An Autopsy Case of Dextromethorphan Poisoning.

A woman in her 30s who was being treated for a mental illness with several psychotropic drugs was admitted to the hospital after being found in a state of unconsciousness and respiratory arrest at home. She was pronounced dead 12 hours after she was discovered. Her autopsy revealed symmetrical hemorrhagic necrosis in the putamen on both sides of her cerebrum. Although many drugs were detected in her blood, all of those other than dextromethorphan (DXM) were within or below the therapeutic range. Her blood DXM was 1.73 µg/ml at admission and 1.61 µg/ml at autopsy, which were within the toxic range or coma-to-death range. The cause of death was diagnosed as DXM poisoning. DXM can cause hallucinations and euphoria if taken in excess, but since it is available as an over-the-counter drug at general pharmacies, an increasing number of young people are overdosing on it, mistakenly believing it to be a safe drug with few side effects. We believe that further social measures against DXM are necessary in Japan, such as disseminating correct knowledge in society and regulating over-the-counter sales.

Fatal cold medication poisoning in an adolescent.

BACKGROUND: Toxicity from the intentional misuse of over-the-counter (OTC) combination cold products has been widely recognized. Adolescents are most frequently involved and dextromethorphan containing products are the most popular. Desired symptoms include stimulatory effects, euphoria, hallucinations, and dissociation. Potential adverse effects include tachycardia, agitation, hyperthermia, acidosis, and coma. However, mortality is rare [ 1-3]. Co-formulated ingredients such as acetaminophen, pseudoephedrine, and antihistamines may also be present and potentiate dangerous effects. We report a case of an adolescent decedent with markedly elevated postmortem chlorpheniramine (CPA) and dextromethorphan (DXM) blood concentrations and no other identifiable cause of death.

Identifying and treating patients with synthetic psychoactive drug intoxication.

Tens of thousands of ED visits each year are related to synthetic psychoactive drug intoxication. Signs, symptoms, and treatment of toxicity with synthetic cathinones, synthetic cannabinoids, or dextromethorphan overlap greatly and can be challenging. This article describes signs and symptoms of psychoactive drug abuse and how to properly manage these symptoms.

[Morphine (obtained from poppy seeds) and dextrometorfan poisoning­ a case report].

Morphine is one of the many, and pharmacologically most important, opium poppy alkaloid (Papaver somniferum). A poppy plant consists of a lot of alkaloids. Most of them are morphine, codeine, narcotine, papaverine, thebaine, narceine and narcotoline. Most of the alkaloid is in the poppy milk - opium..It is a dried and properly processed juice with precut immature poppy-heads. It induces euphoria, somnolence, has an analgesic effect. In the study was presented a 24-yearold patient who was admitted to the Department of Toxicology and Cardiology because of suspicion of poisoning with unknown drugs. In retrospect, it turned out that he was poisoned brew with 5 kg of poppy and dextromethorphan. In the past, he drank alcohol heavily, used legal highs, amphetamine, methamphetamine, opiates, diazepam, cannabinoids. At the time of admission to the department, his general condition was severe, he was unconscious, with periodic breathing disorders, pinpoint pupils. In the laboratory: opiates>2000 ng/ml, other toxicological tests were negative. On the subsequent days of his stay he remained in a generally very severe condition; he was unconscious. Some electrolyte disorders were observed, as well as characteristics of developing rhabdomyolysis. With the applied intensive medical therapy, a gradual improvement of his general condition was achieved. Due to quadriplegia on the 30th day of the hospitalization, the patient was transferred to the Department of Neurology for further treatment.

[Poisonings with paracetamol, salicylates and dextromethorphan ­ problem evaluation based on data from Toxicological Laboratory and Poison Information Center in Krakow in 2010-2015].

