[Aconitine poisoning due to confusion of aconite leaves with lovage]. / Aconitinvergiftung durch eine Verwechslung von Eisenhutblättern mit Liebstöckel.

Due to a mix-up an older couple (69 years and 71 years) ate a meal with herbs from their garden that contained leaves of monkshood (Aconitum napellus). The monkshood plants grew close to the herbs in their garden. Both patients developed the typical symptoms of aconitine poisoning with paresthesia, hypotension and bradycardia. Over the course of time both developed cardiac arrhythmia with ventricular extrasystoles and required monitoring on the intensive care unit (ICU). The husband was more severely affected and needed catecholamines for successful treatment of hypotension (70/40 mmHg) and bradycardia (45 bpm). The toxicological analysis of the patients' serum taken 3.5 h after ingestion led to the detection of 1.8 ng/ml and 2.0 ng/ml aconitine, respectively. The patients were discharged in good general condition after 1 and 2 days, respectively. Monkshood (Aconitum napellus) is one of the most toxic native plants that can also be found in gardens due to its popularity as an ornamental plant. All parts of the plant contain toxic diterpenoid alkaloids, such as aconitine. Aconitine causes persistent activation of the fast voltage-gated sodium channels resulting in severe cardiac and neurological toxicity. Treatment of aconitine-induced ventricular arrhythmias is challenging as they are often refractory to electrical cardioversion and antiarrhythmic drugs.

Accidental clozapine intoxication in a toddler: clinical and pharmacokinetic lessons learnt.

WHAT IS KNOWN AND OBJECTIVE: Clozapine, a second generation antipsychotic which is relatively safe in overdose, has been used as an effective treatment alternative to traditional antipsychotics. The therapeutic use in children remains controversial. However, in accordance with the increasing prescription in adults, the accidental ingestion in childhood becomes more frequent. We report the youngest case of accidental clozapine ingestion. CASE SUMMARY: A 13-month-old girl presented with acute respiratory insufficiency and coma of unknown origin. The medical history, laboratory and radiological assessment did not link to aetiology until an almost spontaneous arousal after 22 h pointed towards intoxication. The initial standard drug screening using immunoassay had been negative. Hence, liquid chromatography mass spectrometry/mass spectrometry (LC-MS/MS) was performed, and clozapine was detected with a serum concentration of 736 ng/mL. WHAT IS NEW AND CONCLUSION: This case illustrates the diagnostic and forensic pitfalls in a coma of unknown origin due to the limits of toxicological screening immunoassays. LC-MS/MS analysis by an established method showed clozapine metabolites (norclozapine and clozapine-N-oxide) are detectable for longer period, especially in urine, when compared with clozapine. The clinical course is presented in unique correlation with plasma and urine concentrations of clozapine and its metabolites. The elimination pattern of clozapine in toddlers is similar to adults, and the toxic dose was found to be lower when compared with school-age children and adults.

Identification of 48 homologues of phosphatidylethanol in blood by LC-ESI-MS/MS.

Phosphatidylethanol (PEth) is an abnormal phospholipid carrying two fatty acid chains. It is only formed in the presence of ethanol via the action of phospholipase D (PLD). Its use as a biomarker for alcohol consumption is currently under investigation. Previous methods for the analysis of PEth included high-performance liquid chromatography (HPLC) coupled to an evaporative light scattering detector (ELSD), which is unspecific for the different homologues--improved methods are now based on time of flight mass spectrometry (TOF-MS) and tandem mass spectrometry (MS/MS). The intention of this work was to identify as many homologues of PEth as possible. A screening procedure using multiple-reaction monitoring (MRM) for the identified homologues has subsequently been established. For our investigations, autopsy blood samples collected from heavy drinkers were used. Phosphatidylpropanol 16:0/18:1 (internal standard) was added to the blood samples prior to liquid-liquid extraction using borate buffer (pH 9), 2-propanol and n-hexane. After evaporation, the samples were redissolved in the mobile phase and injected into the LC-MS/MS system. Compounds were separated on a Luna Phenyl Hexyl column (50 mm x 2 mm, 3 microm) by gradient elution, using 2 mM ammonium acetate and methanol/acetone (95/5; v/v). A total of 48 homologues of PEth could be identified by using precursor ion and enhanced product ion scans (EPI).

Suicidal poisoning with mercaptodimethur-morphological findings and toxicological analysis.

In the western countries, the number of fatal intoxications with plant protecting agents has decreased to some extent due to laws restricting the use of highly toxic pesticides like halogenated hydrocarbons. Nevertheless, in consideration of the easy availability of most plant protectants, the small fraction of such fatalities among suicides and intoxications is astonishing. An 80-year-old woman died of an intoxication with methiocarb (mercaptodimethur), a carbamate type pesticide and as such a reversible inhibitor of the acetylcholinesterase. The case is presented because it is the first explicit report on a fatal poisoning of a human with methiocarb. The methiocarb concentrations detected were 6,100 microg/g in stomach content, 4.0 microg/ml in heart blood, 11 microg/g in kidney, 1.9 microg/ml in urine, 25 microg/g in liver, 2 microg/g in bile and 2.5 microg/g in brain tissue.

