Profound Hyperthermia Associated with Fentanyl and Cocaine Use with Suspected Synephrine Adulteration

Published:November 12, 2022DOI:



      Although hyperthermia is described following cocaine intoxication, the following two hyperthermic cases were unusual in severity and duration for cocaine alone. Synephrine was found in biological samples of these patients in high concentrations and was suspected to be an adulterant in illicitly obtained drugs.


      Two patients presented to a tertiary care university hospital within two days of each other after recreational drug use with delayed and protracted hyperthermia. Synephrine was later found in high concentrations in biological samples as an unexpected drug adulterant. The first patient's presentation came with delayed recognition of hyperthermia and implementation of aggressive cooling measures; he entered multi-system organ failure with prolonged ICU stay and significant morbidity. The second patient's hyperthermia was promptly recognized, and she received early, aggressive cooling including deep sedation and ice water submersion. She left against medical advice from the hospital at her baseline three days following presentation.
      WHY SHOULD AN EMERGENCY MEDICINE PHYSICIAN BE AWARE OF THIS: Synephrine is a suspected adulterant that may be associated with profound hyperthermia. Early recognition of drug overdose and working knowledge of common adulterants can facilitate early targeted management, such as aggressive cooling measures, which may prevent morbidity and mortality.
      This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
      All authors certify that we have no financial or personal conflicts of interest to disclose.


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