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| Journal of the New Zealand Medical Association,
05-May-2006, Vol 119 No 1233
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Nephrotoxicity of BZP-based herbal party pills: a
New Zealand case report
Mohammed Alansari, David Hamilton
Several serious side effects of the so-called ‘party
pills’ have been documented, including severe agitation, seizures,
paranoia, hyperthermia, abdominal pain, and cardiac arrhythmias.
Nephrotoxicity has been reported usually in association with
rhabdomyolysis.1 This paper describes a 17-year-old New Zealand man who
developed acute renal failure requiring haemodialysis in the absence of
rhabdomyolysis.
Case reportA 17-year-old man who was partying one weekend in Tauranga
consumed a small amount of alcohol and five BZP-based herbal party pills (he had
never previously taken such pills).
After a few hours he started to have bilateral loin pain,
which gradually increased the next day. The pain was radiating to the umbilical
and suprapubic area, aggravated by movement. He had mild, short-lived relief
with one tablet of 400 mg ibuprofen. He had no other symptoms.
He was admitted to a peripheral hospital after 36 hours
because of the severity of the abdominal pain, which required analgesia with
morphine. On examination he was euvolaemic and normotensive. Abdominal
examination showed mild tenderness in the umbilical area and in both loins. Oral
fluids were withheld due to the abdominal pain, and he was given intravenous
fluids.
He was found to have renal impairment with a serum
creatinine 220 μmol/L on admission, which rose the following day to 320
μmol/L. The patient was then transferred to the Renal Unit at Waikato
Hospital, Hamilton with signs of volume overload (jugular venous pressure [JVP]
elevated, puffy face, and bilateral leg oedema).
Further investigations revealed serum creatinine 440
μmol/L, urea 10.6 mmol/L, sodium 140 mmol/L, potassium 4.5 mmol/L,
corrected calcium 2.29 mmol/L, haemoglobin 150 gl, and white cell count 12.0
× 10(9)/L. His liver function tests were normal, creatine kinase 83
μ/L, C-reactive protein (CRP) 94 mg/L, and erythrocyte sedimentation rate
(ESR) 35 mm/hr.
A mid-stream urine (MSU) sample revealed no cells but
protein +++ and urinary protein excretion of 1.77 gram/24 hours. Hepatitis B and
C serology and HIV tests were negative, as were antineutrophil cytoplasmic
antibody and antiglomerular basement membrane antibody levels; serum protein
electrophoresis and complement were normal. On ultrasound he had mildly enlarged
kidneys with high echogenicity.
His abdominal/renal pain persisted for several days, and his
serum creatinine rose to a peak of 778 μmol/L. He was dialysed once. Three
weeks from admission his serum creatinine had returned to 92 μmol/L.
DiscussionThe temporal relationship to consumption of ‘party
pills’ and acute renal failure in a previously healthy young man strongly
supports a causal association.
Party pills have many names in the market:
Charge, Rupture, Jump, ESP, the GoodStuff,
Euphoria, Frenzy, Jax, Exodus, Bolt, Herbal Ecstacy, Pepper Plant, and
Nemi. Most contain benzylpiperazine
(BZP).
BZP was first synthesised in 1944 as an antiparasitic, but
because of its lack of efficacy and significant side effects it was withdrawn.
However, a few studies in the 1970s and 1980s showed that it had a stimulant,
amphetamine-like effect. In the 1990s, the drug began to be used recreationally
in USA, soon after in Europe, then worldwide. However, in 2002 it was made
illegal in USA, and banned in Europe soon afterwards. It was also banned in some
states in Australia including Queensland and NSW. It is legal in New
Zealand.
BZP is often marketed as a
dietary supplement although it has no dietary value. It is included in
some weight-reduction pills. BZP has been called natural or herbal because it
can be derived from pepper plant but in fact it is entirely synthetic and does
not occur naturally in any plant.
The effects of BZP are similar to those created by
amphetamine and are a result of stimulation of the central nervous system. Their
action is mainly on the serotonergic and noradrenergic systems.1
BZP use produces euphoria and keeps the user awake.
Therefore it is commonly used in the dancing scene so that the individual can
dance all night. BZP usually produce tachycardia and hypertension, which are
usually asymptomatic—although in excess they may result in cardiac
toxicity, hyperthermia, dehydration, hallucination, and seizure. The effects of
long-term use are still unknown.
The drug was first reported in New Zealand in 2004 in
Dunedin, when five students presented to Dunedin Hospital’s Emergency
Department with toxic effects.2 Soon after, Waikato Hospital’s Emergency
Department (as well as other New Zealand hospitals) started to receive patients
with toxic effects.3,4
In April 2004, the New Zealand Expert Advisory Committee on
Drugs assessed the party pills under the Misuse of Drugs Act and concluded that
there was insufficient objective evidence showing that BZP was harmful; thus
they recommended that party pills should remain legal in New Zealand.
Thereafter, Social Tonics Association New Zealand (STANZ) issued a code of
practice which advised that sale be limited to those over 18 year of age with
adherence purely on a voluntary basis.6
For stimulants in general, the aetiology of acute renal
failure is believed to be either due to circulatory collapse or rhabdomyolysis
rather than due to a direct toxic effect. Circulatory collapse can be secondary
to hyperthermia (secondary to hypothalamic dysfunction), excessive sweating, and
consequent dehydration, with or without tachyarrhythmia.
Rhabdomyolysis can be due to hyperthermia, severe agitation,
and excessive muscular activity. Accelerated hypertension has been implicated in
one case of acute renal failure secondary to amphetamine,7 and angiitis in
another.8
Whilst nonsteroidal anti-inflammatory drugs (NSAIDs) have
been implicated in acute renal failure, our case’s symptoms preceded the
ingestion of one tablet of the NSAID ibuprofen. Moreover, he had no comorbidity
which may be associated with NSAID use—induced acute renal failure,
notably use of high doses, prolonged courses, diabetes, heart failure,
hypertension and concomitant use of diuretics, and calcium channel
blockers.9
We postulate that the acute renal failure observed here may
be related to a direct toxic effect of the party pills on the kidneys, in the
absence of rhabdomyolysis or circulatory disturbance. His vasculitis screen was
negative and apart from the one dose of ibuprofen 1 day before admission, there
was no other medication or herbal medicine intake before or after the party
pills ingestion.
Spontaneous resolution of acute renal failure ensued.
Author information:
Mohammed Alansari, Medical Registrar, Waikato Hospital, Hamilton; David V
Hamilton, Locum Consultant Nephrologist, Waikato Hospital, Hamilton (currently
Consultant Nephrologist, Norfolk and Norwich University Hospital, Norwich,
UK).
Correspondence:
Mohammed Alansari, Waikato Hospital, Private Bag 3200, Hamilton. Email: mohalansari@yahoo.com
References:
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