Document Type : Case Report
Authors
1 Department of Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, London, UK.
2 Department of General Medicine, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, London, UK.
3 Department of Clinical Toxicology, Faculty of Life Sciences and Medicine, King’s College London, London, UK.
Abstract
Background: In this study, we report on a patient with acute stimulant toxicity following the use of two bath salt products purchased over the Internet in the UK, where two novel cathinones and a substituted phenylmorpholine were detected on toxicological screening.
Case Report: A 52-year-old male with ADHD presented to ED with chest pain, shortness of breath, sweating, and agitation after nasal insufflation of Internet purchased ‘bath salt’ products “Ocean Burst” and “Lunar Wave”. He was anxious and agitated, but did not have delusions, paranoia or delirium. On examination, he was tachycardic (113bpm), hypertensive (171/115mmHg), and normothermic (36.0°C). He was tremulous, but his tone and reflexes were normal and there was no clonus. Initial blood tests were normal and initial Troponin I was 32.2ng/L; reduced to 28.3ng/L on repeat (low risk for ACS if ≤34 ng/L on repeat). ECG showed sinus rhythm (99bpm) left axis deviation, QTc 462msecs, QRS 100msecs, with no ischaemic changes. He was treated with oral diazepam (total 25mg) and IV fluids in the ED. Following the admission, he required a further 60mg of oral diazepam for ongoing agitation. His symptoms resolved within 24 hours and he was discharged.
Analytical Results: Serum, urine and drugs samples analysed using ultra performance liquid chromatography interfaced to high resolution accurate mass spectrometry:
- ‘Ocean Burst’: N-ethyl pentedrone, alpha PHiP;
- ‘Lunar Wave’: 3-chlorophenmetrazine, 4-methylmethamphetamine, alpha PHiP;
- Serum/urine: the cathinones N-ethylpentedrone and alpha-PHiP were detected, along with the substituted phenylmorpholine 3-Chlorophenmetrazine.
Conclusion: The novel cathinones detected in this patient, related to the use of ‘bath salts’, were associated with acute stimulant toxicity. Analytical confirmation of NPS products in patients presenting with acute NPS toxicity is important in the surveillance of the NPS currently available and to inform public health interventions
Keywords
Main Subjects
- European Monitoring Centre for Drugs and Drug Addiction. Synthetic cathinones drug profile. Available from: https://www.emcdda.europa.eu/publications/drug-profiles/synthetic-cathinones_en [Last accessed 22 April 2024].
- Spiller HA, Ryan ML, Weston RG, Jansen J. Clinical experience with and analytical confirmation of “bath salts” and “legal highs” (synthetic cathinones) in the United States. Clin Toxicol. 2011; 49: 499-505.
- Warrick B, Hill M, Hekman K, Christensen R, Goetz R, Casavant MJ, Wahl M, Mowry JB, Spiller H, Anderson D, Aleguas A, Gummin D, Thomas R, Nezlek C, Smolinskel S. A 9-state analysis of designer stimulant, “bath salt,” hospital visits reported to poison control centers. Ann Emerg Med. 2013; 62: 244-251.
- Crulli B, Dines AM, Blanco G, Giraudon I, Eyer F, Liechti ME, Miró Ò, Hovda KE, Heyerdahl F, Yates C, Vallersnes OM, Wood DM, Dargan PI, Euro-DEN Research Group. Novel psychoactive substances-related presentations to the emergency departments of the European drug emergencies network plus (Euro-DEN plus) over the six-year period 2014-2019. Clin Toxicol (Phila). 2022; 60: 1318-1327.
- European Monitoring Centre for Drugs and Drug Addiction. European Drug Report 2023: Trends and Developments. Available from: https://www.emcdda.europa.eu/publications/european-drug-report/2023_en [Last accessed 22 April 2024].
- Service CP. Psychoactive substances act 2016. Norwich, England; p. Chapter 2.
- Wagmann L, Manier SK, Felske C, Gampfer TM, Richter MJ, Eckstein N, Meyer MR. Flubromazolam-Derived Designer Benzodiazepines: Toxicokinetics and Analytical Toxicology of Clobromazolam and Bromazolam. J Anal Toxicol. 2021; 45: 1014-1027.
- Brunetti P, Giorgetti R, Tagliabracci A, Huestis MA, Busardò FP. Designer Benzodiazepines: A Review of Toxicology and Public Health Risks. Pharmaceuticals (Basel). 2021; 14: 560.
- Hikin LJ, Coombes G, Rice-Davies K, Couchman L, Smith PR, Morley SR. Post mortem blood bromazolam concentrations and co-findings in 96 coronial cases within England and Wales. Forensic Sci Int. 2024: 354: 111891.
