Naltrexone is a semi-synthetic opioid that has competitive antagonist activity at mu opioid receptors. Naltrexone has proven to be efficacious in the treatment of alcohol and opioid dependence, and a long-acting injectable form of naltrexone was developed to overcome noncompliance. Therefore, injectable naltrexone has the potential to become an important medication for the treatment of opiate and alcohol dependence. Acute eosinophilic pneumonia (AEP) is a rare acute respiratory illness of varying severity that may lead to acute respiratory distress syndrome and death. Initially, AEP was thought to be idiopathic; however, it has become apparent that AEP can have identifiable causes including medications, infections, and other inhalational exposures, especially tobacco smoke. AEP is generally a diagnosis of exclusion confirmed by the presence of bronchoalveolar lavage (BAL) fluid eosinophilia. Recognition and elimination of the causative factor for AEP and providing glucocorticoid therapy are key principles in the management of AEP of non-infectious origin. Prognosis is generally excellent if AEP is diagnosed early and managed appropriately, even in patients with acute respiratory failure. The diagnosis of AEP is generally overlooked given the shared clinical attributes with acute lung injury due to other causes, including severe community-acquired pneumonia. A 32-year-old lady presented to the emergency department (ED) with symptoms of dyspnea, chest pain, cough, and subjective fevers since three days. She received a dose of intramuscular Naltrexone for the treatment of alcohol and opiate dependence on the day of symptom onset. Initially, she was noted to be hypoxic, and oxygen supplementation was initiated through a nasal cannula. While in the ED, she was placed on a non-rebreather mask because of worsening hypoxia. Chest imaging showed diffuse bilateral pulmonary infiltrates. Initial laboratory data were pertinent for elevated WBC count with mild peripheral eosinophilia. Antibiotics were administered for the treatment of suspected community-acquired pneumonia. Upon hospital admission, she was started on steroids for the management of suspected eosinophilic pneumonia secondary to injectable naltrexone. Bronchodilator therapy was initiated, and antibiotics were discontinued. The patient's oxygen requirements improved. Pulmonology consultation was requested, and the patient underwent bronchoscopy. BAL studies showed predominance of lymphocytes with no eosinophils. However, lung biopsy showed findings consistent with drug-induced eosinophilic pneumonitis. The patient's hypoxia resolved with steroid therapy. The patient was discharged with a course of oral steroids, albuterol inhaler, and outpatient pulmonology follow-up.

INTRODUCTION: “Intussusception” is a term initially used by the Scottish surgeon, Dr. John Hunter in 1789 which means invaginating or telescoping. It is caused by any condition that disrupts the normal physiological mechanism of intestinal peristalsis. Intussusception in adults is rare with incidence of 2-3 cases per population of 1000000 annually. The most common cause of intussusception in adults is neoplasms. CASE DESCRIPTION/METHODS: 22-year-old female, with multiple past episodes of abdominal pain and vomiting, presented with one day duration of sudden onset worsening abdominal pain, vomiting and diarrhea. The stools were black but without tarry clots or frank blood. She also had four episodes of non-bilious and non-bloody emesis. Of note, she had more than one year history of extensive marijuana use. Upon presentation, her vitals were unremarkable. Physical exam was pertinent for diffuse abdominal tenderness without guarding or rebound. Initial labs were unremarkable except for an elevated lactic acid level (4.6 Mmol/L). Pregnancy test was negative. Patient received anti-emetics, proton pump inhibitor and IV fluids. She then underwent a CT scan of the abdomen and pelvis which revealed a small bowel intussusception in the left hemiabdomen. She was made NPO and subsequently underwent both upper endoscopy and colonoscopy which were normal. She was treated conservatively with bowel rest, anti-emetics and IV fluids. She gradually improved with resolution of symptoms on day four of hospital stay. Her intussusception had resolved on a follow up small bowel series. She was discharged home with outpatient Gastroenterology follow up. DISCUSSION: There is enough evidence to support that cannabis acts on several segments of the bowel. It has been demonstrated that interaction through inhibition of intrinsic cholinergic mechanisms can result in cannabis-induced inhibition of gastrointestinal motility. Fernández-Atutxa et al. and Olga et al. presented a 3 patient case series and a case report respectively with clinical presentation similar to our patient. These patients were diagnosed with intussusception with no apparent organic cause but had a history of extensive marijuana use. Our case presentation is intended to pay attention to adverse effects of cannabis in light of increasing legalization and increasing therapeutic use of cannabis and its derivatives.