[Acute intoxication with isopropanol]. / Akute Intoxikation mit Isopropanol.

Isopropanol is an ingredient of commonly used industrial and household agents. Intoxication can occur unintentionally, in suicide attempts or by alcohol abusers when used as a substitute for ethanol. Symptoms involve the gastrointestinal tract, the central nervous system, and the cardiovascular system at higher doses. Mortality is especially high in patients with deep coma and marked hypotension. This report describes a case of life-threatening isopropanol intoxication of a prison inmate successfully treated by haemodialysis.

Three fatalities associated with the synthetic cannabinoids 5F-ADB, 5F-PB-22, and AB-CHMINACA.

The use of synthetic cannabinoids (SC) has been widespread in certain groups of drug users for many years. In the scientific literature many intoxication cases and a number of fatalities after the use of synthetic cannabinoids were reported. In this paper three death cases are described with involvement of the synthetic cannabinoids 5F-PB-22, AB-CHMINACA, and 5F-ADB. The three cases occurred in the eastern region of Germany, which is known as a region of high methamphetamine abuse. All decedents were male, between 25 and 41 years old, and had a known history of drug use. Femoral blood concentrations of the synthetic cannabinoids were measured using a validated LC-MS/MS method. The concentration of 5F-PB-22 in the first case was 0.37ng/mL, the concentration of AB-CHMINACA in the second case was approximately 4.1ng/mL (extrapolated) and the 5F-ADB concentration in the third case was 0.38ng/mL. Compared to other published cases the concentrations in the here presented cases seem to be in the lower range. However, taking into account the scene of death, the results of the forensic autopsy and the full toxicological analysis, the deaths can be explained as a direct consequence of consumption of synthetic cannabinoids, although in case one and two relevant amounts of ethanol were found, and in case three trimipramine and olanzapine were present in non-toxic concentrations. It has to be noted that concentrations of synthetic cannabinoids in femoral blood cannot directly be judged as toxic or lethal due to the possibility of postmortem redistribution and the development of tolerance after frequent use. Therefore, all available information has to be considered carefully before stating SC use as the cause of death.

Squalene in hair--a natural reference substance for the improved interpretation of fatty acid ethyl ester concentrations with respect to alcohol misuse.

Fatty acid ethyl esters (FAEE) are incorporated into hair mainly from sebum. For this reason, the use of their concentration CFAEE as marker of excessive alcohol consumption is complicated by interindividual differences of the activity of the sebum glands and of elimination by hair care and hair cosmetics. Furthermore, an influence of the investigated hair length due to increasing accumulation from proximal to distal was found. Therefore, it was examined whether these sources of error can be avoided if in addition to CFAEE the relative FAEE concentrations CFAEE/CSQ related to squalene SQ as a natural reference compound were used for interpretation. Sebum contains about 10-20% SQ. A sensitive and reliable method for the determination of SQ in addition to FAEE from the same hair extracts by high performance liquid chromatography with photo diode array detector (HPLC-DAD) was developed. The concentrations of ethyl myristate, ethyl palmitate, ethyl oleate, ethyl stearate and squalene were determined and CFAEE/CSQ was calculated for 13 teetotallers, 16 social drinkers, 12 fatalities with excessive alcohol abuse at life time and 9 cases with unclear alcohol anamnesis. CSQ ranged from 0.02 to 1.97 microg/mg (mean 0.67 microg/mg). From the results follows that squalene enables a control of the lipid content of hair and a correction of CFAEE in cases with deviations from the usual lipid content in a similar way as creatinine in urine. Preliminary values of CFAEE/CSQ were suggested for the upper limit for teetotallers (< 0.6 ng/microg) and the lower limit for excessive alcohol abuse (> 1.5 ng/microg). However, the relative concentration CFAEE/CSQ cannot completely replace the absolute concentration CFAEE, and both should regularly be used for an improved interpretation with respect to alcohol abuse.

Analytical investigations in a death case by suffocation in an argon atmosphere.

