Intracerebral hemorrhage and vasculitis related to ephedrine abuse

Qualitative confirmation procedure for ephedrines as acetonide derivatives in doping urine samples by gas chromatography/electron ionization mass spectrometry

Ephedrines are sympathomimetic amines which have central nervous system stimulating properties and, for this reason, some of them are forbidden in sport by the World Antidoping Agency (WADA). They are screened and quantitated in urine by several published techniques and confirmed by gas chromatography/mass spectrometry (GC/MS). In this paper, a simple and easy confirmation procedure for norpseudoephedrine, norephedrine, ephedrine and pseudoephedrine in human urine by GC/electron ionization (EI)-MS is described. After the addition of diphenylamine as internal standard, a liquid-liquid extraction procedure under alkaline conditions with tert-butyl methyl ether was applied to the samples. The analytes were derivatized with acetone and pyridine to form the correspondent oxazolidine derivatives (acetonide). The EI mass spectra of all the studied substances have many diagnostic ions with relative abundance in accordance with WADA requirements and show great structural information content. The fragmentation of theses derivatives is discussed.

Treatment of sympathomimetic induced intraventricular hemorrhage with intraventricular urokinase

Intraventricular hemorrhage (IVH) occurred in a 32-year-old man following the use of both ephedrine and pseudoephedrine. Cerebral angiography and transcranial Doppler studies showed changes suggestive of vasculitis. We describe the management and investigations of a unique case of IVH. This patient was treated with ventriculostomy and intraventricular urokinase (UK). A favorable outcome was obtained with independent function at 10 weeks post hemorrhage. The use of intraventricular thrombolysis for drug-induced IVH has not previously been reported, although it has been shown to be a safe and potentially beneficial intervention.

Cocaine use and stroke

Stroke is the third most common cause of death in developed countries. In England and Wales, 1000 people under the age of 30 have a stroke each year. Cocaine is the most commonly used class A drug, and the first report of cocaine-induced stroke was in 1977. Since the development of alkaloidal "crack" cocaine in the 1980s, there has been a significant rise in the number of case reports describing both ischaemic and haemorrhagic stroke associated with cocaine use. Cocaine is a potent central nervous system stimulant, and acts by binding to specific receptors at pre-synaptic sites preventing the reuptake of neurotransmitters. The exact mechanism of cocaine-induced stroke remains unclear and there are likely to be a number of factors involved including vasospasm, cerebral vasculitis, enhanced platelet aggregation, cardioembolism, and hypertensive surges associated with altered cerebral autoregulation. The evidence surrounding each of these factors will be considered here.

Electron ionization mass spectra of ephedrines in a doping confirmatory procedure: a curious migration of the trimethylsilyl group in the N-acetyl-O-trimethylsilyl derivatives

Ephedrines have central nervous system stimulating properties and, for this reason, some of them are forbidden in sport by the World Antidoping Agency (WADA). They are screened and quantitated in urine by several published techniques and confirmed by gas chromatography/mass spectrometry (GC/MS). In this paper, a simple confirmation procedure for norpseudoephedrine, norephedrine, ephedrine and pseudoephedrine in human urine by GC/electron ionization (EI)-MS is described. After the addition of levallorphane as internal standard, a liquid-liquid extraction procedure under alkaline conditions with tert-butyl methyl ether was applied to the samples. The analytes were derivatized with acetic acid anhydride and N-methyl-N-trimethylsilyltrifluoroacetamide to form N-acetyl-O-trimethylsilyl derivatives. The EI mass spectra of all the studied substances have many diagnostic ions with relative abundance in accordance with WADA requirements and show great structural information content. A curious migration of the trimethylsilyl group is proposed.

Metabolites of ephedrines in human urine after administration of a single therapeutic dose

Ephedrine (EPH), pseudoephedrine (PEPH), phenylpropanolamine (PPA), methylephedrine (MEPH) and cathine are sympathomimetic amines. These drugs are commonly found in over-the-counter (OTC) cold medicines and some dietary supplements. In Taiwan, the misuse of these drugs has resulted in an increase in athletic violations. Excretion studies of the ephedrine-related drugs have been performed to better understand the metabolic yields of ephedrines in urine. After consuming a single clinical dose of each of these drugs, urine samples from volunteers (n=3 for each drug) were subjected to tert-butyl-methyl-ether (TBME) extraction and trifluoroacetic acid (TFAA) derivatization before gas chromatography-mass spectrometry (GC-MS) analysis. Most ephedrines were excreted unchanged in urine, including EPH (40.9%), PEPH (72.2%), and PPA (59.3%). However, only a relatively small amount of MEPH (15.5%) was excreted unchanged in urine. In addition, a trace amount of PPA (1.6%) and cathine (0.7%) was found to be the metabolites of EPH and PEPH, respectively. Urinary EPH, PEPH, and PPA reached peaks at 2-6h and disappeared in urine at approximately 24-48 h post-administration. For MEPH, the peaks of excretion extended from 4 to 12h post-administration and were undetectable at approximately 48 h. A single clinical dose of EPH (25 mg) may exceed threshold level (10 microg/mL) in sport drug testing if the urine samples are tested within approximately 8h post-administration. However, a single dose of MEPH (20 mg) never reached the threshold value (10 microg/mL).

Rheumatic manifestations of diseases associated with substance abuse

Rheumatic manifestations of substance abuse are uncommon but recognized complications. Repeated injections of drugs and adulterants represent repeated antigenic challenge. The population at greatest risk is that of young males, although females with eating disorders are more apt to develop myopathy, clubbing, or periostitis. Alcohol, the most common substance abused, is associated more often with myopathy. In IV drug abusers, hepatitis B viral infection, bacterial endocarditis, primary skeletal infections, and venous complications are most common in that order. However, the spectrum may evolve as the pattern of substance abuse changes. First, the frequency of cocaine dependence is rapidly approaching that of alcohol. Two regular cocaine users are reported as having Raynaud's phenomenon and abnormal serologies. Second, synthesis of lookalike drugs may produce new associations, such as parkinsonism after IV N-methyl-4-phenyl-1,2,3,6-tetrahydropyridine. Third, the increased use of ipecac and purgatives in eating disorders is an important consideration in young women with otherwise unexplained myopathy or arthritis. Finally, patients with AIDS are presenting with autoimmune phenomena or a spectrum of unusual infections that change as the epidemic evolves. Increased recognition of these symptom complexes may lead to earlier, more accurate diagnoses and avoidance of unnecessary diagnostic evaluations and delays in treatment.