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Severe Clinical Toxicity Caused by 25I-Nbome Confirmed Analytically

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Severe Clinical Toxicity Caused by 25I-Nbome Confirmed Analytically Vol. 65, No 4/2018 567–571 https://doi.org/10.18388/abp.2018_2627 Regular paper Severe clinical toxicity caused by 25I-NBOMe confirmed analytically using LC-MS-MS method Wojciech Waldman1,2*, Maria Kała3, Wojciech Lechowicz3, Dominika Gil3 and Jacek Sein Anand1,2 1Department of Clinical Toxicology, Medical University of Gdansk, Gdańsk, Poland; 2Pomeranian Center of Toxicology, Gdańsk, Poland; 3Institute of Forensic Research, Kraków, Poland Rhabdomyolysis is a relatively rare, but potentially se- Rhabdomyolysis may be of traumatic or non-traumat- rious complication of various diseases. Muscular inju- ic origin. The former is associated with crushing, burn- ry and resultant release of electrolytes, myoglobin and ing, stenosis or occlusion of blood vessels with resultant other enzymatic proteins e.g. creatine kinase (CK) into ischemia, strenuous physical exercise, prolonged seizures circulation may result in multi-organ failure requiring an or immobilization. The non-traumatic rhabdomyolysis, extensive treatment. Non-traumatic causes of rhabdomy- which appear to be at least 5 times more frequent, may olysis, like poisonings, appear to be much more frequent be a consequence of toxic injury caused by medications, than traumatic causes. We present the case of a patient illicit drugs, plant toxins, animal poisons, electrolyte and who developed exceptionally massive rhabdomyolysis, metabolic disorders, infections, neuroleptic malignant with CK up to 516 455 U/l, after ingestion of a relative- syndrome, dermatomyositis and polymyositis. It is usual- ly small dose of a novel psychoactive substance known ly the result of multiple contributing factors. (Efstratiadis as “Alice in Wonderland”. Laboratory quantification was et al., 2007; Keltz et al., 2013). performed using a validated LC-MS/MS method in a It is noteworthy that despite the fact that rhabdomy- whole blood sample. olysis can result from exposure to at least 150 various medications and toxins, it is usually a consequence of Key words: 25I-NBOMe, novel psychoactive substances, designer toxic injury caused by illicit drugs and alcohol (Melli et drug, party pill, rhabdomyolysis, multi organ failure al., 2005). Received: 11 June, 2018; revised: 10 August, 2018; accepted: Most patients do not show the classical triad of symp- 10 September, 2018; available on-line: 19 October, 2018 toms associated with rhabdomyolysis, i.e. swelling, mus- * cle pain and discoloration of urine. e-mail: [email protected] Abbreviations: 25I-NBOMe, 2,5-dimethoxy-4-iodo-N-(2-methoxy- The individuals with rhabdomyolysis typically present benzyl)phenethylamine; HS/GC-MS, head-space gas chromatog- muscle weakness, pain in isolated muscle groups and/ raphy mass spectrom etry; HPLC-FL, fluorescent high performance or poor general condition. Biochemical abnormalities in- liquid chromatography; LC-MS/MS, liquid chromatography with clude increased activity of CK, observed as early as 4-6 tandem mass spectrometry; LOD, limit of detection; LOQ, limit of quantitation; NPS, novel psychoactive substances; CT, computed hours after the exposure to an etiological factor of rhab- tomography; CVVHD CiCa, continuous venovenous hemodialysis domyolysis. According to Sharon (Sharon, 2005), the with citrate calcium; iHD, intermittent hemodialysis; CK, creatine ki- activity of CK in patients with massive rhabdomyolysis nase; LDH, lactate dehydrogenase; AlAT, alanine aminotransferase; ranges between 10 000 U/l and more than 100 000 U/l. AspAT, aspartate aminotransferase; CRP, C reactive protein; INR, in- ternational normalized ratio; APTT, activated partial thromboplas- We report a case of a 20-year-old male who devel- tin time. oped massive rhabdomyolysis with a maximum serum concentration of CK exceeding 500 000 U/l (normal lim- it: < 200 U/l) and multi-organ failure after a recreational INTRODUCTION use of a party pill known as “Alice in Wonderland”. According to the best of our knowledge only Luckoor Compound 25I-NBOMe was created in research labo- (Luckoor et al., 2017) described such an extreme increase ratories as a potent serotonin (5-HT2A) receptor agonist, in CK activity. but because of its high hallucinogenic properties it has Toxicological studies have detected 25I-NBOMe alone been used as an alternative to other drugs such as ly- as a substance responsible for the clinical picture and sergic acid diethylamide. This has been associated with the course of intoxication. Laboratory quantification was severe toxicity and fatalities. Prevalence of 25I-NBOMe performed using a validated LC-MS/MS method in a use and acute toxicity for the years 2010–2015 are given whole blood sample. by Wood (Wood et al., 