The aim of the paper was to study frequency of laboratory determinations and toxicological information related to over-the-counter drugs (OTC): paracetamol (acetaminophen), salicylates and dextromethorphan. The research was based on data from Toxicological Laboratory and Poison Information Center UJ CM in Krakow in years 2010-2015. Paracetamol was determined averagely 102 times a year, more than 50% (57 cases) were positive with confirmation of poisoning. The least number of paracetamol poisoning was noted in 2011 (35 cases), the most were in 2015 (98 cases). In the time span there were averagely 40 salicylates check measurements a year, less than 50% (15 cases) were positive. Dextromethorphane was confirmed averagely in 31 patients a year, decrease of the drug intoxications was noted in 2013-2015. Paracetamol and dextromethorphan were the most often the cause of poisoning in group of patients 13-18 years old, salicylates ­ more than 30 years. In the group of small children there were only a few poisonings with paracetamol. Toxicological information data related to paracetamol, salicylates and dextromethorphan were similar to data from toxicological laboratory. Mean year numbers of drug poisoning information were: 90 (paracetamol), 14 (salicylates), 30 (dextromethorphan). The differences were in patients age distribution. Acute poisonings with OTC were related mainly to paracetamol, young patients (13- 18 years) and young adults (19-29 years). Salicylates poisoning information were related mainly to the group of adult patients (> 30 years), dextromethorphan was abused mainly by oung patients (13-18 years). There were no observed poisonings with salicylates and dextromethorphan in children, but there were toxicological information about paracetamol and salicylates poisoning and overdose in group of children (1-6 years).

[Drug poisonings in children hospitalized in The Regional Hospital No. 2 in Rzeszow in the years 2010-2014]. / Zatrucia lekami u dzieci hospitalizowanych w Szpitalu Wojewódzkim Nr 2 w Rzeszowie w latach 2010-2014.

INTRODUCTION: Drug poisoning is a frequent cause of hospitalization in children and youth. The aim of the study was to evaluate the prevalence of drug poisoning in children in the region of Rzeszów city. MATERIAL AND METHODS: Medical records of paediatric patients hospitalized in The Regional Hospital No. 2 in Rzeszow between 2010 and 2014 was reviewed and data were collected using scientific protocol. The following factors were analyzed: type of medication causing intoxication, the causality of the event, duration and seasonality of hospitalization as well as demographic data, such as the patient's age and sex. RESULTS: Within the analyzed period 295 children (194 girls and 101 boys) aged between 6 months and 18 years were hospitalized due to acute drug poisoning. Nonopioid painkillers, antiepileptic drugs and sedatives, affecting the cardiovascular system were the main classes of ingested medications. A growing phenomenon of recreational use of drugs which induce euphoria, especially dextromethorphan, was observed among young people. CONCLUSIONS: Due to rising incidence of drug poisoning in childhood physicians and pharmacists should extend their efforts to instruct and educate parents and caregivers about correct drag dosing, safe storage conditions and principles of poisoning prevention.

Common ocular effects reported to a poison control center after systemic absorption of drugs in therapeutic and toxic doses.

PURPOSE OF REVIEW: Ocular effects resulting from medications assist toxicologists in determining substances involved when treating a poisoned patient. The intention of this review is to discuss the most common ocular effects, the medications that cause them, and the mechanisms by which they occur. RECENT FINDINGS: According to National Poison Data System, the most common reported ocular effects following a drug ingestion/injection/inhalation are mydriasis, miosis, and nystagmus. The most common drug/drug classes reported to a regional poison control center causing these ocular effects include the following: first, mydriasis - amphetamines and diphenhydramine; second, miosis - clonidine and opioids; third, nystagmus - dextromethorphan. However, many other drugs/substances can cause these effects along with other systemic effects. SUMMARY: Ocular findings are a pertinent component of any patient assessment involving therapeutic and/or toxic exposure to medications and other substances.

[Age and gender trends of inpatient recreational acute dextromethorphan intoxication hospitalized in Pomeranian Center of Toxicology between 2009-2011]. / Struktura wieku i plci pacjentów hospitalizowanych w Pomorskim Centrum Toksykologii, w latach 2009 - 2011, z powodu rekreacyjnych zatruc dekstrometorfanem.

