Baylor University Medical Center Proceedings July 2014 - (Page 223)
Multiorgan dysfunction related to chronic ketamine abuse
Joseph M. Pappachan, MD, Binu Raj, MBBS, Sebastian Thomas, MD, and Fahmy W. Hanna, MD
Ketamine abuse is being increasingly reported worldwide. The drug can
produce a dissociative state and hallucinations, making ketamine a favorite recreational agent among drug addicts. Chronic ketamine abuse
can damage many organs, including the brain, heart, liver, gastrointestinal
tract, and genitourinary system. We report a patient with chronic ketamine abuse who presented with severe cachexia, upper gastrointestinal
involvement, hepatobiliary dysfunction, and acute kidney injury.
K
etamine is a general anesthetic agent commonly used in
pediatric patients, especially for neurosurgery and for
surgeries requiring cardiopulmonary bypass (1). Ketamine can produce a dissociative state and hallucinations and therefore is not commonly used in adult anesthetic
practice. Because of the hallucinatory effects of the drug, recreational ketamine abuse has been increasingly reported in recent
years. Chronic ketamine abuse can damage many body organs
(1, 2). We report a patient with chronic ketamine abuse who
presented with severe cachexia, upper gastrointestinal involvement, hepatobiliary dysfunction, and acute kidney injury.
CASE PRESENTATION
A 59-year-old man presented to the emergency department
with vomiting, lower abdominal pain, dysuria, and urinary incontinence of 5 days duration. For several months he had a
poor appetite and dyspepsia, and he had gradually lost weight.
He was known to have chronic obstructive airway disease and
enlarged kidneys detected by an ultrasonographic study. He had
a 40 pack-year history of smoking, consumed about 20 units of
alcohol (1 unit = 10 mL of pure alcohol) weekly, and inhaled
ketamine powder intranasally almost every day for about 3 years.
He lived alone and was not sexually active in the immediate past.
On examination he looked dehydrated and cachectic, and
his sclerae were mildly icteric. His body mass index was 14.5
kg/m2 and his blood pressure, 90/60 mm Hg. Biochemical and
hematological laboratory results are shown in Table 1. The electrocardiograph and chest radiograph did not show any abnormalities. An abdominal ultrasonographic study revealed bilateral
hydronephrosis and hydroureter, hypoechoic liver with periportal
hyperechogenicity, and mild dilatation of the common bile duct.
The urinary bladder wall was thickened with increased trabeculaProc (Bayl Univ Med Cent) 2014;27(3):223-225
tions. A computed tomographic scan of the abdomen without
contrast revealed a full distended stomach (Figure 1a), bilateral
hydronephrosis (Figure 1b) and hydroureter, and a thickened
urinary bladder wall (Figure 1c). The bladder was contracted.
The patient was initially managed with intravenous hydration, thiamine, and continuous urinary drainage through
an indwelling catheter. Esophagogastroduodenoscopy showed
grade 3 esophagitis and mild gastritis. The histology from the
esophageal mucosa revealed only chronic inflammatory changes.
A magnetic resonance cholangiopancreatography showed mild
dilatation of the proximal common bile duct with narrowing of
the common hepatic duct without cholelithiasis. The cisterna
chyli was also dilated. There was no evidence of intraabdominal
malignancy. Screening tests for viruses (HIV, hepatitis A, B, C,
E, Epstein-Barr virus, and cytomegalovirus), autoimmune liver
disorders (autoimmune hepatitis, primary biliary cirrhosis, and
primary sclerosing cholangitis), and metabolic liver diseases
(hemochromatosis and Wilson's disease) were negative.
The patient was further managed with oral and intravenous
hydration, a multivitamin supplement, and omeprazole. The
acute kidney injury and the liver function abnormalities improved gradually (Table 1). He gained 3 kg body weight within
a week of inpatient medical treatment.
With a diagnosis of ketamine-induced multisystem illness,
he was advised to refrain from further drug abuse and was discharged to a community-based drug rehabilitation program.
His general health steadily improved, and on a subsequent outpatient clinic visit 2 months later, he weighed 50 kg (a total
weight gain of 8 kg). An abdominal ultrasonographic study
revealed complete resolution of the hepatobiliary abnormalities,
the hydronephrosis, and the hydroureter on both sides.
DISCUSSION
Ketamine is a phencyclidine derivative that is licensed for
anesthetic use in humans and in veterinary medicine, especially
From the Departments of Endocrinology, Diabetes, and Metabolism (Pappachan,
Hanna), Anesthesiology (Raj), and Gastroenterology (Thomas), University Hospital
of North Staffordshire, Stoke-on-Trent, United Kingdom.
Corresponding author: Joseph M. Pappachan, MD, Department of Endocrinology
and Metabolism, University Hospital North Staffordshire, Stoke on Trent, ST4 6QG,
UK (e-mail: drpappachan@yahoo.co.in).
223
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