title: An outbreak of acute delirium from exposure to the synthetic cannabinoid AB-CHMINACA.
abstract: BACKGROUND
  Synthetic cannabinoid containing products are a public health threat as reflected by a number of outbreaks of serious adverse health effects over the past 4 years. The designer drug epidemic is characterized by the rapid turnover of synthetic cannabinoid compounds on the market which creates a challenge in identifying the particular etiology of an outbreak, confirming exposure in cases, and providing current information to law enforcement.
  
  
  RESULTS
  Between 28 May 2014 and 8 June 2014, 35 patients were evaluated and treated at the University of Florida Health Medical Center in Gainesville following reported exposure to a synthetic cannabinoid containing product obtained from a common source. Patients demonstrated acute delirium (24) and seizures (14), and five required ventilator support and ICU-level care; none died. The presence of N-[(1S)-1-(aminocarbonyl)-2-methylpropyl]-1-(cyclohexylmethyl)-1H-indazole-3-carboxamide (AB-CHMINACA), or one of its predicted metabolites was confirmed in 15 of 21 cases. A rapid public health response and aggressive public messaging prevented further morbidity, identified the source, and led to law enforcement seizure of the implicated product.
  
  
  CONCLUSIONS
  The significance of this outbreak lies as much in the rapid occurrence of unpredictable, life-threatening adverse health effects from a newly identified synthetic cannabinoid compound as it does in the multidisciplinary investigation and novel partnership between local public health, the laboratory, and the chemical industry, resulting in termination of the outbreak.
  
  
  CONCLUSIONS
  A coordinated response and collaboration between law enforcement, the local public health, emergency medical services and Health Center staff, were all key interventions in preventing a more substantial public health outbreak resulting from use of a novel synthetic cannabinoid compound. Real time collaborations between toxicology laboratories, suppliers of analytical standards and the public health system may be useful in the face of future novel chemical exposures.
authors.affiliation: a Division of Infections Disease, Department of Emergency Medicine , The University of Florida College of Medicine , Gainesville , FL , USA .
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Tyndall
authors.affiliation: b Department of Laboratory Medicine , University of California San Francisco , San Francisco , CA , USA .
authors.forename: Roy
authors.initials: R
authors.lastname: Gerona
authors.affiliation: a Division of Infections Disease, Department of Emergency Medicine , The University of Florida College of Medicine , Gainesville , FL , USA .
authors.forename: Giuliano
authors.initials: G
authors.lastname: De Portu
authors.affiliation: c Office of Diversion Control/Drug and Chemical Evaluation Section, Drug Enforcement Administration , Springfield , VA , USA .
authors.forename: Jordan
authors.initials: J
authors.lastname: Trecki
authors.affiliation: a Division of Infections Disease, Department of Emergency Medicine , The University of Florida College of Medicine , Gainesville , FL , USA .
authors.forename: Marie-Carmelle
authors.initials: MC
authors.lastname: Elie
authors.affiliation: a Division of Infections Disease, Department of Emergency Medicine , The University of Florida College of Medicine , Gainesville , FL , USA .
authors.forename: Judith
authors.initials: J
authors.lastname: Lucas
authors.affiliation: a Division of Infections Disease, Department of Emergency Medicine , The University of Florida College of Medicine , Gainesville , FL , USA .
authors.forename: John
authors.initials: J
authors.lastname: Slish
authors.affiliation: d Division of Infections Disease, Department of Pathology , Immunology and Laboratory Medicine, The University of Florida College of Medicine , Gainesville , FL , USA .
authors.forename: Kenneth
authors.initials: K
authors.lastname: Rand
authors.affiliation: a Division of Infections Disease, Department of Emergency Medicine , The University of Florida College of Medicine , Gainesville , FL , USA .|e Division of Laboratory Medicine, Department of Pathology , The University of Virginia , Charlottesville , VA , USA .
authors.forename: Lindsay
authors.initials: L
authors.lastname: Bazydlo
authors.affiliation: f UF Health Shands , Gainesville , FL , USA .
authors.forename: Martina
authors.initials: M
authors.lastname: Holder
authors.affiliation: a Division of Infections Disease, Department of Emergency Medicine , The University of Florida College of Medicine , Gainesville , FL , USA .
authors.forename: Matthew F
authors.initials: MF
authors.lastname: Ryan
authors.affiliation: g Florida Department of Health, Alachua County , Gainesville , FL , USA .
authors.forename: Paul
authors.initials: P
authors.lastname: Myers
authors.affiliation: h Department of Medicine , The University of Florida College of Medicine , Gainesville , FL , USA .
authors.forename: Nicole
authors.initials: N
authors.lastname: Iovine
authors.affiliation: f UF Health Shands , Gainesville , FL , USA .
authors.forename: Michelle
authors.initials: M
authors.lastname: Plourde
authors.affiliation: a Division of Infections Disease, Department of Emergency Medicine , The University of Florida College of Medicine , Gainesville , FL , USA .
authors.forename: Emily
authors.initials: E
authors.lastname: Weeks
authors.affiliation: i Ochsner Clinic Foundation Hospital , New Orleans , LA , USA .
authors.forename: James R
authors.initials: JR
authors.lastname: Hanley
authors.affiliation: j Cayman Chemical , Ann Arbor , MI , USA , and.
authors.forename: Greg
authors.initials: G
authors.lastname: Endres
authors.affiliation: j Cayman Chemical , Ann Arbor , MI , USA , and.
authors.forename: Danielle
authors.initials: D
authors.lastname: St Germaine
authors.affiliation: j Cayman Chemical , Ann Arbor , MI , USA , and.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Dobrowolski
authors.affiliation: k National Center for Environmental Health, Centers for Disease Control and Prevention , Atlanta , GA , USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Schwartz
mesh_terms: D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D001711:Biotransformation; D002186:Cannabinoids / Q000737:chemistry / Q000493:pharmacokinetics / Q000633:toxicity*; D003693:Delirium / Q000139:chemically induced* / Q000453:epidemiology / Q000628:therapy; D015198:Designer Drugs / Q000737:chemistry / Q000493:pharmacokinetics / Q000633:toxicity*; D004196:Disease Outbreaks; D005260:Female; D006801:Humans; D007191:Indazoles / Q000633:toxicity*; D008297:Male; D008875:Middle Aged; D015394:Molecular Structure; D012189:Retrospective Studies; D014633:Valine / Q000031:analogs & derivatives* / Q000633:toxicity; D055815:Young Adult
chemical_list: D002186:Cannabinoids; D015198:Designer Drugs; D007191:Indazoles; D014633:Valine; C000606289:N-(1-(aminocarbonyl)-2-methylpropyl)-1-(cyclohexylmethyl)-1H-indazole-3-carboxamide
keywords: CNS/psychological; Metabolic; Organ/tissue specific; Respiratory support; Synthetic cannabinoids