Dextromethorphan (DXM) is a derivative of codeine with an antitussive properties. Acute poisonings with this drug are related to serious, often life-threatening clinical symptoms. In the last decade the number of DXM poisonings increased and the problem was particularly noticeable among adolescents. The aim of this study was to analyze selected demographic and clinical parameters of patients who were hospitalized due to DXM poisoning in Pomeranian Centre of Toxicology between 2009-2011. The study included 170 individuals which was 2.7% of all admissions in this period. In 2009 and 2010, the proportion of patients poisoned with DXM did not exceed 1.5%, while in the years 2011- 2013 it tripled and reached up to 3.5%. The age of patients ranged from 12 to 42 (mean 18) years. Women were more frequently hospitalized. The dose of ingested DXM ranged from 150 to 2700 (mean 588.7) mg. The analysis revealed that the dose of ingested DXM was increasing with the age of patients.

An autopsy case of a young man with a single overdose of dextromethorphan.

Dextromethorphan (DXM) is an over-the-counter antitussive that is commonly used worldwide. Recently, DXM has become popular among young individuals because of its euphoric, hallucinogenic, and dissociative properties. Despite an increasing number of patients with DXM addiction, fatal cases of DXM poisoning are rare, and patients with fatalities often ingest DXM along with other drugs. Here, we report an autopsy case in which DXM was detected without multidrug ingestion. A man in his early twenties was found dead at home; no external injuries or obvious internal lesions were found during the autopsy. The toxicological analyses revealed extremely high concentrations of DXM, and no drugs other than DXM were detected. To the best of our knowledge, this is the first case report to describe a death caused by a single overdose of DXM in Japan. Public awareness regarding the risks associated with a massive ingestion of DXM should be increased.

[Dextromethorphan (DXM): new methods of intoxications among teenagers--a case description]. / Dekstrometorfan (DXM): nowe metody odurzania sie nastolatków--opis przypadku.

The study highlighted the problem of intoxication using substances and/or preparations, to which nowadays young people have unrestricted access. Based on the case developed in the Department of Forensic Medicine of the Medical University of Gdansk, our team members were able to gather information showing "ingenuity" of today's teenagers, which was reflected in the types of preparations used to induce a state of euphoria and intoxication. The study was based on the case of a 17-year-old woman, who took Acodin in combination with compressed air used to clean computer keyboards in order to induce psychoactive effects. The study used qualitative and quantitative methods: GC-FID and GC-MS. The results were compared with data from the literature.

Intentional Coricidin product exposures among Illinois adolescents.

OBJECTIVES: We sought to describe the demographics and trends of Coricidin product abuse in children in Illinois and to calculate an approximate total charge to the health-care system. METHODS: In this retrospective database review, we identified 652 cases of intentional exposure to Coricidin products among children < 18 years old in the Illinois Poison Center database from 2001 to 2006. Demographic, historical, clinical, and outcome data were recorded. RESULTS: The mean (standard deviation) age was 15.7 (1.58) years. A significant increase in exposures occurred during the study period which showed a cyclic nature with peaks in the fall months. Of the patients with disposition data available, 28.6% were admitted to a critical care unit, 15.2% to a noncritical care hospital unit, 6.3% were admitted for inpatient psychiatric care, and 46.4% were evaluated in the emergency department and discharged home. Moderate or major outcomes were reported in 42.7% of cases in which data were available. No deaths were reported. The total approximate hospital charge was $2,119,881.90 or $353,313.65/year. CONCLUSIONS: Intentional abuse of Coricidin products reported to the poison center occurred primarily among adolescents and was often associated with significant short-term clinical effects and a clear financial burden to the health-care system. SCIENTIFIC SIGNIFICANCE: This investigation demonstrates that Coricidin product abuse continues to be a problem particularly among adolescents. Parents and clinicians need to continue to be aware of these substances as drugs of abuse and curbing sales to adolescents should be considered.

Dextromethorphan abuse masquerading as a recurrent seizure disorder.

