Acute Liver Failure Following ‘Bath Saltʼ Abuse: A Case Report

Abstract

Purpose: ‘Bath salts' describe a class of highly addictive designer drugs with stimulant effects that contain various amphetamine derivatives and amphetamine-like compounds. Prior reports of ‘bath salt' intoxication describe a spectrum of neuropsychiatric symptoms and medical sequelae, including death. We report a case of severe multi-organ failure, including liver dysfunction, following nasal insufflation of a commonly abused ‘bath salt' known as “Eight ballz®.” A healthy 28-year-old male was admitted for acute psychosis presenting as hallucinations, agitation, and paranoia. He reported using 500 mg of “Eight ballz®” intranasally prior to symptom onset. On admission, he required intubation for progressive respiratory distress. The patient demonstrated severe anion gap lactic acidosis with an elevated osmolal gap, as well as hyperkalemia, a rapidly rising creatine phosphokinase (CPK) and acute kidney injury. AST and ALT were 233 and 46 units/L and total and direct bilirubin levels were normal. Urine toxicology screen, screen for special alcohols, CT head and CSF analysis were unremarkable. He was aggressively hydrated and extubated the next day, but continued to have worsening rhabdomyolysis. CPK and serum creatinine peaked at 264,460 units/L and 6.2 mg/dL, respectively. Intravenous sodium bicarbonate, furosemide, and metolazone were administered to augment urine output. By hospital day 4, he developed acute liver failure with a peak AST and ALT of 3065 and 3876 units/L, respectively. The following day, his total and direct bilirubin peaked at 8.7 and 6.5 mg/dL, respectively. GGT and peak alkaline phosphatase were 131 and 163 units/L, respectively. Coagulation studies remained normal and abdominal ultrasound was negative. Intravenous N-acetylcysteine was administered for 24 hours with moderate improvement in transaminases. Complicating his course was acute pancreatitis with amylase and lipase levels peaking on hospital day 10 (258 and 910 units/L, respectively). At discharge, the patient's transaminases, pancreatic enzymes, creatinine, and CPK had trended down dramatically. Providers must consider ‘bath salt' intoxication in patients presenting with evidence of sympathomimetic toxidrome given the risk of multi-organ dysfunction, including liver and pancreatic toxicity.Figure: Transaminases and pancreatic enzymes by hospital day.