Multi-organ dysfunction due to bath salts: are we aware of this entity?

Methylenedioxypyrovalerone (MDPV) is a synthetic, cathinone-derivative, central nervous system stimulant taken to produce a cocaine- or methamphetamine-like high. Physical manifestations include tachycardia, hypertension, arrhythmias, hyperthermia, sweating, rhabdomyolysis, hyperkalaemia, disseminated intravascular coagulation, oliguria and seizures. We report a patient who presented with severe metabolic acidosis, multi-organ dysfunction, rhabdomyolysis, hyperkalaemia and seizures. This case highlights that even though a urine drug screen for routine psychostimulant drugs is negative, clinicians need to be vigilant about the adverse effects of MDPV as a possible cause of multi-organ dysfunction. Substances such as this can only be detected by special tests, such as gas/liquid chromatography mass spectrometry. This is the first reported case of MDPV toxicity successfully treated in Australia to the best of our knowledge.

Devastating Delayed Leukoencephalopathy Associated with Bath Salt Inhalation.

BACKGROUND: "Bath salts" or synthetic cathinone toxicity remains a potentially deadly clinical condition. We report a delayed leukoencephalopathy with persistent minimally conscious state. METHODS: Case report. RESULTS: A 36-year-old man presents with delayed encephalopathy, dysautonomia, fulminant hepatic failure, and renal failure from severe rhabdomyolysis after consuming bath salts. MRI showed diffusion restriction in the splenium of the corpus callosum and subcortical white matter. CONCLUSIONS: The combination of acute leukoencephalopathy, rhabdomyolysis and fulminant hepatic failure may point to bath salt inhalation and should be known to neurointensivists.

The effect of banning MDPV on the incidence of MDPV-positive findings among users of illegal drugs and on court decisions in traffic cases in Finland.

In this study, we sought to determine what impact the banning of 3, 4- methylenedioxypyrovalerone (MDPV) had on the incidence of MDPV-positive findings and on user profiles in driving under the influence of drugs (DUID) and postmortem (PM) investigations in Finland. All MDPV-positive cases and a selection of corresponding court cases between 2009 and 2012 were examined. The median serum concentration of MDPV in DUID cases was 0.030 mg/L and in PM blood 0.12 mg/L. The number of MDPV-positive cases decreased both in DUID and PM investigations after the drug was banned. The decrease in the mean monthly numbers of MDPV-positive DUID cases was 51.1%. In court cases, MDPV was rarely mentioned until banned and frequently mentioned thereafter. Of the convicted, 37% were without a fixed abode, 98% had other charges besides that of DUID, and 13% appeared in the study material more than once. In MDPV-positive PM cases, the proportion of suicides was very high (24%). Research on new psychoactive substances is required not only to support banning decisions but more importantly to be able to provide a scientific assessment of the risks of these new substances to the public and potential users.

Sympathomimetic syndrome, choreoathetosis, and acute kidney injury following "bath salts" injection.

"Bath salts" is a well known street drug which can cause several cardiovascular and neuropsychiatric symptoms. However, only one case of acute kidney injury has been reported in the literature. We present a case with sympathomimetic syndrome, choreoathetosis, gustatory and olfactory hallucinations, and acute kidney injury following the use of bath salts. A 37-year-old man with past medical history of hypertension and depression was brought to the emergency center with body shaking. Three days before admission he injected 3 doses of bath salts intravenously and felt eye pain with blurry vision followed by a metallic taste, strange smells, profuse sweating, and body shaking. At presentation he had a sympathomimetic syndrome including high blood pressure, tachycardia, tachypnea, and hyperhydrosis with choreoathetotic movements. Laboratory testing revealed leukocytosis and acute kidney injury with a BUN of 95 mg/ dL and a creatinine of 15.2 mg/dL. Creatine kinase was 4,457 IU/dL. Urine drug screen is negative for amphetamine, cannabinoids, and cocaine; blood alcohol level was zero. During his ICU stay he became disoriented and agitated. Supportive treatment with 7.2 liters of intravenous fluid over 3 days, haloperidol, and lorazepam gradually improved his symptoms and his renal failure. Bath salts contain 3,4-methylenedioxypyrovalerone, a psychoactive norepinephrine and dopamine reuptake inhibitor. Choreoathetosis in this patient could be explained through dopaminergic effect of bath salts or uremic encephalopathy. The mechanism for acute kidney injury from bath salts may involve direct drug effects though norepinephrine and dopamine-induced vasoconstriction (renal ischemia), rhabdomyolysis, hyperthermia, and/or volume contraction.

