Current practice

Ann Biol Clin 2017; 75 (4): 462-5

Drowsiness and uncommon fever

in a child after cannabis ingestion
Somnolence et fièvre inhabituelle chez
un enfant après ingestion de cannabis

Catherine Feliu1,2 Abstract. Trivialization of cannabis consumption goes hand in hand with a
Yoann Cazaubon1,2 growing exposure of children and the number of cannabis poisoning cases is
Aurélie Fouley1 steadily increasing. As clinical presentation can be different from what is cur-
rently seen in adults, added to the fact that it is not always suspected, diagnosis
Hélène Guillemin1
of cannabis intoxication in children is often delayed or missed. A 16-month-old
Hervé Millart1,2 girl was admitted to the pediatric emergency unit for an important drowsiness
Claire Gozalo1 combined to moderate fever. After elimination of infectious causes, a toxic
Zoubir Djerada1,2 origin was considered and biological analyses led to the diagnosis of involun-
1 Laboratoire de pharmacologie et tary acute cannabis intoxication. In conclusion, cannabis intoxication in child
toxicologie, Hôpital Maison Blanche, has uncommon presentations compared to that seen in adults. In this context,
CHU de Reims, Reims, France biological analyses have a great importance for a rapid diagnosis and also for
2 SFR Cap-Santé-EA3801-Université de
the understanding intoxication circumstance. This is of paramount importance
Reims, Laboratoire de pharmacologie
médicale, Faculté de médecine de
because it may lead to consider child protection measures.
Reims, Reims, France
<cfeliu@chu-reims.fr>
Key words: child, involuntary intoxication, drowsiness, cannabis, mass spec-
trometry

Résumé. La banalisation de la consommation de cannabis va de pair avec une

augmentation de l’exposition des enfants. Le nombre de cas d’intoxications chez
les enfants par le cannabis ne cesse d’augmenter. La symptomatologie pouvant
être différente de celles observées chez les adultes, le diagnostic de l’intoxication
au cannabis chez les enfants est souvent retardé ou manqué, d’autant plus qu’il
n’est pas toujours suspecté. Une fille de 16 mois a été admise à l’unité d’urgence
pédiatrique pour une somnolence importante associée à une fièvre modérée.
Après élimination des causes infectieuses, une origine toxique a été consi-
dérée et les analyses biologiques ont mené au diagnostic d’intoxication aiguë
involontaire au cannabis. En conclusion, l’intoxication au cannabis chez l’enfant
présente des manifestations peu communes par rapport à celles observées chez
l’adulte. Dans ce contexte, les analyses biologiques ont une grande importance
pour un diagnostic rapide, mais aussi pour la compréhension des circonstances
d’intoxication, ceci pouvant conduire à envisager des mesures de protection de
l’enfance.

Article received November 16, 2016, Mots clés : enfant, intoxication involontaire, somnolence, cannabis, spec-
accepted January 4, 2017 trométrie de masse
doi:10.1684/abc.2017.1261

With the trivialization of cannabis consumption, the num- toxicological tests (rapid tests in first intention and specific
ber of cannabis poisoning in child is steadily increasing. tests as mass spectrometry for confirmation) to make the
This case describes an involuntary cannabis intoxication in right diagnosis and improve patient care during and after
an infant and shows the importance of using the adequate the hospital stay.
To cite this article: Feliu C, Cazaubon Y, Fouley A, Guillemin H, Millart H, Gozalo C, Djerada Z. Drowsiness and uncommon fever in a child after cannabis ingestion.
462 Ann Biol Clin 2017; 75(4): 462-5 doi:10.1684/abc.2017.1261

