Does Procalcitonin “Get High” on Flakka? A Case of Extreme Procalcitonin Elevation Due to Psychostimulant Abuse

Abstract

SESSION TITLE: Poisoning and Drug Overdose 1 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: We present the first reported case of cathinone associated procalcitonin elevation in the absence of infection. These agents may warrant consideration as potential confounders of procalcitonin values. CASE PRESENTATION: A 42 year-old Caucasian male presented to the emergency room after being found on the street by law enforcement while hallucinating and exhibiting violent behavior. He reported using amphetamines, cocaine, MDMA and “flakka” within a 24-hour period. Further history at that time was limited by agitation. He required 10 mg haloperidol, 4 mg lorazepam, restraints, and ultimately endotracheal intubation for airway protection. Pertinent vitals included hyperthermia to 39.8 Celsius and tachycardia to 136 beats/minute. No leukocytosis was present on complete blood count (WBC=9,700 cells/mcL). Procalcitonin (PCT) was elevated to 7.23 ng/mL. Rhabdomyolysis was diagnosed: total creatinine kinase=46,149 U/L, AST=893, ALT=201. Acute kidney injury (AKI) secondarily presented with serum creatinine=5.15 mg/dL and estimated GFR=12 mL/min/1.73 m2. Imaging was unrevealing: chest x-ray showed no acute cardiopulmonary disease, KUB non-obstructive bowel gas pattern and CT head without contrast had no mass or infarct. Cultures revealed no signs of infection with two negative blood cultures and negative urine culture. Urine toxicology was positive for amphetamines, cocaine, opiates, and benzodiazepines. The following day he was extubated. Fever resolved and renal function slowly returned to baseline with aggressive IV fluids. DISCUSSION: PCT production increases in neuroendocrine cells of the lung and intestines during infection as a response to inflammatory cytokines and bacterial endotoxins. Because of this, PCT has established itself as a useful biomarker for antibiotic de-escalation. Despite utility as a marker for sepsis and systemic inflammation, clinicians must be wary of confounding factors that increase PCT. For example, there are case reports of cocaine and amphetamine associated PCT elevations. Extensive literature review shows no documented cases of flakka associated PCT elevation. Alpha-Pyrrolidinopentiophenone, known colloquially as flakka, is a relatively new street drug in the cathinone class. It has powerful psychostimulant effects including hallucinations, sympathetic stimulation and agitation. Cathinone’s biochemical effects on PCT are unknown. CONCLUSIONS: PCT should be regarded as a sensitive but not specific tool. This case demonstrates PCT elevation without infection, which can thus be attributed to sympathomimetics including the novel drug flakka. Reference #1: A. Lovas, et al., (2014). Extreme Procalcitonin Elevation without Proven Bacterial Infection Related to Amphetamine Abuse. Case Reports in Critical Care, 2014. Reference #2: C. Wacker, et al., “Procalcitonin as a diagnostic marker for sepsis: a systematic review and meta-analysis,” The Lancet Infectious Diseases, vol.13, no.5, pp.426-435, 2013. DISCLOSURE: The following authors have nothing to disclose: Grant Nelson, Stuart Shah, James Cury No Product/Research Disclosure Information