Hyperthermia and multiorgan failure after abuse of "bath salts" containing 3,4-methylenedioxypyrovalerone.

"Bath salts" are being increasingly used as drugs of abuse. These products have been found to contain a variety of compounds, including 3,4-methylenedioxypyrovalerone (MDPV). We present a case of a 25-year-old man who injected bath salts and acutely developed severe agitation, hyperthermia, and tachycardia. Despite aggressive early medical management, including dialysis, he progressed to multiorgan system failure, although he ultimately recovered after a prolonged hospital course. The only chemical substance detected on comprehensive toxicologic testing was MDPV, a synthetic cathinone analogue. According to our case, MDPV abuse may result in adverse multisystem organ effects, including rhabdomyolysis, cardiac injury, hepatic injury, and renal failure. It is unknown whether these end-organ effects were due to direct cellular toxicity induced by MDPV or a result of the patient's marked agitation and hyperthermia. Acute management should focus on the rapid identification of organ injury and appropriate supportive care.

Serotonin syndrome associated with MDPV use: a case report.

Serotonin syndrome is associated with use of certain street drugs, including methamphetamine, cocaine, and ecstasy. We describe a case of a woman who developed clinical findings consistent with serotonin syndrome after insufflation of 3,4-methylenedioxypyrovalerone (MDPV), a synthetic amphetamine. MDPV belongs to a group of substances called phenylethylamines, which are ß-ketone analogs of other drugs of abuse, such as amphetamines and 3,4-methylenedioxymethamphetamine. She also received fentanyl initially during her hospitalization, which has also been associated with serotonin syndrome. In addition to benzodiazepines and supportive care, she was treated with cyproheptadine for 8 days, with slow resolution of her symptoms.

Emergency department visits after use of a drug sold as "bath salts"--Michigan, November 13, 2010-March 31, 2011.

On February 1, 2011, in response to multiple news reports, the Michigan Department of Community Health (MDCH) contacted the Children's Hospital of Michigan Poison Control Center (PCC) regarding any reports of illness in the state caused by the use of recreational designer drugs sold as "bath salts." Unlike traditional cosmetic bath salts, which are packaged and sold for adding to bath water for soaking and cleaning, the drugs sold as "bath salts" have no legitimate use for bathing and are intended for substance abuse. These products can contain stimulant compounds such as 3,4-methylenedioxypyrovalerone (MDPV) or 4-methylmethcathinone (mephedrone). The PCC told MDCH that, earlier in the day, the PCC had learned that numerous persons had visited the local emergency department (ED) in Marquette County with cardiovascular and neurologic signs of acute intoxication. This report summarizes the subsequent investigation, which identified 35 persons who had ingested, inhaled, or injected "bath salts" and visited a Michigan ED during November 13, 2010-March 31, 2011. Among the 35 patients, the most common signs and symptoms of toxicity were agitation (23 patients [66%]), tachycardia (22 [63%]), and delusions/hallucinations (14 [40%]). Seventeen patients were hospitalized, and one was dead upon arrival at the ED. The coordinated efforts of public health agencies, health-care providers, poison control centers, and law enforcement agencies enabled rapid identification of this emerging health problem. Mitigation of the problem required the execution of an emergency public health order to remove the toxic "bath salts" from the marketplace. Lessons from the Michigan experience could have relevance to other areas of the United States experiencing similar problems.

Bath salts: an emerging danger.

We report a case of psychosis in an individual who has ingested a new compound known as "bath salts." Bath salts represent an emerging public health threat due to serious neuropsychiatric and behavioral symptoms associated with their use.