Archives of Academic Emergency Medicine. 2022; 10(1): e12 CA S E RE P O RT A 25-Year-Old Chronic Ketamine User with Urinary Symp- toms; a Case Report Chin-Chu Wu1, Aming Chor-Ming Lin2,3∗ 1. Department of Medical Imaging, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan. 2. Emergency Department, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan. 3. School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan. Received: December 2021; Accepted: December 2021; Published online: 31 January 2022 Abstract: Ketamine is mainly used for short-acting general anesthesia, chronic pain, sedation, depression, and bipolar disorder. Long-term ketamine use may cause lower urinary tract symptoms and voiding dysfunction. Small capacity and fibrotic bladder can be associated with chronic ketamine use. Here, we present a 25-year-old male with a history of chronic ketamine use complicated with contracted heart-shape bladder. Keywords: Tomography, X-Ray Computed; Ketamine; Urologic Diseases; Urinary Tract Infections Cite this article as: Wu CC, Lin ACM. A 25-Year-Old Chronic Ketamine User with Urinary Symptoms; a Case Report. Arch Acad Emerg Med. 2022; 10(1): e12. https://doi.org/10.22037/aaem.v10i1.1449. 1. Introduction Sustained ketamine use results in small capacity, and fibrotic and contracted bladder, which can lead to damage to the urinary tract system. The clinical presentations range from suprapubic pain, small volume voids, and irritative lower tract symptoms to painful hematuria. Long-term abusers with a small and fibrotic bladder and poor compliance are at high risk for complications including hydronephrosis, vesi- coureteral reflux, urolithiasis, chronic renal failure, and re- current urinary tract infections (1). We herein report a case of chronic ketamine use, complicated with contracted blad- der with a heart-shape appearance on computed tomogra- phy (CT) scan. 2. Case presentation A 25-year-old man presented to the emergency department with complaint of fever, urinary frequency, dysuria, bilateral dull flank pain, and unspecific abdominal pain for one week. He had a history of bipolar disorder and chronic ketamine use. On arrival, his blood pressure was 138/82 mmHg, with ∗Corresponding Author: Aming Chor-Ming Lin; Emergency Department, Shin Kong Wu Ho-Su Memorial Hospital, 95 Wen Chang Rd, Shih Lin Dis- trict, Taipei 111 Taiwan. Tel: 886-02-28332211 Ext 2082, Fax: 886-02-28353547, E-mail: M002001@ms.skh.org.tw, ORCID: http://orcid.org/0000-0002-3842- 7216. a heart rate of 101 beats/minute, a respiratory rate of 20 beats/minute, and oxygen saturation of 98% on room air. His temperature was 38.2 °C. On physical examination, the patient had lower abdominal tenderness and bilateral flank knocking pain. The rest of physical examination were unremarkable. The complete blood cell count showed the following results: leukocyte count 14500/mm3 with 92% of segmented neutrophils, hemoglobin 10.8 gram/deciliter, platelet 520000/microliter, and an international normalized ratio (INR) of 0.8. Urinalysis showed severe pyuria and gross hematuria. Other laboratory findings included: glucose 100 milligram/deciliter, blood urea nitrogen (BUN) 38 mg/dl, serum creatinine 2.6 mg/dl, sodium 135 mEq/L, potassium 4.1 mEq/L, and serum glutamic oxaloacetic transaminase (SGOT) 48 U/L. The patient underwent ab- dominopelvic computed tomography (CT) scan without contrast material due to renal insufficiency. Axial view of abdominopelvic CT scan showed thick-wall bladder with pseudo-diverticula, dilatation of bilateral proximal ureter, and left hydronephrosis (figure 1). Coronal view of CT scan showed a contracted heart-shape bladder (figure 1). A di- agnosis of ketamine-associated uropathy, complicated with urinary tract infection, was made. The patient was started on intravenous fluids, parenteral antibiotics, and continuous urinary drainage through a Foley. On the following days, urine and blood cultures yielded Escherichia coli. He recov- ered with conservative management and was discharged 12 This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem CC. Wu and ACM. Lin 2 Figure 1: Axial (left) and coronal (right) views of the patient’s abdominopelvic computed tomography scan. days later. 3. Discussion Ketamine is a non-competitive N-methyl-D-aspartate re- ceptor antagonist medication, mainly used for short-acting general anesthesia, chronic pain, sedation, depression, and bipolar disorder (2). Ketamine is also used as a recreational drug due to its hallucinogenic and dissociative effects. Be- cause of its low price and easy usage, use of ketamine as a recreational drug is being increasingly reported world- wide. Long-term ketamine abuse may cause severe lower urinary tract symptoms and voiding dysfunction. Chronic ketamine use can damage many organs including the brain, heart, liver, gastrointestinal tract, and genitourinary system (3). Urinary tract abnormalities are the most commonly re- ported undesirable chronic effects related to ketamine abuse (4, 5). Chronic ketamine abuse may be associated with ulcer- ative cystitis, urge incontinence, decreased bladder volume, decreased bladder compliance, detrusor overactivity, and painful hematuria (6). Secondary renal damage can occur in long-term abusers (7, 8). Lower urinary tract symptoms may be associated with chronic urinary infection and ketamine- associated ulcerative cystitis. Cessation of ketamine use and proper treatment may improve most lower urinary tract symptoms. 4. Limitations Patients with a history of chronic ketamine use with persis- tent lower tract symptoms need to be encouraged to imme- diately cease its use and refer to a urologist for assessment. Contracted bladder patients with frequent recurrent urinary tract infection should be investigated. CT is useful in detect- ing the causes of urinary symptoms, such as calculi, blad- der debris, bladder fibrosis, and poor bladder compliance, as well as in early diagnosis of ketamine-associated uropathy. 5. Declarations 5.1. Acknowledgments We acknowledge all the staff of department of diagnostic ra- diology and emergency department of Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan. 5.2. Author contribution All authors passed four criteria for authorship contribution based on recommendations of the Internal Committee of Medical Journal Editors. 5.3. Funding and support None. 5.4. Conflict of Interest None. References 1. Yek J, Sundaram P, Aydin H, Kuo T, Ng LG. 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Erowid Extracts. Nov 2010;19:12-4. 6. Chu PSK, Ma WK, Wong SCW, Chu RWH, Cheng CH, Wong S, et al. The destruction of the lower urinary tract by ketamine abuse: a new syndrome? BJU international. 2008;102(11):1616-22. 7. Wu S, Lai Y, He Y, Li X, Guan Z, Cai Z. Lower urinary tract destruction due to ketamine: a report of 4 cases and review of literature. Journal of addiction medicine. 2012;6(1):85-8. 8. Mason K, Cottrell A, Corrigan A, Gillatt D, Mitchel- more A. Ketamine-associated lower urinary tract destruc- tion: a new radiological challenge. Clinical radiology. 2010;65(10):795-800. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Introduction Case presentation Discussion Limitations Declarations References