Fulminant hepatic failure following marijuana drug abuse: Molecular adsorbent recirculation system therapy
A 23-year-old male college student presented to the emergency department with a history of malaise, fatigue and vomiting of 1 week duration. He also had a history of yellowish discoloration of the sclera and breathlessness of 3 days and developed altered sensorium a day prior to presentation. There was no history of oliguria, hematuria, dysuria or graveluria. There was no history of focal weakness of limbs or seizures and bleeding manifestations. He had no significant past medical, surgical or family history. He had no drug allergy. His father gave a history of marijuana abuse for the past few months and denied history of smoking and alcohol. On examination, he was irritable pale and icteric, blood pressure was 130/80 mmHg. Cardio-respiratory examination was unremarkable. Abdomen was soft and showed no evidence of hepatosplenomegaly. Neurological examination revealed no evidence of focal neurological deficit or meningeal signs of irritation. His laboratory parameters are given in .\nTests for hepatitis A, hepatitis B, hepatitis C and E, human immunodeficiency virus, cytomegalovirus, parvovirus, Wilson’s disease, autoimmune hepatitis and acetaminophen induced hepatitis were all negative. Chest radiograph and ultrasonogram of the abdomen were normal. Blood and urine culture were sterile. Peripheral smear for malaria parasite, anti-dengue antibodies and leptospira serology were all negative. Cerebrospinal fluid analysis was unremarkable. Blood and urine for tetrahydrocannabinol (THC) were positive. The diagnosis of acute fulminant hepatitis secondary to marijuana abuse was considered as other causes of fulminant hepatic failure were all ruled out and blood and urine were positive for THC. He was given supportive care and antibiotics. His condition worsened over the next 2 days and developed respiratory distress requiring intubation and ventilator support. Sequential laboratory reports are shown in . On the 3rd day, he was initiated on extra-corporal liver-purification system; MARS. After three sessions of MARS, each lasting 8 h, there was a remarkable improvement in level of sensorium and biochemical parameters. He was extubated on the 6th day and by 10th day his liver parameters came down remarkably. He was discharged after 3 weeks. On follow-up, his biochemical parameters were normal.