2015). Rhabdomyolysis is a condition characterized by dam- age of muscular tissue with resultant release of electro- MATERIALS AND METHODS lytes, myoglobin and other enzymatic proteins, such as CK, lactate dehydrogenase (LDH), alanine aminotrans- ferase (AlAT) and aspartate aminotransferase (AspAT), Clinical part into circulation. This may lead to hypotonia and renal A 20-year-old Caucasian male patient with no failure due to complex process of fluid escape from cir- significant past medical history was admitted to a culation to the injured muscles (Huerta-Alardin et al., hospital after a seizure episode he experienced during 2005; Bosch et al., 2009). a party. According to the witnesses, just before the 568 W. Waldman and coworkers 2018 Table 1. The most important abnormalities in physical examination and main treatment strategy System Main physical findings Main treatment strategy Glasgow Coma Score 4 points on (E1+V1+M2) Intubation State of consciousness Deeply unconscious Presented with periodical strains and seizure episo- Neurological condition des Antiepileptic treatment Supraventricular tachyarrhythmia, Metoprolol and amiodarone, Cardio-circulatory system paroxysmal atrial fibrillation, sinus bradycardia, hy- intensive fluid repletion, continuous infusion of potension noradrenaline Tachypnea, Respiratory system hypoxia, Mechanical ventilation, acute respiratory failure tracheotomy Oliguria, CVVHDF CiCa, Renal function gross hematuria, anuria iHD Antipyretic, Temperature Hyperthermia, up to 40°–41°C mechanical cooling Generalized muscle edema, Muscular system Interfascial tightness syndrome Supportive treatment. Coagulation disturbances. 23 units Fresh Frozen Plasma, Hematology. anemia, 10 units Frozen Erythrocytes, thrombocytopenia 3 units Platelet Concentrate, Parental nutrition with Kabiven Peripheral emulsion Metabolism status Catabolism for 30 days, enteral nutrition Infection (carbapenem-resistant Acinetobacter bau- mannii, Staphylococcus aureus, Escherichia coli and Wide-spectrum antibiotic therapy (gentamycin, Infectious complications Pseudomonas aeruginosa) in bronchoalveolar lavage colistin) fluid Legend: CVVHD CiCa; Multifiltrat, continuous venovenous hemodialysis with citrate calcium; iHD; Fresenius, intermittent hemodialysis procedure attack, the male took an illegal psychoactive agent of Table 2. Laboratory work-up showed as below unknown name. No traces of opiates, amphetamine, Normal The largest methamphetamine, cocaine, phencyclidine and Chosen lab tests Units range deviation tetrahydrocannabinol were found in routine toxicological screen of the urine sample. Due to unclear etiology of the pH – 7.35–7.45 6.4 patient’s condition, comprehensive differential diagnostics pCO2 mmHg 35–48 105 were implemented, including computed tomography above the (CT) of the head and lumbar puncture. None of these lactate concentra- mmol/l 0.5–1.6 detection limit tests revealed any significant abnormalities. The most tion >30 important abnormalities in physical examination, main treatment strategy and biochemical results were shown in Potassium mg/dl 3.5–5.1 5.2 Table 1 and Table 2. Calcium mg/dl 8.8–10.2 7.72 The muscle swelling gradually resolved beginning on Phosphorus mg/dl 2.5–4.5 6.2 the 14th day of the hospital stay, and a pulse could be determined on both radial arteries. The status of the pa- CK U/I < 200 516 455 tient stabilized during subsequent days, and then gradual- Creatinine mg/dl 0.7–1.2 2.73 ly improved. Also, normalization of fluid, electrolyte and metabolic balance was observed, along with the return AlAT U/I 5–37 2899 of a spontaneous lower limb mobility in response to AspAT U/l 5–37 6722 touch and acoustic stimulation. After discontinuing the Total /direct bili- mechanical ventilation, the rehabilitation was intensified, rubin mg/dl <1.2/<0.3 7.09/4.57 which resulted in a gradual normalization of the patient’s motor function. INR – 0.8–1.2 3.67 Prothrombin activity % 80–120 27 Analytical part APTT s 26–37 75 Analysis of biological material APTT ratio – 0.80–1.20 2.25 D-dimer ng/ml <500 55 342 Reagents and materials. 25I-NBOMe and me- Fibrynogen g/l 1.80–3.50 1.58 phedrone-D3, used as an internal standard (IS) were purchased from Cerilliant (Round Rock, Texas, USA). Antithrombin III % 80–120 29 Acetonitrile (MeCN) (HPLC-grade) and formic acid (98–100%) were bought from Merck (Warsaw, Po- CRP mg/l <5.0 154.7 land). Legend: INR, international normalized ratio; APTT, activated partial Blank blood samples used for validation of the thromboplastin time; CK, creatine kinase; AspAT, aspartate aminotrans- method and preparing controls were obtained from ferase; AlAT, alanine aminotransferase; CRP, C reactive protein Vol. 65 Severe clinical toxicity caused by 25I-NBOMe 569 Figure 1. The MRM chromatograms of 25I-NBOMe (0.24 ng/ml) in the blood sample of the patient, and IS (Mephedrone-D3 at 50
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