Methamphetamine Toxicity Clinical Presentation

Updated: Dec 19, 2016
  • Author: John R Richards, MD, FAAEM; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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Presentation

History

Cardiovascular signs and symptoms of methamphetamine use are as follows [26, 27, 28, 29, 30, 31] :

  • Chest pain, aortic dissection, myocardial ischemia/infarction
  • Palpitations, tachyarrhythmia
  • Dyspnea and edema
  • Hypertension

Central nervous system manifestations of methamphetamine use are as follows [32, 33, 34, 35] :

  • Agitation, violent behavior, self-harm
  • Coma
  • New-onset seizure, movement disorders
  • Emotional lability, confusion, psychosis, paranoia, hypersexuality, and hallucinations
  • Headache

Respiratory manifestations of methamphetamine use are as follows [36, 37, 38] :

  • Dyspnea
  • Wheezing
  • Pneumothorax

Skin manifestations of methamphetamine use are as follows [39] :

  • Delusional parasitosis
  • Abscess, cellulitis

Gastrointestinal manifestations of methamphetamine use are as follows [14, 40] :

  • Abdominal pain
  • Obstruction

Dental manifestations of methamphetamine use are as follows [41, 42] :

  • Caries
  • Peridental abscesses
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Physical

Acute and long-term methamphetamine use may lead to abnormal findings on examination of the following organ systems:

  • Cardiovascular
  • Central nervous system
  • Gastrointestinal
  • Renal
  • Skin
  • Dental

Cardiovascular findings are as follows:

  • Tachycardia and hypertension is frequently observed [43]
  • Atrial and ventricular arrhythmias may occur [43]
  • Chest pain from cardiac ischemia and infarction following methamphetamine use has been reported; patients are at risk because of accelerated atherosclerosis from chronic use; acute aortic dissection or aneurysm has been associated with methamphetamine abuse [30, 27]
  • Hypotension may be observed with methamphetamine overdose with profound depletion of catecholamines [44]
  • Acute and chronic cardiomyopathy results directly from methamphetamine cardiac toxicity and indirectly from chronic hypertension and ischemia; intravenous use may result in endocarditis; patients may present with dyspnea, edema, and other signs of acute congestive heart failure (CHF) exacerbation [45, 28]

Central nervous system findings are as follows:

  • New-onset seizures may occur from direct CNS methamphetamine toxicity [34]
  • Acute and chronic methamphetamine exposure has been associated with a jerking, choreoathetoid movement disorder; these repetitive movements, hyperactivity, and inability to focus thought have been referred to as "tweaking" [33, 35]
  • Headache and cerebrovascular accidents with focal neurologic deficits may be caused by hemorrhage or vasospasm, cerebral edema, and cerebral vasculitis [31]
  • Acute psychosis, agitation, violence, and paranoia frequently results from alteration in CNS dopamine, serotonin, and glutamate pathways [46, 13]
  • Coma may result from depletion of catecholamine stores and/or concomitant ingestion of sedatives such as ethanol or narcotics [44]

Respiratory findings are as follows:

  • Barotrauma, including pneumomediastinum, pneumothorax, and pneumopericardium may result from forceful inhalation [36]
  • Acute noncardiogenic pulmonary edema and pulmonary hypertension may result from acute and chronic use, as well as from adulterants introduced during intravenous use such as talc or cornstarch [36, 37, 38]
  • Wheezing from reactive airway disease may be induced by methamphetamine [36]

Gastrointestinal findings are as follows:

  • Hepatocellular damage has been reported with methamphetamine after acute and chronic abuse; direct effects such as hypotension, hepatotoxic contaminants, hepatic vasoconstriction, lipid peroxidation, occult viral causes, and necrotizing angiitis have been postulated [47]
  • Severe abdominal pain may result from acute mesenteric vasoconstriction; methamphetamine has also been associated with the formation of ulcers and ischemic colitis. [40]
  • Necrotizing angiitis with arterial aneurysms and sacculations have been observed in the liver, pancreas, and small bowel of methamphetamine drug abusers [31]

Renal failure associated with amphetamines has been related to the following [48] :

  • Hypoxemia
  • Rhabdomyolysis
  • Necrotizing angiitis
  • Acute interstitial nephritis
  • Cardiovascular shock with subsequent acute tubular necrosis

Skin findings include the following:

  • Delusions of parasitosis and chronic skin-picking may result in neurotic excoriations and prurigo nodularis ("speed bumps") [4]
  • Methamphetamine injectors frequently present with abscess and cellulitis, which they often blame on a "spider bite" [39]
  • Production workers in illicit methamphetamine laboratories may present with extensive thermal and/or chemical burns. [49]

On dental examination, severe caries, especially of the maxillary teeth, is commonly seen in chronic methamphetamine users ("meth mouth"). This results from maxillary artery vasoconstriction, xerostomia, and poor hygiene. [41, 42]

Pregnancy and lactation

Methamphetamine use during pregnancy can be fatal to the mother and fetus. [50, 51] Methamphetamine has been shown to cause placental vasoconstriction and interfere with placental monoamine transporters resulting in spontaneous abortion. [52]

Methamphetamine is secreted in breast milk. A case of infant death from ingestion of methamphetamine-toxic breast milk has been reported. [53]

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Causes

Methamphetamine is a derivative of phenylethylamine. The substances differ structurally in that a methyl group attaches to the terminal nitrogen to form methamphetamine.

Most of the methamphetamine abused in the United States is produced in so-called superlabs, many of which are located in Mexico. [18] However, methamphetamine is relatively easy and inexpensive to synthesize, and small-scale illicit production occurs in home kitchens, workshops, recreational vehicles, and rural cabins. [4, 49, 54] Instructions for synthesis can be found on the Internet and the precursors are not difficult to obtain.

A common method of synthesis begins with ephedrine, which is reduced to methamphetamine using hydriodic acid and red phosphorus. Alternative approaches include using a different acid, a different catalyst, or a substituted ephedrine (eg, chloroephedrine, methylephedrine). The federal government and some states have enacted laws decreasing the availability of necessary precursor chemicals such as ephedrine, but many of these agents can still be obtained in other countries.

The methamphetamine produced by ephedrine reduction is a lipid-soluble pure base form, which is fairly volatile and can evaporate if left exposed to room air temperature. This product is converted to the water-soluble form, methamphetamine hydrochloride (HCl) salt. The manufacture of "ice", the smokable form of methamphetamine, from standard quality methamphetamine HCl is essentially a purification process.

Illicitly synthesized methamphetamine is frequently contaminated by nonstimulant organic or inorganic impurities. Poisoning from heavy metals, such as lead and mercury, or from carcinogenic solvents used in the synthesis process, has been reported. [55, 56] Street methamphetamine may be mixed with other drugs, including cocaine and phencyclidine.

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