A 25-year-old man was found by police acting wildly after injecting bath salts containing MDPV. He developed multiple organ failure including renal failure, hepatic failure, and rhabdomyolysis. His lab values peaked severely before gradually returning to normal over two weeks with intensive care. Bath salts contain stimulants like MDPV that cause dangerous effects by disrupting neurotransmitter systems, especially dopamine, in a similar but more potent way than cocaine and amphetamines. Their use can lead to severe physical and mental health emergencies that require supportive critical care.

1. “BATH SALTS” INTOXICATION
BY: JUSTINA SAMUEL

2. CASE PRESENTATION
 25-year old man, who after injecting bath salts, was found by police running wildly, acting combatively, and foaming
at the mouth.
 Physical exam: mydriasis, rightward deviation of the eyes, and extreme warmth.
 Next 2 days  renal failure, fulminant hepatic failure, disseminated intravascular coagulation and rhabdomyolysis.
 Aspartate aminotransferase peaked at 16,688 U/L, INR 9.3, creatinine kinase 253,377 U/L, creatinine 10.2 mg/ dL,
and troponin 29 ng/mL.
 Required hemodialysis while in the MICU because of anuric renal failure, and remained intubated for 9 days. Mental
status returned to baseline by day 13 and his lab values except for his creatinine normalized by day 18. The patient
required hemodialysis for 1 month, after which his creatinine normalized and his urine output returned to normal.
 Urine from the day of admission  3,4 methylenedioxypyrovalerone (MDPV) level of 140 ng/mL

3. BACKGROUND
• "Bath salts" are central nervous system stimulants that inhibit the
norepinephrine-dopamine reuptake system
• It is typically sold as a white powder or in crystal form, and the usual dose is
between 50mg and 300mg.
• Most commonly found compound within “ bath salts” is
methylenedioxypyrovalerone (MDPV).
• MDPV belongs to the phenethylamine class and is structurally similar to
cathinone, an alkaloid found in the plant Catha edulis, and
methamphetamine.

4. • On September 7, 2011 the US Drug Enforcement Agency announced
emergency scheduling to control MDPV, mephedrone and methylone, all
chemicals found in "bath salts".
• On July 9, 2012, responding to rising cases of bath salts abuse, President
Obama signed into law the Synthetic Drug Abuse Prevention Act, which
bans MDPV, mephedrone and 29 other bath salts ingredients.
• On July 26, the Drug Enforcement Administration announced that it had
seized more than five million packets of synthetic drugs and arrested 90
people in a nationwide crackdown called Operation Log Jam.

5. • Before the DEA ruling, “bath salts" were easily accessible in convenience
stores, gas stations, over the Internet and in head shops.
• "Bath salts“ are sold for roughly $20 per package. The "bath salt" powder
appears white or slightly yellow-colored.
• Method of ingestion varies, but are most commonly nasally inhaled or
ingested.
• Rectal administration, gingival delivery, and intramuscular or intravenous
injection have all been reported.

7. COMMON OR STREET NAMES
• Ivory Wave
• Vanilla Sky
• Cloud Nine
• Blue Silk
• Red Dove
• Ocean Snow
• Lunar Wave
• Scarface
• Drone
• Meow Meow

8. PATHOPHYSIOLOGY
• Bath salts work by stimulating release and inhibiting the reuptake of
norepinephrine, serotonin, and dopamine
• Two primary mechanisms:
1. Inhibiting monoamine uptake transporters.
2. Causing the release of neurotransmitters from intracellular stores via changing the
vesicular pH or inhibiting the vesicular monoamine transport (VMAT2) receptor.
• These substances are mostly excreted via the urine and can be measured by gas or
liquid chromatography-mass spectrometry in the blood, urine and stomach contents.
They can also be analyzed in hair.

9. AT THE ROOT OF EVERYTHING: DOPAMINE
• Dopamine is a natural neurotransmitter involved in the basic
experience of pleasure.
• Chocolate, sex, gambling: all cause a rush of dopamine in the brain's
reward center, the nucleus accumbens.
• Dopamine also has profound effects on memory, learning, motivation
and motor control

10. • Studies have shown that taking bath salts was similar to taking
amphetamine and cocaine at the same time.
• Amphetamine and cocaine all produce excessive dopamine in the synapse,
but through different mechanisms.
• Amphetamines primarily work by causing an abnormal amount of dopamine
to surge forth from the nerve cells, shifting the brain's reward pathways into
overdrive. Cocaine acts as a reuptake inhibitor.
• Except for one thing: MDPV is 10 times stronger

11. SIDE EFFECTS/SYMPTOMS
PHYSICAL EFFECTS
• Tachycardia
• Hypertension
• Arrhythmias
• Hyperthermia
• Sweating
• Mydriasis
• Muscle tremor and spasms
• Seizures
• Stroke
• Cerebal edema
• Respiratory distress
• Cardiovascular collapse
BEHAVIORAL/MENTAL STATUS EFFECTS
• Panic attacks
• Anxiety
• Agitation
• Paranoia
• Hallucinations
• Psychosis
• Aggressive behavior
• Violent behavior
• Self-destructive behavior
• Self-mutilation
• Suicidal ideation
• Insomnia

12. TREATMENT/MANAGEMENT
• Mainstay of therapy  supportive care
• For agitation, seizures, tachycardia, and hypertension  benzodiazepines
• Significant hyperthermia  passive or active cooling.
• All moderately to severe symptomatic patients should have an ECG, be
placed on a cardiac monitor, and receive serial temperature checks.
• Lab studies including electrolytes, renal and liver function tests, cardiac
markers and creatine kinase, as well as testing for co-ingestants.
• Asymptomatic patients with no other suspected co-ingestions or psychiatric
symptoms generally may be discharged.

13. REFERENCES
• C. Smith, A. P. Cardile, and M.
Miller, “Bath salts as a ”legal high”,”
American Journal of Medicine, vol.
124, no. 11, 2011.
• Syed F. Imam, Hetalben Patel,
Monay Mahmoud, Nisha A.
Prakash, Matthew S. King, Richard
D. Fremont. (2013) Bath Salts
Intoxication: A Case Series. The
Journal of Emergency Medicine