title: Psychosis from a bath salt product containing flephedrone and MDPV with serum, urine, and product quantification.
abstract: BACKGROUND
  The use of designer drugs commonly marketed as bath salts or plant food has risen dramatically in recent years. Several different synthetic cathinones have been indentified in these products, including mephedrone, 3,4-methylenedioxypyrovalerone (MDPV), and 4-fluoromethcathinone (flephedrone). We report a case of bath salt intoxication with quantitative MDPV and flephedrone levels in a patient's serum and urine, and from the bath salt product.
  
  
  METHODS
  A 23-year-old male with a prior psychiatric history arrived via EMS for bizarre behavior, suicidality, and hallucinations after reportedly insufflating a bath salt. He was found to have MDPV levels of 186 and 136 ng/mL in his serum and urine, respectively, and flephedrone levels of 346 and 257 ng/mL in the serum and urine, respectively. The white powder in question was found to contain 143 μg MDPV and 142 μg flephedrone per milligram powder. His psychosis and agitation resolved with lorazepam, droperidol, and observation in the emergency department.
  
  
  CONCLUSIONS
  Agitation, psychosis, movement disorders, tachycardia, and hypertension have all been attributed to the use of MDPV; there are no prior reports detailing clinical experience with flephedrone. Considering that our patient's serum flephedrone levels were twofold higher than his MDPV level, it is likely flephedrone contributed to his clinical toxicity. This case suggests the possibility that fluorinated cathinones, such as flephedrone, may have altered metabolism and/or elimination which may affect their course of clinical toxicity. This case highlights the evolving composition of synthetic cathinones found in bath salt products.
authors.affiliation: Division of Medical Toxicology, Department of Emergency Medicine, University of California-San Diego, 200 W Arbor Dr #8925, San Diego, CA 92103-8925, USA. stephenthorntonmd@yahoo.com
authors.forename: Stephen L
authors.initials: SL
authors.lastname: Thornton
authors.forename: Roy R
authors.initials: RR
authors.lastname: Gerona
authors.forename: Christian A
authors.initials: CA
authors.lastname: Tomaszewski
mesh_terms: D000470:Alkaloids / Q000138:chemical synthesis / Q000633:toxicity; D052117:Benzodioxoles / Q000097:blood* / Q000633:toxicity / Q000652:urine*; D015198:Designer Drugs / Q000633:toxicity; D004329:Droperidol / Q000627:therapeutic use; D006801:Humans; D007327:Insufflation; D008140:Lorazepam / Q000627:therapeutic use; D008297:Male; D011427:Propiophenones / Q000097:blood* / Q000633:toxicity / Q000652:urine*; D011605:Psychoses, Substance-Induced / Q000175:diagnosis* / Q000188:drug therapy; D011618:Psychotic Disorders / Q000209:etiology / Q000503:physiopathology*; D011619:Psychotropic Drugs / Q000138:chemical synthesis / Q000633:toxicity; D011759:Pyrrolidines / Q000097:blood* / Q000633:toxicity / Q000652:urine*; D012492:Salts; D055815:Young Adult; D000094982:Synthetic Cathinone
chemical_list: D000470:Alkaloids; D052117:Benzodioxoles; D015198:Designer Drugs; D011427:Propiophenones; D011619:Psychotropic Drugs; D011759:Pyrrolidines; D012492:Salts; C023665:cathinone; C578181:4-fluoromethcathinone; D008140:Lorazepam; D004329:Droperidol; D000094982:Synthetic Cathinone