Cannabis Hyperemesis Syndrome in the Differential Diagnosis of Bathtub Deaths: Two Forensic Cases.

Nay G.; Selan J.; Levi G.; Nordenholz K.; Kelly L. · The American journal of forensic medicine and pathology · 2026

**Background & Methods** This forensic pathology case report examines two fatal cases involving males (ages 38 and 44) with documented cannabis hyperemesis syndrome (CHS) who were found deceased in bathtub and shower settings. The investigation utilized comprehensive forensic methodology including scene examination, autopsy findings, toxicologic analysis, and vitreous chemistry review to assess the role of CHS in the deaths. **Key Findings** • Both decedents had significant medical histories of chronic cannabis use complicated by CHS, characterized by severe cyclic vomiting, nausea, and abdominal pain; both were discovered in water-immersion settings (bathtub/shower environments). • Forensic examination revealed interpretive challenges in determining CHS as a primary or contributing cause of death, highlighting the need for systematic investigation of scene conditions, autopsy results, toxicology findings, and complete medical histories. • The cases underscore that CHS and its related complications warrant consideration in medicolegal death investigations, as the syndrome may contribute to fatal outcomes through aspiration, electrolyte disturbances, or loss of consciousness in water-immersion scenarios. **Dosage & Administration** Not reported. **Safety & Adverse Effects** Cannabis hyperemesis syndrome manifests as severe cyclic vomiting, nausea, and abdominal pain in chronic users. The reported cases suggest potential fatal complications associated with CHS, including the risk of drowning or aspiration in water-immersion settings, though specific mechanisms of death were not explicitly detailed in the abstract. **Evidence Quality** This is a case report study representing the lowest level of clinical evidence (Level 5). Significant limitations include the small sample size (n=2), retrospective descriptive nature, lack of comparative controls, and inability to establish definitive causation. The study provides observational data from forensic investigations rather than controlled clinical research. While the cases illustrate diagnostic and investigative challenges in forensic pathology, findings cannot be generalized to broader CHS populations. The primary value lies in raising awareness among forensic pathologists about CHS as a potential medicolegal consideration rather than establishing epidemiologic risk or mortality data. Enhanced familiarity with CHS presentation and complications in chronic cannabis users is emphasized as important for forensic practitioners.

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