Acute Psychosis Induced by Bath Salts: A Case Report with Clinical and Forensic Implications

Bath salts are new designer drugs with stimulant effects on the central nervous system. White or brown powder sold online and in mini‐marts under different brand names, bath salts can be used by injecting, snorting, smoking, or ingesting with food or drink. The case of a 30‐year‐old Caucasian male who developed acute psychosis within a few hours of injecting himself with bath salts is described. The patient was hospitalized with a complaint of hearing voices. The drug also induced in the patient a state of euphoria, increased energy level, along with decreased need for sleep and decreased appetite. The psychological effects of the bath salts subsided within a few hours of injection and his reality testing remained consistently intact over the next 3 days of hospitalization. This case brings to attention the fact that bath salts were legal throughout the United States until recently and is still not completely controlled. This report informs clinicians of harmful effects of bath salts, including severe agitation with possible rhabdomyolysis, psychosis, suicidal ideation, hypertension, tachycardia, and death.     

Analysis of the First- and Second-Generation Raving Dragon Novelty Bath Salts Containing Methylone and Pentedrone

In recent years, a large number of designer drugs sold as “Bath Salts” have appeared on the market. In July of 2011, Raving Dragon Novelty Bath Salts was obtained over the Internet. This product became unavailable in October of that year coinciding with the DEA issuing a temporarily schedule of mephedrone, methylone, and MDPV. Four months later in February of 2012, a new product was released from the same company under the new name Raving Dragon Voodoo Dust. The contents of both products were identified using spectroscopy methods: nuclear magnetic resonance, infrared, UV–visible, tandem mass spectrometry, and high-resolution time-of-flight mass spectrometry. It was determined that Raving Dragon Novelty Bath Salts contained methylone. The replacement product Raving Dragon Voodoo Dust contained the unscheduled drug pentedrone. The Raving Dragon brand of products illustrates the rapid change of ingredients in these products to circumvent laws restricting availability, distribution, and use.     

Deaths Involving Methylenedioxypyrovalerone (MDPV) in Upper East Tennessee

Two deaths involving 3, 4‐methylenedioxypyrovalerone (MDPV) are reported. MDPV is a synthetic cathinone stimulant found in “bath salts” with neurological and cardiovascular toxicity. Biological specimens were analyzed for MDPV by GC/MS and LC/MS. A White man was found dead with signs of nausea and vomiting after repeatedly abusing bath salts during a weekend binge. Femoral venous blood and urine had MDPV concentrations of 39 ng/mL and 760 ng/mL. The second fatality was a White man with a history of drug and bath salt abuse found dead at a scene in total disarray after exhibiting fits of anger and psychotic behavior. Femoral venous blood and urine had MDPV concentrations of 130 ng/mL and 3800 ng/mL. The blood and urine MDPV concentrations are within the reported recreational concentration ranges (blood 24–241 ng/mL and urine 34–3900 ng/mL). Both decedents’ deaths were attributed to relevant natural causes in a setting of MDPV abuse.     

Identification of 1‐(2,3‐dihydro‐1H‐inden‐5‐yl)‐2‐(ethylamino)pentan‐1‐one (bk‐IVP) in a Seized Drug Exhibit

To circumvent the law by evading regulation and obscuring their identities in routine analyses, numerous substituted cathinones have entered the illicit drug market. These compounds have been coined “bath salts” by users. In the described case, the laboratory received an unknown white powder for controlled substances identification. The sample could not be immediately identified using standard methods and procedures. Ultimately, the structure was elucidated using GC‐MS, NMR, FTIR, GC‐SPIR, UV, and color tests to be 1‐(2,3‐dihydro‐1H‐inden‐5‐yl)‐2‐(ethylamino)pentan‐1‐one (bk‐IVP), a cathinone analog with a rarely observed nonoxygenated bicyclic ring system. Features of spectra and chemical tests are reported that distinguish this class of cathinones from heterocyclic analogs.     

Measurement of Uncertainty for Aqueous Ethanol Wet‐Bath Simulator Solutions Used with Evidential Breath Testing Instruments

Aqueous ethanol wet‐bath simulator solutions are used to perform calibration adjustments, calibration checks, proficiency testing, and inspection of breath alcohol instruments. The Toxicology Bureau of the New Mexico Department of Health has conducted a study to estimate a measurement of uncertainty for the preparation and testing of these wet‐bath simulator solutions. The measurand is identified as the mass concentration of ethanol (g/100 mL) determined through dual capillary column headspace gas chromatography with flame ionization detector analysis. Three groups were used in the estimation of the aqueous ethanol wet‐bath simulator solutions uncertainty: GC calibration adjustment, GC analytical, and certified reference material. The standard uncertainties for these uncertainty sources were combined using the method of root‐sum‐squares to give u_c = 0.8598%. The combined standard uncertainty was expanded to U = 1.7% to reflect a confidence level of 95% using a coverage factor of 2. This estimation applies to all aqueous ethanol wet‐bath simulator solution concentrations produced by this laboratory.     

