We were uncertain about the plausibility that acute cocaine intoxication caused Ms. K’s medical sequelae, in light of her toxicology findings. If cocaine use was the inciting event, and because the delirium reportedly had developed over several hours, we would expect cocaine to be detected in the toxicology screen. However, it was not detected. Cocaine can remain detectable in urine for 2 to 4 days,7 which raised our speculation that remote cocaine abuse could account for Ms. K’s current presentation and the timeline the roommate initially relayed to EMS personnel was inaccurate. We needed to clarify the timeline and progression of Ms. K’s symptoms with the roommate. In addition, we suggested to the medical team that alternative substances of abuse could be causing Ms. K’s symptoms and the roommate might be the only person who could unveil this possibility.
Table 1
DSM-IV-TR criteria for delirium due to multiple etiologies
| A. Disturbance of consciousness (ie, reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention |
| B. A change in cognition (such as memory deficit, disorientation, language disturbances) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia |
| C. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day |
| D. There is evidence from the history, physical examination, or laboratory findings that the delirium has >1 etiology (eg, >1 etiological general medical condition, a general medical condition plus substance intoxication or medication side effect) |
| Source: Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000 |
Table 2
Diagnostic criteria for cannabis and cocaine intoxication
| Diagnostic criteria | Cannabis intoxication | Cocaine intoxication |
|---|---|---|
| Recurrent use | + | + |
| Symptom onset | During or shortly after use | During or shortly after use |
| Behavioral changes | Impaired motor coordination | Hypervigilance, stereotyped behaviors |
| Psychological changes | Euphoria, anxiety, sensation of slowed time, social withdrawal, impaired judgment | Euphoria, anxiety, tension, anger, changes in sociability, interpersonal sensitivity, impaired social or occupational functioning |
| Associated criteria (≥2) | Conjunctival injection, increased appetite, dry mouth, tachycardia | Tachycardia or bradycardia, papillary dilation, elevated or lowered blood pressure, chills/perspiration, nausea/vomiting, evidence of weight loss, psychomotor changes, muscular weakness, chest pain, cardiac arrhythmias, seizure, dyskinesia, dystonia, delirium, coma |
| Source: Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000 | ||
HISTORY: Unknown substance
Ms. K’s roommate is contacted for supplemental history. The roommate reports that recently he observed Ms. K “snorting” a brown/tan-colored substance. He had not seen her use this substance previously, and when he asked her what it was, she reportedly said that it was “PeeVee” (also called “bath salts”) purchased over the Internet.
The authors’ observations
MDPV is a novel chemical compound that is used as a recreational drug (Table 3).8 It commonly is acquired from Internet sources and sold as “bath salts.” Its use first emerged in approximately 2004, and its popularity has been increasing because of its easy availability and relatively low cost.9 The American Association of Poison Control Centers received 302 calls related to MDPV toxicity in 2010 and 5,625 calls related to MDPV use between January 1 and October 31, 2011.10,11
MDPV has psychoactive properties, with stimulant effects acting as a norepinephrine-dopamine reuptake inhibitor.8,9,12 When snorted, ingested orally, or inserted rectally, the agent produces effects comparable to cocaine or psychostimulants such as methylphenidate or dextroamphetamine.
Acute effects of MDPV include heightened alertness, diminished need for sleep, hyperarousal, and euphoria.8,9 These symptoms often are accompanied by increases in heart rate and blood pressure, sweating, and peripheral vasoconstriction. Individuals may abuse MDPV to acquire sustained attention, reduce their need for sleep, or for aphrodisiac effects. In many cases, anxiety and irritability can accompany the desired euphoric effects. For some, the euphoric effects can be superseded by anxiety or agitation. Mood and attention effects are estimated to last 3 to 4 hours; however, tachycardia and hypertension can persist for 6 to 8 hours.
MDPV use can trigger cravings and lead to binging. Euphoric stimulation with MDPV can become dysphoric as the dose and duration of use increase. Extended use has been associated with agitation, irritability, aggression, panic and marked anxiety, psychosis, and delirium.8,9 Anxiety can range from mild dysphoric stimulation to extreme panic-like states. In moderate forms, a state of sympathetic discharge can occur, producing physiologic effects resembling panic attacks, including hypertension, tachycardia, sweating, and peripheral vasoconstriction. In more severe cases, users may experience a feeling of impending doom, marked distress, and frank psychosis. Patients may experience disorientation and unsystematized paranoid delusions. Case reports of intoxication have described self-injurious behaviors, such as cutting, which may account for the contusions observed on Ms. K’s face and arms. Increasingly, MDPV use has resulted in ER presentations with patients manifesting abrupt onset confusion, anxiety, and self-injurious behaviors.