- Mérette SAM, Thériault S, Piramide LEC, Davis MD, Shapiro AM. Bromazolam. Blood Concentrations in Postmortem Cases-A British Columbia Perspective. J Anal Toxicol. 2023; 47: 385-392.
- Manaloto FR, Meneses VM, Mata DC. A Two-Year Evaluation of Flualprazolam Concentrations in Orange County Drivers: Effects on Driving and Field Sobriety Test Performance. J Anal Toxicol. 2023; 46: 1038-1044.
- Ehlers PF, Deitche A, Wise LM, Patrick SL, Holloway-Beth A, Ellison R, Trecki J, Gerona R, Wahl MS. Notes from the Field: Seizures, Hyperthermia, and Myocardial Injury in Three Young Adults Who Consumed Bromazolam Disguised as Alprazolam - Chicago, Illinois, February 2023. MMWR Morb Mortal Wkly Rep. 2024; 72: 1392-1393.
- Pieprzyca E, Skowronek R, Czekaj P. Toxicological Analysis of Cases of Mixed Poisonings with Synthetic Cathinones and Other Drugs of Abuse. J Anal Toxicol. 2023;46: 1008-1015.
- Espinosa-Velasco M, Reguilón MD, Bellot M, Nadal-Gratacós N, Berzosa X, Gómez-Canela C, et al. Repeated administration of N-ethyl-pentedrone induces increased aggression and impairs social exploration after withdrawal in mice. Prog Neuropsychopharmacol Biol Psychiatry 2022; 117: 110562.
- Polish Sanitary Inspector Warning . Główny Inspektor Sanitarny ostrzega: nowa substancja psychoaktywna. Available from: https://www.gov.pl/web/gis/glowny-inspektor-sanitarny-ostrzega-nowa-substancja-psychoaktywna [Last accessed 22 April 2024].
- Adamowicz P, Jurczyk A, Gil D, Szustowski S. A case of intoxication with a new cathinone derivative α-PiHP - A presentation of concentrations in biological specimens. Leg Med (Tokyo). 2020: 42: 101626.
- Wachholz P, Celiński R, Bujak-Giżycka B, Skowronek R, Pawlas N. A fatal case of poisoning with a cathinone derivative: α-PiHP and its postmortem distribution in body fluids and organ tissues. J Anal Toxicol. 2023; 47: 547–551.
- Zawadzki M, Wachełko O, Tusiewicz K, Szpot P. Severe poisoning after smoking a mixture of 4-fluoroisobutyryl fentanyl (4-FiBF) and alpha-pyrolidinoisohexaphenone (α-PiHP). J Forensic Leg Med. 2022; 85: 102287.
- UK Government. Drugs and driving: the law – Table of drugs and limits Available from: https://www.gov.uk/government/collections/drug-driving#table-of-drugs-and-limits [Last accessed 22 April 2024]
- Helander A, Bäckberg M. Epidemiology of NPS Based Confirmed Overdose Cases: The STRIDA Project. Handb Exp Pharmacol. 2018; 252: 461-473.
- Helander A, Bäckberg M, Beck O. Drug trends and harm related to new psychoactive substances (NPS) in Sweden from 2010 to 2016: Experiences from the STRIDA project. PLoS One. 2020; 15: e0232038.
- White JC, Wood DM, Hill SL, Eddleston M, Officer J, Dargan PI, Dunn M, Thomas SHL. Acute toxicity following analytically confirmed use of the novel psychoactive substance (NPS) methiopropamine. A report from the Identification of Novel psychoActive substances (IONA) study. Clin Toxicol (Phila). 2019; 57: 663-667.
- Craft S, Dunn M, Vidler D, Officer J, Blagbrough IS, Pudney CR, Henderson G, Abouzeid A, Dargan PI, Eddleston M, Cooper J, Hill SL, Roper C, Freeman TP, Thomas SHL. Trends in hospital presentations following analytically confirmed synthetic cannabinoid receptor agonist exposure before and after implementation of the 2016 UK Psychoactive Substances Act. Addiction. 2022; 117: 2899-2906.
- Abouchedid R, Hudson S, Thurtle N, Yamamoto T, Ho JH, Bailey G, Wood M, Sadones N, Stove CP, Dines A, Archer JRH, Wood DM, Dargan PI. Analytical confirmation of synthetic cannabinoids in a cohort of 179 presentations with acute recreational drug toxicity to an Emergency Department in London, UK in the first half of 2015.Clin Toxicol (Phila). 2017; 55: 338-345.