Hepatitis A virus infection associated with cannabis use

Abstract

We identified a case of acute Hepatitis A virus (HAV) infection linked to cannabis use. The local Public Health department received report of a man in his mid-20s with a classic presentation of hepatitis - jaundice, abdominal pain, vomiting, general malaise, and dark urine - as well as elevated serum aminotransferase levels and a positive anti-HAV IgM. Upon questioning, he reported no contact with ill individuals, or travel outside his metropolitan area. His exclusive source of water was the local municipal supply. He reported consuming mainly pre-packaged lower risk foods from large chain-style supermarket stores and eating at several local restaurants. While administering the questionnaire, the investigator identified that the patient smoked cannabis. Upon request, the patient agreed to provide a sample of cannabis for testing purposes. A viral elution of fresh cannabis leaves was completed. The sequences derived from the patient's serum sample and the eluate from the cannabis leaves were identical, but did not match any other HAV sub-genotype 1B sequences from Canadian isolates within the National Microbiology Laboratory database. Hepatitis A virus can survive >60 days when dried and kept at room temperature and low humidity; HAV can remain infectious in water at room temperature for 300 days. It cannot be concluded with certainty that the cannabis was the source of the hepatitis A; however, as other sources were excluded, or were of lesser probability, the association of cannabis with his disease acquisition remains strong.

Figure 1. Maximum likelihood phylogenetic tree of the VP1-P2A junction (nucleotides 2903 to 3275, according to the reference strain HM-175) showing the relationship between Canadian HAV 1B isolates

Legend: The reference HAV 1B strain HM-175-M14707 is in bold font. Numbers indicate the reproducibility after 1,000 bootstraps, and only bootstraps values higher than 70% are shown. Genotypes 1A and 3A are included as outliers. The scale bar indicates 2% sequence diversity. Patient and cannabis leaves eluate isolates (red font) are compared to other 1B isolates from the same (blue font) or other provinces (black font). Epidemiologically linked cases from different outbreak clusters illustrating the genomic sequence identity are encircled