Case presentation
A 16-month-old girl was admitted to the pediatric emer-
gency unit for an important drowsiness. She was unable
to remain seated and to open eyes. Physical examina-
tion revealed the following parameters: body temperature,
38.3◦ C; heart rate, 136 beats/minute; blood pressure 110/20
mmHg; respiratory rate regular at 30/minute; oxygen sat-
uration, 98%; non-reactive mydriasis. Venous blood gas,
complete blood count and blood ionogram showed no
abnormality. The antipyretic treatment initiated during the
transfer to the hospital brought the fever down.
Due to the onset of fever and sedation, infection was sus-
pected.
Chest radiology did not reveal any sign of infection. Lum-
bar puncture and urine were collected for biochemical and
bacteriological examination. No bacteria or virus could be
detected neither in lumbar puncture nor in urine. Biochem-
ical parameters were also normal for both matrices. Serum
C-reactive protein and procalcitonin were normal.
Diagnosis of infection was therefore excluded and a
toxic cause was evoked. Urinary toxicology analysis by
immunochromatography was carried out, turning out posi-
tive for paracetamol and cannabis.
After questioning, the mother explained the child had
picked up in the street a small pebble that she had ingested.
The mother had tried to extract the pellet from the child’s
mouth without success. Six hours after ingestion, fever and
behavioral disorders such as grumpiness had appeared. Six
hours after the first symptoms an important drowsiness
occurred.
Mass spectrometry confirmed the presence of cannabis in
urine. Concentrations of tetrahydrocannabinol (9-THC)
and its metabolites in blood were quantified by liquid
chromatography coupled with tandem mass spectrometry:
4.1 ␮g/L, 7.4 ␮g/L and 174.3 ␮g/L for 9-THC,
11-hydroxy-tetrahydrocannabinol (11-OH-THC) and
11-nor-9-carboxytetrahydrocannabinol (THC-COOH),
respectively. Toxicological screening did not reveal any
other drug or poison. Oral cannabis consumption was
suspected since 11-OH-THC concentration was higher
than 9-THC [1].
Additionally, to confirm the information provided by the
mother about a single and accidental exposure in the street,
analysis of a hair strand was also performed. An unequiv-
ocal proof of cannabis active chronic consumption is the
detection of the THC-COOH in the hair. If only 9-THC
is detected, external contamination by smoking cannabis
is suspected. In our case, only 9-THC was quantified
(0.46 ng/mg) in the child’s hair.
Finally, these results confirmed an acute accidental inges-
tion. Nevertheless, external contamination of the hair
suggested a passive exposure of the child in the family
Ann Biol Clin, vol. 75, n◦ 4, juillet-août 2017
Cannabis intoxication in child
environment despite the mother’s story. The child recov-
ered after two days of hospitalization and returned home
with oversight by social services.
Discussion
Marijuana is a dry mixture of crushed leaves and flowers
of Cannabis sativa. 9-THC, tetrahydrocannabinol, is
the major psychoactive drug which activates two specific
cannabinoid-binding receptors (CB1 and CB2). CB1
receptors are distributed in the central nervous system
(substantia nigra, basal ganglia, hippocampus and cerebral
cortex), whereas CB2 receptors are mainly localized
peripherally in the immune system. CB1 receptors inhibit
the release of neurotransmitters such as acetylcholine,
noradrenalin, dopamine and serotonin. Even if the mech-
anisms of psychoactive effects are not fully understood,
CB1 receptors seem to be responsible for the mediation of
clinical effects [2].
Due to its high lipid-solubility, 9-THC is rapidly dis-
tributed into the adipose tissues, liver, lungs and central
nervous system where it exerts its psychoactive effects
[1]. 9-THC undergoes oxidative metabolism in the
liver (figure 1). The main metabolites are 11-hydroxy-
tetrahydrocannabinol (11-OH-THC) and 11-nor-9-
carboxytetrahydrocannabinol (THC-COOH).
Only 11-OH-THC has a psychoactive effect (figure 1) [1].
When cannabis is ingested, only 5-20% of 9-THC reaches
systemic circulation, because of its chemical instability
and of an important first-pass effect in the liver. Moreover,
9-THC is hydroxylated in 11-OH-THC in the intestinal
mucosa. Consequently, after an oral ingestion, 11-OH-
THC concentration is higher than 9-THC concentration
in blood [1]. The peak plasmatic concentration is achieved
2 to 6 hours after ingestion, and psychoactive effects appear
up to 1 to 3 hours after.
The majority of the 9-THC is excreted in metabolized
form within 72 hours in the feces (40%, 11-OH-THC
and THC-COOH) and urine (30%, THC-COOH). The
elimination half-life is highly variable, depending on the
quantity taken and the frequency of use. THC-COOH can
be excreted in urine up to 1 month after the last consumption
in regular smokers [1].
The effects of marijuana are largely described in the litera-
ture [1]. It provides a “well-being” state. Generally, people
take cannabis to feel calm, euphoric or slightly disinhib-
ited. Cannabis can also induce tachycardia, hypertension
and nausea. Cognitive disorders, perceptual alterations, hal-
lucinations, excessive sedation or anxiety may occur [1].
In children, drowsiness is the most frequently described
symptom but hypotonia, mydriasis, agitation, tachycardia
are also reported [3-5]. Some isolated cases also described
463
Current practice

Detection in blood : 2 to 10 hours THC Oral consumption

after consumption psychoactive
Undetected in urine
Intestinal mucosa

Hepatic microsomes

11-OH-THC 11-OH-THC
psychoactive

Hepatic microsomes

Detection in blood : 6 to 48 hours

Detection in urine : 1 day to more THC-COOH
than 1 month Non psychoactive
depending on frequency and dose
comsuption

Figure 1. Pharmacokinetics of cannabis: metabolism and detection window depending on mode of consumption.

breathing problems, hypoventilation, apnea and coma
[3, 4].
In this clinical case, important drowsiness and mydriasis are
similar to those described in the literature. Hyperthermia
on the contrary is not described in the literature in acute
intoxication.
Accidental cannabis poisoning in young children has been
increasing for many years [6]. The majority of cases involve
children under 2 years old. Intoxications occur most of the
time in the family environment, which has to be compared
with the trivialization of cannabis consumption in the gen-
eral population. Seriousness of the intoxication is variable:
from mild to severe [3-6], and even life-threatening. How-
ever, the evolution of these cases is favorable and so far no
death has been reported. Increase in 9-THC concentration
in the consumed products seems to be partly responsible
for this situation. Indeed, the mean concentration of 9-
THC has been multiplied by approximately 3 in 15 years to
reach, in 2013, 17.4% in the resin and 12.6% in grass. The
most common overdose incidents in children occur when
the drug has been combined with food in an “edible” form
of marijuana [6].
Conclusion
This cannabis poisoning is a typical example of an increas-
ing domestic accident, still too often forgotten. In children,
the nonspecific clinical signs result in a delay on diag-
nosis and management of this intoxication. Clinicians
should be aware of the magnitude of the phenomenon
and should not hesitate to question the children’s family
about it. In front of a possible intoxication in a child, a
first-intention urinary screening has to be done to get a
quick result. If positive, quantitation of the incriminated
drug(s) can be done on a blood sample to confirm the
drug taking and to estimate the gravity of the intoxication.
Comparing the ratios of the drug and its metabolites in dif-
ferent biological matrices (blood, urine, and hair) will then
allow distinguishing between acute and chronic poisoning
when necessary. This last point cannot be neglected when
dealing with children, as child protection measures may
therefore have to be considered. This whole process will
result in an improvement in the diagnosis of the type of
intoxication and therefore will improve patient care and
monitoring.
Conflicts of interest: All authors report no financial inter-
ests or potential conflicts of interest.
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