Critical Care

TOPIC: Critical Care

TYPE: Fellow Case Reports

KETAMINE ABUSE DISORDER SYNDROME: FROM ELECTROLYTE IMBALANCES TO

UROLOGIC PATHOLOGY AND HEPATOBILIARY FAILURE
RATNAM SANTOSHI CLAUDIA DE ARAUJO DUARTE SANWAL MEHTA CHRISTIANA ATUAKA AND YIZHAK
KUPFER

INTRODUCTION: Ketamine, a noncompetitive N-methyl-D-aspartate glutamate receptor (NMDAR) antagonist initially

developed in 1963 as an anesthetic, has been recently used for analgesia and treatment of asthma and depression. Its popularity,
resulted in an increased incidence of addiction, especially in East Asia and in United States. Chronic use of ketamine affects
neurologic, urologic, and gastrointestinal systems. We hereby describe a rare case of chronic recreational ketamine use that
presented with severe hyponatremia, hyperkalemia, hemorrhagic cystitis and intrahepatic biliary ductal dilation and acute hepatic
failure with cholestatic pattern
CASE PRESENTATION: 26-year-old Asian woman presented with generalized weakness, lethargy, and hematuria. She endorsed
using ketamine for 3 months but denied any other medications use. Found to have severe protein energy malnutrition with BMI
of 14 kg/m2. Lab values showed severe hyponatremia (98 mmol/L); hyperkalemia (7.8 mmol/L), bicarbonate (11) and anion gap
(21), associated peaked T waves on electrocardiogram and normal renal function. Total bilirubin (3.7mg/dL), direct bilirubin
(2.2mg/dL), transaminases 5 times above upper normal and alkaline phosphatase (1426 IU/L) showing cholestasis pattern. Urine
sodium was 32, urine toxicology was negative, HIV was non-reactive, Hepatitis B core and surface antibody was reactive, cortisol
was 32. Computed tomography imaging and magnetic resonance cholangiopancreatography showed mild intrahepatic and
extrahepatic biliary duct dilatation without visible etiology; gallbladder was unremarkable and a bifid right renal pelvis and
bilateral moderate-severe hydronephrosis. Patient was admitted to intensive care unit. Received multiple hyperkalemic cocktails
and was started on isotonic fluids for resuscitation. Hyperkalemia resolved; hyponatremia appropriately corrected not more than
8-10meq/ 24hrs. Acetylcysteine infusion was started for liver failure. Urology was consulted for hematuria and managed with foley
catheter which improved with frequent irrigations. Patient had Escherichia coli bacteremia and treated with antibiotics. Patient
clinically improved and safely discharged home.
DISCUSSION: Ketamine causes smooth muscle relaxation directly through inhibiting the activation of NMDA receptors,
resulting in biliary dilation and subsequent cholestasis in the absence of an obstructing lesion; due to accumulation of enantiomer

CRITICAL CARE
in racemic ketamine (s-ketamine) as observed in vitro. Lower urinary tract symptoms, including cystitis have been described.
Hydronephrosis has been very rarely reported
CONCLUSIONS: This case has a very peculiar presentation given the findings of severe electrolyte abnormalities, upper-urinary
tract and liver involvement. We highlight the importance of identifying this pathology for early intervention and appropriate
management and prevent long term sequelae.
REFERENCE #1: Zhu W, Ding Z, Zhang Y, Shi J, Hashimoto K, Lu L. Risks Associated with Misuse of Ketamine as a Rapid-
Acting Antidepressant. Neurosci Bull. Dec 2016;32(6):557-564. doi:10.1007/s12264-016-0081-2
REFERENCE #2: Wang JW, Kivovich V, Gordon L. Ketamine Abuse Syndrome: Hepatobiliary and Urinary Pathology Among
Adolescents in Flushing, NY. Pediatr Emerg Care. Aug 2017;33(8):e24-e26. doi:10.1097/PEC.0000000000000502
REFERENCE #3: Xu J, Lei H. Ketamine-an update on its clinical uses and abuses. CNS Neurosci Ther. Dec 2014;20(12):1015-20.
doi:10.1111/cns.12363
DISCLOSURES: No relevant relationships by Christiana Atuaka, source¼Web Response
No relevant relationships by Claudia De Araujo Duarte, source¼Web Response
Speaker/Speaker's Bureau relationship with pfizer Please note: $1001 - $5000 by Yizhak Kupfer, source¼Admin input,
value¼Consulting fee

chestjournal.org 617A
 No relevant relationships by Sanwal Mehta, source¼Web Response
No relevant relationships by Ratnam Santoshi, source¼Web Response
DOI: https://doi.org/10.1016/j.chest.2021.07.592
Copyright ª 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
CRITICAL CARE

618A [ 160#4S CHEST OCTOBER 2021 ]