Drug Induced Liver Injury Secondary to ‘ Monkey Dust’

Abstract

Introduction: Monkey dust - a type of bath salts, is a recreational drug. Bath salts are synthetic cathinones derived from the shrub grown in East Africa, Southern Arabia and people chew its leaves leading to mild stimulant effects. Bath salts are increasingly becoming more popular among recreational drugs. Their use is detrimental and sometimes lethal. There is very limited data on systemic adverse effects of bath salts and liver injury pattern is not well described in the literature. We present a challenging case of bath salts induced liver injury concomitantly presenting with acute hepatitis C infection. Case presentation: A 40 year old male presented with right upper quadrant and epigastric abdominal pain, nausea, vomiting, fever and jaundice for 4 days. He reported injecting bath salts with shared needles in last 4 weeks and smoked marihuana regularly. He reported no alcohol use, herbal supplements or use of any hepatotoxic medications, however he gave history of unprotected sex. His vital signs and physical exam were unremarkable were except for mild epigastric tenderness. His laboratory data showed AST >717 U/L, ALT 2435 U/L, alkaline phosphatase 185 U/L and total bilirubin 4.1 with direct bilirubin of 3.3 mg/dL. His hepatitis profile came back positive for hepatitis C genotype 2b with viral load of 6900 IU/mL. He also had positive ANA and anti smooth muscle antibody. His abdominal sonogram showed no evidence of biliary obstruction or vascular thrombosis. His liver biopsy showed pattern consistent with drug induced liver injury. He was treated supportively and 4 weeks later his hepatitis C viral load became undetectable with normalization of his liver enzymes. Discussion: Bath salts induced liver injury is rare and requires high degree of clinical suspicion as most patients have polysubtance abuse and high risk for simultaneous viral infections. Patients often present with agitation, panic attack, violent behavior and other stimulant effects. It is thought that the stimulant effect is due to decreased uptake of dopamine and norepinephrine in the brain cells. Patients should be monitored in the intensive care unit for severity of symptoms which can often be lethal. Routine drug screen essays do not detect bath salts. Patient safety should be entertained and benzodiazepines should be used for sedation. Treatment is mainly supportive with intravenous hydration. It is important to recognize this entity as it may potentially lead to liver failure.