Dextromethorphan (DXM) has unique toxicity that may be difficult to diagnose. We present a case of a young woman who presented to our emergency department (ED) initially diagnosed with recurrent seizures. Paramedics brought a 19-year-old woman to the ED. Witnesses noted "shaking," which the patient did not recall. The patient denied fever, antecedent trauma, or neurological complaint. She was recently administered lamotrigine for bipolar disorder. She was a former alcoholic with no history of developing withdrawal. She admitted to marijuana use but denied use of any other illicit substances. Her vital signs and physical examination were unremarkable. She had a normal brain computed tomography, electrocardiogram, and laboratory evaluation. There was no alcohol detected. Her urine drug screen was negative for opiates, benzodiazepines, cocaine, amphetamines, barbiturates, phencyclidine, and tricyclic antidepressants. She was diagnosed with new-onset seizure and discharged home. No abnormalities were seen in the brain magnetic resonance imaging scan and electroencephalogram. She was scheduled for a cardiac syncope workup, but never followed through. Two months later, she presented to the hospital again for a similar complaint. Coworkers reported witnessing sudden tonic-clonic movements and confusion. On ED presentation, the patient was tachycardic with a heart rate of 110 beats/min and had horizontal nystagmus. She was alert with a flat affect. She did not recall events but answered questions appropriately. Repeat radiographic and laboratory evaluations were normal including urine drug screen and computed tomography. Upon questioning, she admitted to abusing DXM for the past several months. A serum DXM level at this time was 988.3 ng/mL. She was admitted to the hospital for 24 hours without sequelae. All further diagnostic testing was cancelled, and she was referred to a drug rehabilitation program. Abuse of DXM is increasing in incidence. The serum level of our patient was almost 10-fold greater than the reported therapeutic level. The toxicity of DXM is unique, and abuse should be considered in all patients presenting to the ED with new-onset seizure. Dextromethorphan abuse should be considered in young adults who present with previously undiagnosed seizure activity.

[Clinical practice guidelines in dextromethorphan poisoning pre-hospital management]. / Wytyczne postepowania w przypadku zatrucia dekstrometorfanem - postepowanie przedszpitalne.

Guideline for out - of Hospital triage and initial management of patients with suspected ingestion of dextromethorphan is presented in the study. The guideline was created by the American Association of Control Centers to assist poison center personnel while dealing with poison information service.

Pediatric Fatalities Associated With Over-the-Counter Cough and Cold Medications.

BACKGROUND AND OBJECTIVES: In 2008, over-the-counter cough and cold medications (CCMs) underwent labeling changes in response to safety concerns, including fatalities, reported in children exposed to CCMs. The objective of this study is to describe fatalities associated with exposures to CCMs in children <12 years old that were detected by a safety surveillance system from 2008 to 2016. METHODS: Fatalities in children <12 years old that occurred between 2008 and 2016 associated with oral exposure to one or more CCMs were identified by the Pediatric Cough and Cold Safety Surveillance System. An expert panel reviewed all cases to determine the causal relationship between the exposure and death, if the intent of exposure was therapeutic, and if the dose was supratherapeutic. Other contributing factors related to the child's death were also identified as part of a root cause analysis. RESULTS: Of the 180 eligible fatalities captured during the study period, 40 were judged by the expert panel to be either related or potentially related to the CCM. Of these, the majority (n = 24; 60.0%) occurred in children <2 years old and involved nontherapeutic intent (n = 22; 55.0%). The most frequently involved index ingredient was diphenhydramine (n = 28; 70.0%). In 6 cases (n = 6; 15.0%), the CCM was administered to murder the child. In another 7 cases (n = 7; 17.5%), death followed the intentional use of the CCM to sedate the child. CONCLUSIONS: Pediatric fatalities associated with CCMs occurred primarily in young children after deliberate medication administration with nontherapeutic intent by a caregiver.

Dextromethorphan, chlorphenamine and serotonin toxicity: case report and systematic literature review.

