Case series: 9 patients with acute kidney injury after smoking a synthetic cannabinoid

orgazmo3.5 out of 5 stars

Acute kidney injury associated with smoking synthetic cannabinoid. Buser GL et a. Clin Toxicol 2014;52:663-673.


In the summer of 2012, two patients presented to emergency departments in western Oregon complaining of nausea, vomiting and flank pain that started shortly after smoking a synthetic cannabinoid product. Both patients had elevated serum creatinine levels and hypertension. Renal biopsy revealed acute tubular injury with inflammation in both patients. Extensive work-up did not reveal any other possible cause of renal disease.

A public health investigation identified seven other patients in the region who presented with acute kidney injury (AKI) within 2 weeks of smoking a synthetic cannabinoid. Some key features of these cases include:

  • Exposure to several synthetic cannabinoid products, including “Clown Loyal,” Johnny Clearwater” (caramel corn), “Lava,” and “Orgazmo” (pineapple).
  • The synthetic cannabinoid XLR-11 was detected in each of 2 involved products that were tested, as well as in clinical specimens from one of five patients tested.
  • All patients recovered, although received a short course of hemodialysis.

This article is a very complete and finely done description both of the clinical syndrome of AKI associated with use of synthetic cannabinoids, and the related public health investigation. [HT @DougBorys]

Related posts:

Four (really three) cases of acute kidney injury associated with us of synthetic cannabinoids

MMWR: synthetic pot suspect in cases of kidney failure

Blueberry “spice” in Wyoming linked to cases of renal failure

Methoxetamine: a ketamine analog that is NOT bladder friendly

MXE3.5 out of 5 stars

Methoxetamine — a novel recreational drug with potent hallucinogenic properties. Zawilska JB. Toxicol Lett 2014 Aug 13. pii: S0378-4274(14)01298-3. doi: 10.1016/j.toxlet.2014.08.011. [Epub ahead of print]


Methoxetamine (MXE) is a structural analog of ketamine, with effects that are similar but more intense and longer-lasting. Street names include:

  • MXE
  • Mexxy
  •  M-ket
  • MEX
  • Kmax
  • Special M
  • MA
  • “Legal ketamine”
  • Minx
  • Jipper
  • Roflcoptr

Since chronic exposure to ketamine is known to cause ulcerative cystitis, MXE is sometimes touted as “bladder friendly.” However, lack of clinical reports of GU tract injury associated with MXE most likely just reflects our limited experience with this drug. Recent animal studies have shown that mice exposed to MXE daily for 3 months develop bladder inflammation with fibrosis and renal damage.

Clinical effects of MXE generally fall into one of two categories:

  1. Neurological: anxiety, agitation violent aggression, hallucinations, altered mental status, catatonia, cerebellar ataxia.
  2. Cardiovascular: tachycardia, hypertension, cardiac depression, respiratory depression.

A hallmark of MXE overdose is cerebellar toxicity. Treatment is supportive, with fluids, benzodiazepines, and anti-emetics as needed.

This is a well done, helpful review article, with an up-to-date set of references included articles published in 2014. Recommended.

By the way, although as of this writing MXE is not a controlled substance under federal law, a number of states have regulated it.

Related posts:

A “big Christmas cardigan”: recreational use of ketamine and methoxetamine

Acute cerebellar syndrome? Think methoxetamine

Methoxetamine: a designer ketamine analogue

Comprehensive review of new designer drugs


On the internet, nobody knows if it’s 25C-NBOMe (“N-bomb”)

25C-NBOMe (N-bomb)

25C-NBOMe (N-bomb)

2 out of 5 stars

25C-NBOMe: Preliminary Data on Pharmacology, Psychoactive Effects, and Toxicity of a New Potent and Dangerous Hallucinogenic Drug. Bersani FS et al. Biomed Res Int 2014;2014:734749. Epub 2014 Jul 3.

Full Text

The NBOMe drugs are phenethylamine derivatives of the 2C psychedelics. The 2 methoxybenzyl groups act to provide protection and stability, drastically increasing the potency of this drug. Although sometimes sold as LSD, 25C- NBOMe (N-bomb) is much more potent and dangerous.

This article uses both published scientific literature and discussions on Web bulletin boards and chat groups in an attempt to define the effects of this drug. The authors argue that since the internet is a crucial factor in marketing and disseminating novel psychoactive substances and since peer-reviewed articles about these substances are scarce, using unconfirmed anecdotal reports on sites like Bluelight and Drugs-Forum is justified.

I don’t buy it. However, the authors do reference several medical papers about N-bomb. for example,  a recent article by Grautoff and Kahler described a 19-year-old man who supposedly snorted N-bomb and developed seizures, acute kidney failure and acute lung failure. Unfortunately, the article is in German and the abstract does not specify whether the exposure was laboratory-confirmed.



Tox Tunes #85: Goodnight, Irene (Jerry Lee Lewis and Van Morrison)

Goodnight, Irene” was introduced by the folksinger and blues musician Lead Belly (Huddie Ledbetter, 1888-1949) and became a big hit for The Weavers in 1950. This fascinating song tells a somewhat murky story about unrequited passion and suicidal fantasies. The Weavers, however, left out the reference to opiates in Lead Belly’s original lyrics:

I love Irene
I swear I do
I love her ’til the sea runs dry
If Irene turns her back on me
I’m gonna take morphine and die.

Jerry Lee Lewis and Van Morrison keep this verse in their version.

Lead Belly’s original also implies love for a girl who is possibly underage, and also — at least to my interpretation — hints of murder. It limns a story that is much more coherent:

And here is The Weavers’ hit version from 1950. It is a much tamer, much less dangerous song. And I’ve never forgiven them for those awful strings:


Review of scorpion envenomation

Asian forest scorpion

Asian forest scorpion

3 out of 5 stars

Scorpion Envenomation. Isbister GK, Bawaskar HS. N Engl J Med 2014 Jul 31;371:457-463.


“O! full of scorpions is my mind, dear wife!”

With over 1700 species of scorpions found all over the world, this brief review article is much too short and unfocused to provide more than a superficial overview of its topic.

The authors point out that most scorpion stings cause, at most, minor toxicity with pain and other local effects only. Most serious envenomations are associated with the Buthidae family, which include the genus Centruroidesseveral of which are found in North America and commonly cause neuromuscular excitation.

Major toxicity is associated with α-toxins, which inhibit deactivation of voltage-gated sodium channels causing sympathetic and parasympathetic autonomic excitation, as well as the release of catecholamines epinephrine and norepinephrine. This can result in:

  • hypertension
  • myocardial injury
  • cardiogenic shock
  • impaired left ventricular function
  • hypotension
  • cardiac conduction abnormalities
  • pulmonary edema

Features of the sympathomimetic or cholinergic toxidromes can be prominent.

Use of antivenom in cases of scorpion stings is controversial, and this article really doesn’t provide much enlightenment regarding the pros and cons. The authors do note that although antivenom would seem to be more useful in cases of clinically severe envenomation, by the time clinical severity is apparent it may be rather late in the game — although antivenom can bind toxins and prevent progression, it does not reverse established injury. (A list of scorpion antivenoms available worldwide, as well as a summary of the effects of envenomation, can be found here.)

This fascinating video, featuring Dr. Leslie Boyer from the University of Arizona, makes the case for use of antivenom in stings by the Arizona bark scorpion (Centruroides sculpturatus):