteria allow measuring the severity of the subsequent disorder, and listing the medical and social consequences. Using these criteria can help the GP to decide when the patient should be referred to an addiction-specialized unit. The GP has also to spot the different physical and psychiatric complications of cannabis use, in order to coordinate care between the different specialists.

Cannabis arteritis: a new case report and a review of literature

Cannabis arteritis manifests in cannabis users, independently of tobacco consumption. Around 50 cases were reported in the literature since the first description of this entity in 1960. We report the case of a 36-year-old man, cannabis user, without vascular risk factor who developed digital necrosis on the right foot. The pedal pulses were not palpable. He had no abnormal laboratory findings. Arteriography revealed distal segmental lesions and occlusion of popliteal artery. This arteritis was linked to cannabis use, but the patient did not stop cannabis consumption. His symptoms became even worse and he eventually developed sub-acute ischaemia in his left leg despite vascular treatments. Amputation of the right second toe and of the left leg finally became necessary. Cannabis arteritis is relatively similar to thromboangiitis obliterans in its clinical and arteriographical presentation. A parallelism can be made between the role of tobacco in thromboangiitis obliterans pathogenesis and the role of cannabis in cannabis arteritis. Cannabis use must be searched in young patients presenting with arteriopathy. Cannabis arteritis may indeed represent a frequent cause of juvenile peripheral obstructive arterial disease, but is probably under-diagnosed.

Cutaneous Vasculitis Update: Neutrophilic Muscular Vessel and Eosinophilic, Granulomatous, and Lymphocytic Vasculitis Syndromes

Most biopsies of cutaneous vasculitis will exhibit a small vessel neutrophilic vasculitis [leukocytoclastic vasculitis (LCV)] that is associated with immune complexes on direct immunofluorescence examination or, less commonly, antineutrophilic cytoplasmic antibodies (ANCA) by indirect immunofluorescence testing. Is in uncommon for skin biopsy to reveal solely a neutrophilic arteritis signifying the presence of cutaneous polyarteritis nodosa or, if accompanied by significant lobular panniculitis, nodular vasculitis/erythema induratum. In other cases, cutaneous vascular damage (fibrinoid necrosis, muscular vessel wall disruption, or endarteritis obliterans) will be mediated by a nonneutrophilic inflammatory infiltrate. Eosinophilic vasculitis can be a primary (idiopathic) process that overlaps with hypereosinophilic syndrome, or it can be a secondary vasculitis associated with connective tissue disease or parasite infestation. Authentic cutaneous granulomatous vasculitis (versus vasculitis with extravascular granulomas) can represent a cutaneous manifestation of giant cell arteritis, an eruption secondary to systemic disease such as Crohn's disease or sarcoidosis, or a localized disorder, often a post-herpes zoster (HZ) phenomenon. Lymphocytic vasculitis is a histologic reaction pattern that correlates with broad clinical differential diagnosis, which includes connective tissue disease - mostly systemic lupus erythematosus (SLE), endothelial infection by Rickettsia and viruses, idiopathic lichenoid dermatoses such as perniosis or ulcerative necrotic Mucha-Habermann disease, and angiocentric cutaneous T-cell lymphomas. Skin biopsy extending into the subcutis, identifying the dominant inflammatory cell and caliber of vessels affected, extravascular histologic clues such as presence of lichenoid dermatitis or panniculitis, and correlation with clinical data allows for accurate diagnosis of these uncommon vasculitic entities.