The aim of this review was to describe a patient with serotonin toxicity after an overdose of dextromethorphan and chlorphenamine and to perform a systematic literature review exploring whether dextromethorphan and chlorphenamine may be equally contributory in the development of serotonin toxicity in overdose. A Medline literature review was undertaken to identify cases of serotonin toxicity due to dextromethorphan and/or chlorphenamine. Case reports were included if they included information on the ingested dose or plasma concentrations of dextromethorphan and/or chlorphenamine, information about co-ingestions and detailed clinical information to evaluate for serotonin toxicity. Cases were reviewed by two toxicologists and serotonin toxicity, defined by the Hunter criteria, was diagnosed when appropriate. The literature was then reviewed to evaluate whether chlorphenamine may be a serotonergic agent. One hundred and fifty-five articles of dextromethorphan or chlorphenamine poisoning were identified. There were 23 case reports of dextromethorphan, of which 18 were excluded for lack of serotonin toxicity. No cases were identified in which serotonin toxicity could be solely attributed to chlorphenamine. This left six cases of dextrometorphane and/or chlorphenamine overdose, including our own, in which serotonin toxicity could be diagnosed based on the presented clinical information. In three of the six eligible cases dextromethorphan and chlorphenamine were the only overdosed drugs. There is substantial evidence from the literature that chlorphenamine is a similarly potent serotonin re-uptake inhibitor when compared with dextrometorphan. Chlorphenamine is a serotonergic medication and combinations of chlorphenamine and dextromethorphan may be dangerous in overdose due to an increased risk of serotonin toxicity.

Impact of the voluntary withdrawal of over-the-counter cough and cold medications on pediatric ingestions reported to poison centers.

PURPOSE: To assess the impact of a voluntary withdrawal of over-the-counter cough and cold medications (OTC CCMs) labeled for children under age 2 years on pediatric ingestions reported to the American Association of Poison Control Centers. METHODS: Trend analysis of OTC CCMs ingestions in children under the age 6 years resulting from therapeutic errors or unintentional poisonings for 27 months before (pre-) and 15 months after (post-) the October 2007 voluntary withdrawal was conducted. The rates and outcome severity were examined. RESULTS: The mean annual rate of therapeutic errors involving OTC CCMs post-withdrawal, in children less than 2-years of age, 45.2/100,000 (95%CI 30.7-66.6) was 54% of the rate pre-withdrawal, 83.8/100,000 (95%CI 67.6-104.0). The decrease was statistically significant p < 0.02. In this age group, there was no difference in the frequency of severe outcomes resulting from therapeutic errors post-withdrawal. There was no significant difference in unintentional poisoning rates post-withdrawal 82.1/100,000 (66.0-102.2) vs. pre-withdrawal 98.3/100,000 (84.4-114.3) (p < 0.21) in children less than 2-years of age. There were no significant reductions in rates of therapeutic errors and unintentional poisonings in children ages 2-5 years, who were not targeted by the withdrawal. CONCLUSIONS: A significant decrease in annual rates of therapeutic errors in children under 2-years reported to Poison Centers followed the voluntary withdrawal of OTC CCMs for children under age 2-years. Concerns that withdrawal of pediatric medications would paradoxically increase poisonings from parents giving products intended for older age groups to young children are not supported.

Five deaths resulting from abuse of dextromethorphan sold over the internet.

Dextromethorphan is a widely available over-the-counter antitussive that produces intoxicating, hallucinogenic, and dissociative effects at doses significantly exceeding the therapeutic range. We report the deaths of five teenage males in three incidents in three states (WA, FL, and VA) who purposefully ingested large doses of dextromethorphan for recreational purposes and died as a result of the direct toxic effects of the drug. The dextromethorphan was obtained from the same internet supplier in each case. Postmortem blood dextromethorphan concentrations ranged from 950 to 3230 ng/mL (median 1890 ng/mL). Three subjects had diphenhydramine present, one had a trace of alprazolam, and two were positive for cannabinoids. In each case, the death was attributed to dextromethorphan toxicity or toxicity from dextromethorphan and other drugs. The article discusses the metabolism, pharmacology, and potential for drug interactions for dextromethorphan and the likely mechanisms for toxicity. The dextromethorphan concentrations in all five subjects significantly exceeded the therapeutic range and are consistent with concentrations reported in other cases of dextromethorphan abuse and toxicity. The deaths resulted in the prosecution of three individuals involved in sale or distribution of the drug.