A Cautionary Tale of Synthetic Marijuana Use (P4.317)

Objective: To describe a case of super-refractory epilepsy caused by smoking synthetic marijuana (“spice”/”K2”) that was treated with intravenous immunoglobulin (IVIG) and plasmapheresis (PLEX). Background: CNS toxicity from the use of synthetic marijuana is known to cause paranoia and hallucinations. Previous case reports have also implicated its use in causing new-onset seizures in patients without other seizure risk factors. Design/Methods: Case report Results: A nineteen year old right-handed Caucasian male with Hepatitis C, prior intravenous drug use, and recent “spice” use was transferred to a tertiary referral center with status epilepticus. Patient had three seizures in the last six months prior to hospitalization in the context of smoking “spice”, which he had been using for one year. Routine urine and serum toxicology were unrevealing. Extensive serum and cerebrospinal fluid testing for infectious, inflammatory, autoimmune, paraneoplastic, and mitochondrial etiologies were unremarkable. Patient had no abnormal lesions on MRI brain and full-body PET. He was in refractory status epilepticus and treated with midazolam infusion for eight days with the addition of six antiepileptic drugs. One month after discharge to acute rehabilitation, patient was readmitted for status epilepticus after report of recurrent “spice” use. Patient remained in status despite a trial of ketamine infusion and pentobarbital-induced coma. Due to poor clinical response, he empirically received a course of high-dose methylprednisolone, three courses IVIG (four days each), and seven days of PLEX. Additionally, patient was randomized for SAGE-547 trial for super-refractory epilepsy and received either study medication or placebo. Four months after patient’s readmission, his seizures were finally controlled. Conclusions: Epilepsy attributed to the use of synthetic marijuana poses both diagnostic and therapeutic challenges. Clinical vigilance and history are key to diagnosis as synthetic cannabinoids are not detected by routine urine and serum toxicology screening. For super-refractory status epilepticus, immunomodulating therapy with intravenous immunoglobulin and plasmapheresis may be necessary. Disclosure: Dr. Zhang has nothing to disclose. Dr. Patel has nothing to disclose. Dr. Dani has nothing to disclose.