Hallucinations in a child: a case demonstrating the pitfalls of urine dipstick drug testing

We describe a child who presented with hallucinations in whom urine dipstick testing was positive for amphetamines. As a result the child protection team were involved. Subsequently, the urinalysis done by gas chromatography showed no amphetamines but a large quantity of ephedrine. The child had been given cough mixture which contains ephedrine. A cross-reaction had occurred between ephedrine and amphetamine when using the urinary dipsticks. This case highlighted the importance of clinicians being aware of the diagnostic accuracy and pitfalls of the investigations requested. In particular, this is critical when the results of such tests have such far reaching medicolegal and social consequences.