Illicit use of a crystalized, smokable form of methamphetamine ("ice") has markedly increased [1]. Small doses can produce significant central nervous system, cardiovascular, and systemic toxic effects. We describe a previously healthy man who developed choreoathetosis and rhabdomyolysis after using crystalized methamphetamine.

A 50-year-old man presented to an inner-city hospital in metropolitan Atlanta reporting a 2-day history of hiccups and uncontrollable writhing movements of his face and hands. He had not previously experienced any similar symptoms. He denied any family history of movement disorders, ethanol or substance abuse, intake of medications, or previous illnesses. He was employed as an insect exterminator and had not recently changed any of the chemicals with which he worked. In fact, he had been on vacation from his job for the previous week.

Physical examination showed a hypomanic affect and noticeable choreiform movements of the upper extremities, head, and neck. His temperature was 38 °C, and orthostatic changes were evident. Dry mucous membranes and flat neck veins were noted. He was alert and oriented but also hyperverbal, with loose associations, tangential thoughts, and a decreased attention span.

Laboratory values included a sodium level of 119 mEq/L, a potassium level of 2.9 mEq/L, a chlorine level of 62 mEq/L, a bicarbonate level of 34 mEq/L, a blood urea nitrogen level of 63 mg/dL, a creatinine level of 6.0 mg/dL, a phosphorus level of 6.3 mmol/L, a serum glutamic-oxaloacetic transaminase level of 177 IU/L, and a uric acid level of 9.7 mg/dL. Examination of room-air blood gases showed a PO₂ of 65 mm Hg, a PCO₂ of 40 mm Hg, and a pH of 7.61. Urinalysis showed a pH of 8.0 and blood positivity by dipstick, but no erythrocytes were seen on microscopic evaluation. His electrocardiogram was remarkable only for a prolonged QT interval. Additional laboratory studies were significant for a creatine kinase level of 7664 IU/L, which peaked at 19 790 IU/L, and a lactate dehydrogenase level of 491 IU/L. Serum lithium level; ceruloplasmin, ammonia, and thyroid function test results; rheumatoid factor; antinuclear antibodies; and antistreptolysin-O titers were all negative or within normal limits. Extensive drug toxicology screens were positive only for amphetamines.

Treatment included vigorous hydration with normal saline. During a 7-day hospitalization, the choreiform movements, electrolyte abnormalities, and creatine kinase levels gradually returned to normal. On hospital day 6, the patient's girlfriend brought in a packet containing a white crystalline substance, which the patient refused to specifically identify. He admitted, however, that he believed the substance caused his condition. The substance was analyzed in the toxicology laboratory and was determined to be methamphetamine.

Rhee and colleagues [2] reported three cases of acute choreoathetosis associated with amphetamine-like drugs. In addition, a few cases of rhabdomyolysis related to methamphetamine have been documented [3]. A single case of choreoathetosis and rhabdomyolysis related to pemoline, a sympathomimetic agent similar to amphetamine and ritalin, was reported in 1988 [4].

In our patient, the choreoathetosis was probably related to the central dopaminergic effects of methamphetamine [5], as was the patient's mildly psychotic and agitated behavior. Rhabdomyolysis was most likely a result of the drug itself, possibly in combination with the excessive, uncontrollable muscular activity of chorea. The severe metabolic derangements were probably the result of significant dehydration following an "amphetamine run," rhabdomyolysis, and the alkaline property of amphetamines.