A 37-year-old man is brought to the emergency department (ED). Police found the patient running into traffic, yelling obscenities at drivers, slamming his body against passing cars, and trying to break windshields with a beer bottle. A witness described him as having "crazy rage." In the ED, the patient remains combative with police and 4 officers are needed to restrain him. He is disoriented, continues to yell, and appears to be responding to internal stimuli. Temperature is 37.2 C (99 F), blood pressure is 190/96 mm Hg, pulse is 142/min, and respirations are 20/min. Examination shows clear lung fields. The abdomen is soft and nontender. Extraocular movements and cranial nerves are intact. Upper and lower limb deep tendon reflexes are 3+ bilaterally. Serum laboratory results are normal and urine toxicology is negative. While in the ED, the patient has a seizure and is treated with benzodiazepines for both the seizure and the agitation. He is admitted to the medical service and treated supportively. The patient remains psychotic for the next 2 days, but his symptoms then begin to subside and eventually resolve. Which of the following is the most likely explanation for this patient's presentation?

Question

A 37-year-old man is brought to the emergency department (ED).  Police found the patient running into traffic, yelling obscenities at drivers, slamming his body against passing cars, and trying to break windshields with a beer bottle.  A witness described him as having "crazy rage."  In the ED, the patient remains combative with police and 4 officers are needed to restrain him.  He is disoriented, continues to yell, and appears to be responding to internal stimuli.  Temperature is 37.2 C (99 F), blood pressure is 190/96 mm Hg, pulse is 142/min, and respirations are 20/min.  Examination shows clear lung fields.  The abdomen is soft and nontender.  Extraocular movements and cranial nerves are intact.  Upper and lower limb deep tendon reflexes are 3+ bilaterally.  Serum laboratory results are normal and urine toxicology is negative.  While in the ED, the patient has a seizure and is treated with benzodiazepines for both the seizure and the agitation.  He is admitted to the medical service and treated supportively.  The patient remains psychotic for the next 2 days, but his symptoms then begin to subside and eventually resolve.  Which of the following is the most likely explanation for this patient's presentation?

Quizplus · Accepted Answer

Synthetic cathinones, commonly referred to as "bath salts," consist of a large family of amphetamine analogs. As such, they may increase the release, or inhibit the reuptake, of norepinephrine, dopamine, and serotonin. Symptoms of intoxication include severe agitation, combativeness, psychosis, delirium, myoclonus, and, rarely, seizures. Increased sympathetic outflow may lead to significantly increased blood pressure and heart rate. The most distinguishing feature of synthetic cathinone intoxication is the prolonged duration of effect. Delirium and psychosis due to synthetic cathinones may last up to a week, whereas the effects of intoxication with other amphetamines or hallucinogens are usually of much shorter duration. Synthetic cathinones are usually sold as a white powder in small packages labeled as "bath salts," "plant food," "cleaners," or other substances. Synthetic cathinones may be ingested orally, inhaled, or injected. They are not related to the product Epsom salts or any other substances used in bathing. Routine urine toxicology screens cannot detect synthetic cathinones. (Choice A) Brief psychotic disorder may be diagnosed in patients who exhibit >1 day but <1 month of psychotic symptoms (eg, hallucinations, delusions) only if the symptoms are not better explained by substance intoxication/withdrawal, another psychiatric condition, or a medical condition. This patient's presentation is better explained by synthetic cathinone intoxication. (Choice B) Cannabis intoxication is characterized by euphoria with inappropriate laughter, lethargy, distorted sensory perceptions, conjunctival injection, and increased appetite. It is unlikely to have caused this patient's extreme and extended agitation and delirium and would not explain his hyperreflexia and autonomic hyperactivity. Furthermore, cannabis would be detected on a urine toxicology screen and this patient's screen was negative. (Choice C) Cocaine intoxication may cause agitation and psychosis; however, compared with the symptoms of bath salt intoxication, the symptoms of cocaine intoxication are less severe and of shorter duration. Routine toxicology screens typically test for cocaine. (Choice D) MDMA, commonly known as "ecstasy," also has amphetamine-like effects and may lead to delirium and seizures, but it often causes increased feelings of euphoria and intimacy, not combative agitation. In addition, significant hyperthermia may occur in severe MDMA intoxication. (Choice E) Phencyclidine (PCP) intoxication typically presents with psychomotor agitation, combative behavior, diminished pain perception, hallucinations, hypertension, tachycardia, and multidirectional nystagmus. Compared with the symptoms of synthetic cathinone intoxication, the symptoms of PCP intoxication are usually of shorter duration. In addition, PCP is included in standard urine toxicology screens. This patient has normal extraocular movements and his urine toxicology screen is negative for PCP. Educational objective: Synthetic cathinones ("bath salts") have amphetamine-like properties that can cause severe agitation, combativeness, psychosis, delirium, myoclonus, and, rarely, seizures. Tachycardia and increased blood pressure are often present. In contrast to other stimulants and hallucinogens, which have a much shorter duration of effect, the effects of synthetic cathinone intoxication may take up to a week to subside. References: Synthetic cathinones ("bath salts"). (http://www.ncbi.nlm.nih.gov/pubmed/24565885) Bath salts and synthetic cathinones: an emerging designer drug phenomenon. (http://www.ncbi.nlm.nih.gov/pubmed/23911668)

A 37-Year-Old Man Is Brought to the Emergency Department (ED)