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224) A 28-year-old man with no prior history of psychosis was brought to the emergency department after his roommate reported he was standing on his bed screaming that there were snakes everywhere. The roommate also reported that the patient had “snorted a couple of lines of bath salts.” The patient was tachycardic with a heart rate of 144 beats/min. An electrocardiogram showed occasional premature ventricular contractions and a corrected QT interval (QTc) of 430 msec (normal male, <430 msec; female, <450 msec). His temperature was 100.8° F and his pupils were dilated. Standard hematology, chemistry, and liver function tests were normal. Serum levels of acetaminophen and salicylate were negative. A blood alcohol level was also negative. A tier I urine screening test for drugs of abuse (DOA) was negative. Which one of the following best explains why the tier I urine screening test was negative?

The bath salts contained cocaine, which is not detected by tier I DOA screening assays. The bath salts contained methamphetamine, which is not detected by tier I DOA screening assays. The bath salts contained oxycodone, which is not detected by tier I DOA screening assays. The bath salts contained 3,4-methylenedioxymethamphetamine (MDMA), which is not detected by tier I DOA screening assays. The bath salts contain mephedrone, which is not detected by tier I DOA screening assays.

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• There has been a recent surge in the sale, consumption, and abuse of synthetic stimulants packaged and sold as bath salts, which have been found to contain the stimulant compound mephedrone (i.e., 4-methyl-methcathinone).

• Mephedrone is among several synthetic derivatives of cathinones, a Schedule I stimulant substance found in the khat plant grown in east Africa.

• These β-keto analogs of amphetamines share psychoactive properties similar to cocaine, amphetamines, and methylenedioxymethamphetamine (MDMA) and are known to produce a profound deliriogenic toxidrome, generating intense agitation and hallucinations.

• The β-keto analogs are not detected by routine assays that screen for amphetamines. However, they may possibly cause a false-positive test result for phencyclidine (PCP).

• Gas chromatography–mass spectrometry (GC/MS) and liquid chromatography–tandem mass spectrometry (LC/MS-MS) assays have been described that identify synthetic derivatives of cathinones.

Kasick DP, McKnight CA, Klisovic E: “Bath salt” ingestion leading to severe intoxication delirium: two cases and a brief review of the emergence of mephedrone use. Am J Drug Alcohol Abuse 2012;38:176–180.

Sorensen LK: Determination of cathinones and related ephedrines in forensic whole-blood samples by liquid-chromatography-electrospray tandem mass spectrometry. J Chromatogr B 2011;879:727–736.

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Clinical Pathology: Clinical Chemistry

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