February 2013Venkata Kolli, MBBS; Asish Sharma, MD; Mojgan Amani, MD; Durga Bestha, MBBS, Rajeev Chaturvedi, MBBS
Dr. Kolli is Resident,Creighton-Nebraska Psychiatry Residency Program, Omaha, Nebraska; Dr. Sharma is Associate Professor, Department of Psychiatry, University of Nebraska Medical Center, Omaha, Nebraska; Dr. Amani is Resident and Dr. Bestha is Staff Psychiatrist, Carolinas Healthcare System, Charlotte, North Carolina; and Dr. Chaturvedi is Staff Psychiatrist, Lincoln Regional Center, Omaha, Nebraska.

Innov Clin Neurosci. 2013;10(2):10–16

Funding/financial disclosures: No funding was received for the preparation of this article. The authors have no conflicts relevant to the content of this article.

Introduction: Inexpensive, easily accessible combinations of synthetic stimulants commonly sold under the label of “bath salts” are gaining popularity among younger population as recreational drugs.[1] This is reflected in the increasing number of reports highlighting their adverse consequences. We report a case of catatonia in the context of mephedrone use.

Case report: A 19-year-old white woman with no significant medical history, including psychiatric and substance misuse disorders, was brought to the emergency room (ER) by her family due to a sudden change in behavior. She was reported to be “very energetic, hyperactive, pacing with rapid speech” with difficulty in engaging in a conversation. This hyperactive state started alternating with episodes of becoming “slower,” with “pouting of lips, closed eyes, and immobility.” Eventually she became catatonic. No abnormalities were detected in the complete blood picture, complete metabolic and thyroid profile, heavy metal screen, and computed tomography of her head. Electroencephagram (EEG) and magnetic resonance imaging (MRI) of the brain were also reported as within normal limits. The patient was admitted to the inpatient psychiatry unit of the hospital. Upon learning of the patient’s hospitalization, one of her close friends reported to the family that she and the patient had been to a party and had consumed a drink that was supposed to contain “meow meow.” The patient was started on 1mg lorazepam and 1mg haloperidol four times a day. Over the next 72 hours, there was a complete resolution of catatonia and she returned to baseline. The patient was discharged on haloperidol 1mg and lorazepam 0.5mg, both to be taken when necessary.

Discussion: Mephedrone (4-methylmethcathinone) is a synthetic cathinone derivative. Along with 3,4-methylenedioxypyrovalerone (MDPV), mephedrone is the most common ingredient in a group of synthetic cathinones that are sold legally under the name “bath salts.”[2] Mephedrone is referred to by many street names including meow meow, miaow, drone, bubbles, plant food, meph, spice E, M-cat and MMC hammer.[3] It is usually available as a white powder or fine crystals and is snorted or orally ingested, but there are reports of intramuscular, intravenous, and rectal administration.[3] Mephedrone is postulated to act not only by inhibiting the reuptake but also by inducing the release of monoamines, leading to an excess of dopamine, norepinephrine, and serotonin.[2] It has been reported that the serotonin levels can rise by 950 percent, leading to a significant risk of serotonergic syndrome.[4] Adverse effects include autonomic instability, muscle rigidity, dehydration, chest pain, altered sensations, seizures, agitation/aggression, delirium, severe anxiety, paranoia, and hallucinations.[5] It is very important for healthcare professionals to consider the use of mephedrone and other related substances in the differential diagnosis when evaluating the sudden onset of psychosis. We are not aware of any other reports of mephedrone related catatonia. Since routine toxicology screens do usually not detect bath salts, collateral history becomes even more important. Treatment of bath salts ingestion is mainly supportive with adequate safety precautions, including the use of as needed or short-term regime of benzodiazepines and low-dose antipsychotics to prevent harm to self or others. Intravenous fluids may need to be used to prevent renal damage.

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