复方黄柏液涂剂溻渍治疗Wagner 2－3级糖尿病足的疗效观察及其对血清炎症因子的影响

目的 观察复方黄柏液涂剂溻渍治疗Wagner 2-3级糖尿病足的临床疗效及其对炎症因子的影响。方法 将符合纳入标准的52例糖尿病足Wagner 2-3级患者随机分为观察组和对照组,每组26例。观察组给予复方黄柏液涂剂溻渍治疗,对照组给予乳酸依沙吖啶溶液湿敷治疗,比较两组临床疗效、创面面积及血清炎症因子[白细胞介素-1(interleukin-1, IL-1)、白细胞介素-6(interleukin-6, IL-6)、肿瘤坏死因子-α(tumor necrosis factor-α, TNF-α)]变化。结果 观察组临床疗效明显优于对照组(P<0.05);治疗后观察组创面面积明显小于对照组(P<0.05);治疗后观察组IL-1、IL-6、TNF-α水平均较治疗前显著降低(P<0.05),且明显低于对照组(P<0.05)。结论 复方黄柏液涂剂溻渍治疗Wagner 2-3级糖尿病足,可以促进创面愈合,降低炎症因子水平,临床疗效确切。     

“Bath Salts” the New York City Medical Examiner Experience: A 3‐Year Retrospective Review

“Bath salts” are synthetic derivatives of cathinones, compounds found in the leaves of Catha edulis, which possesses amphetamine‐like properties. At the New York City Office of Chief Medical Examiner, we conducted a 3‐year retrospective analysis of deaths in which cathinones were detected. Two categories emerged; those in which cathinones were a contributory cause of death (15 cases) and those in which they were an incidental finding (15 cases). Of the former group, 13 were associated with additional intoxicants; two deaths were attributed solely to cathinone intoxication, both survived 10 h: a man whose postmortem blood methylone concentration was 0.71 mg/L and a woman whose postmortem blood ethylone concentration was 1.7 mg/L. In the latter category, there were several individuals who had higher concentrations of cathinones than the above two, the highest being a blood methylone of 4.8 mg/L. Based upon our data and the literature presented, lethal concentrations of cathinones cannot be established.     

Cannabinoid Hyperemesis Syndrome: Reports of Fatal Cases

Cannabinoid hyperemesis syndrome (CHS) is one of the more clinically challenging effects of cannabis consumption. It is characterized by cyclic attacks of nausea and vomiting in chronic cannabinoid users and learned behavior of compulsive hot bathing. The deaths of a 27‐year‐old female, a 27‐year‐old male, and a 31‐year‐old male with a history of CHS are reported. The decedents had a history of cyclical nausea and vomiting, chronic cannabinoid use and negative laboratory, radiological and endoscopic findings. All presented to the emergency department with nausea and vomiting in the days preceding death and were treated symptomatically. Toxicological analysis revealed tetrahydrocannabinol in postmortem blood. The cause of death of two of the three cases was attributed to CHS. CHS was appreciated in the third case but was not the cause of death. These three cases demonstrate the importance of recognizing CHS as a potential cause or contributing factor to death in cannabinoid user.     

Methylenedioxypyrovalerone (“Bath Salts”),Related Death: Case Report and Review of the Literature,

Cathinone derivatives (bath salts) have emerged as the latest drugs of abuse. 3,4‐methylenedioxypyrovalerone (MDPV) is the primary active ingredient in bath salts used in this country. This article presents the second reported cause of death by MDPV intoxication alone. In April 2011, a delusional man was emergently brought to a hospital, where he self‐reported bath salt usage. He became agitated, developed ventricular tachycardia, hyperthermia, and died. Comprehensive alcohol and drug testing was performed. Using the alkaline drug screen, heart blood contained 0.7 mg/L MDPV and peripheral blood contained 1.0 mg/L MDPV. His bizarre behavior with life‐threatening hyperthermia was consistent with an MDPV‐induced excited delirium state. MDPV is not yet found by routine immunoassay toxicology screens. Testing for MDPV should be considered in cases with a history of polysubstance abuse with stimulant type drugs, report of acute onset of psychogenic symptoms, excited delirium syndrome, or presentation in a hyperthermic state.