Synthetic cathinone toxicity

Background

Chemical structure of cathinone

• Cathinone is naturally occurring β-ketone analog of amphetamine found in the leaves of the “khat” plant (Catha edulis) consumed recreationally in Arabian peninsula and northeast Africa
• Methcathinone first synthesized in 1928
• Sharp increase in exposures around 2007-2011 due to products sold as “bath salts” and labelled “not for human consumption”
• Common synthetic versions found today include mephedrone, methylone, MDPV, and many others

Bupropion is only cathinone derivative used medically in the US and Europe

Mechanism of Action

• Thought to be similar to MOA of amphetamines and MDMA (increase of NE, dopamine and serotonin concentrations in synapses)
  • Inhibition of monoamine uptake transporters
  • Release of neurotransmitters from intracellular stores
• Beta-ketone group decreases ability to penetrate BBB

Clinical Features

• Presents similar to other sympathomimetics
• Patient experiences euphoria, increased energy, agitation, psychosis, hallucinations
• Case reports suggest tachycardia tends to be more severe than hypertension (HR >150 and SBP<150)
• Can lead to psychosis, agitated delirium, seizures, hyperthermia, rhabdo, cardiovascular collapse, renal failure, hepatic dysfunction, DIC and death
  • Retrospective review showed OR of 3.09 and 7.98 for rhabdomyolysis and severe rhabdomyolysis compared to other sympathomimetics

Differential Diagnosis

• Sympathomimetic toxicity
  • Methamphetamines
  • Cocaine
• Anticholinergic toxicity

Evaluation

Workup

EKG, CBC, CMP, PT/INR, CK, APAP, ASA, ethanol

Diagnosis

UDS does not detect synthetic cathinones; must use GCMS

Management

• In general, care is supportive
• IVF for dehydration/rhabdo/AKI
• Benzodiazepines for agitation

Disposition

• If persistently altered, admission for observation
• Otherwise if workup unremarkable and patient alert and oriented, discharge

References

1. Prosser JM, Nelson LS. The toxicology of bath salts: a review of synthetic cathinones. J Med Toxicol. 2012;8(1):33-42. doi:10.1007/s13181-011-0193-z

2. Baumann MH, Partilla JS, Lehner KR. Psychoactive "bath salts": not so soothing. Eur J Pharmacol. 2013 Jan 5;698(1-3):1-5. doi: 10.1016/j.ejphar.2012.11.020. Epub 2012 Nov 23. PMID: 23178799; PMCID: PMC3537229.

3. O’Connor AD, Padilla-Jones A, Gerkin RD, Levine M. Prevalence of rhabdomyolysis in sympathomimetic toxicity: a comparison of stimulants. J Med Toxicol 2015 Jun;11(2):195-200.