A 31-year-old engineer was found dead in a reaction vessel (diameter 0.8 m, height 1.8 m) of a bulb factory some minutes after he had entered it for repair work. Resuscitation attempts with artificial respiration were unsuccessful. Despite autopsy and usual toxicological analyses, no cause of death could be found. Since in the normal production process, argon was used as a protecting gas, the possibility of suffocation in an argon atmosphere was investigated. This was rendered more difficult because of the natural content of 0.93 vol.% argon in air and since the excessive argon could have been removed by the resuscitation attempts. Gas samples from larynx, esophagus, bronchi, and stomach, separated blood samples from both ventricles of the heart and from the vena iliaca externa as well as tissue samples from lung and liver were collected during autopsy into headspace vials in such a way that the loss of gas and a dilution by surrounding air was avoided as far as possible. The samples were analyzed by headspace GC-MS. The abundance of Ar+ (m/z = 40) was used for quantification with N2(2+) (m/z = 14) as internal standard. The following argon concentrations were measured (mean values, case under investigation/comparison cases): gas from larynx 1.79/0.96 vol.%, stomach gas 1.58/0.89 vol.%, heart blood (left ventricle) 7.2/2.7 microg/mL, heart blood (right ventricle) 5.8/2.7 microg/mL, blood from vena iliaca externa 3.6/2.7 microg/mL. A clearly increased concentration was also found in lung tissue, whereas in liver tissue no significant difference in comparison to other cases was measured. From the results, it follows that the deceased inhaled an increased amount of argon a short time before death. The concentrations are consistent with asphyxia and subsequent resuscitation attempts. They cannot be explained by a long-term inhalation of an atmosphere enriched with argon before the incident as it is likely to have occurred in this factory hall.

Wipe-test and patch-test for alcohol misuse based on the concentration ratio of fatty acid ethyl esters and squalene CFAEE/CSQ in skin surface lipids.

Fatty acid ethyl esters (FAEE) are known to be formed in blood and almost all human tissues after alcohol consumption and to be incorporated from sebum into hair where they can be used as long-term markers for excessive alcohol consumption. In order to examine whether skin surface lipids which consist mainly of sebum are an equally useful matrix for measurement of FAEE as alcohol abuse markers, samples were collected by a wipe-test from the forehead of 13 teetotallers, 16 social drinkers, 10 death cases with known recent alcohol misuse and five death cases without indications of alcohol misuse. The samples were analysed by headspace solid-phase microextraction and gas chromatography-mass spectrometry for ethyl myristate, ethyl palmitate, ethyl oleate and ethyl stearate and by high performance liquid chromatography with photodiode array detector for squalene, (SQ), as a natural reference substance which the FAEE concentrations were related to. The ratio mFAEE/mSQ ranged between 0.16 and 1.12 ng/microg (mean 0.34 ng/microg) for the teetotallers and between 0.08 and 0.94 ng/microg (mean 0.37 ng/microg) for the social drinkers with no significant difference between both groups. For the alcoholics 2.4-24.2 ng/microg (mean 13.1 ng/microg) were found. For two volunteers the course of mFAEE/mSQ 2 weeks before and 3 weeks after a single high alcohol dose was pursued by daily wipe tests. A strong increase of mFAEE/mSQ occurred between 7 and 12 days after the drinking event. This delay can be explained by the transition time of about 8 days between sebum production and its appearance on the skin surface known from literature. For seven social drinkers skin surface lipid samples were also collected using drug of abuse patches of the firm PharmCheck. The ratios mFAEE/mSQ in these samples were in the same range as from the wipe-test. The comparison with the self-reported ethanol amounts consumed the week before and during the test gave no good correlation (R2 = 0.42). It can be concluded from the results that FAEE in skin surface lipids can be used for medium-term retrospective detection of heavy drinking.

Comparison of ethyl glucuronide and fatty acid ethyl ester concentrations in hair of alcoholics, social drinkers and teetotallers.

In previous investigations hair analysis for ethyl glucuronide (EtG) and fatty acid ethyl esters (FAEE) proved to be suitable for the detection of excessive alcohol consumption. The aim of this study was to compare EtG and FAEE concentrations in hair of alcoholics, social drinkers and teetotallers. Hair samples from 10 alcoholics in withdrawal treatment, 11 fatalities with documented excessive alcohol consumption, four moderate social drinkers who consumed up to 20 g ethanol per day, and three strict teetotallers were analysed. After external degreasing with n-heptane, extraction with a dimethyl sulfoxide/n-heptane mixture and headspace solid-phase microextraction of the extracts, four fatty acid ethyl esters (FAEEs) (ethyl myristate, ethyl palmitate, ethyl oleate and ethyl stearate) were analysed by gas chromatography-mass spectrometry (GC-MS) with deuterated internal standards. EtG was determined by GC-MS/NCI after ultrasonication of the samples with H2O, cleanup by SPE with aminopropyl columns and PFP derivatisation. The following concentrations were measured for the four groups: teetotallers EtG < 0.002 ng/mg, FAEE 0.05-0.37 ng/mg, moderate social drinkers EtG < 0.002 ng/mg, FAEE 0.26-0.50 ng/mg, alcoholic patients EtG 0.030-0.415 ng/mg, FAEE 0.65-20.50 ng/mg and the fatalities with alcohol history EtG 0.072-3.380 ng/mg, FAEE 1.30-30.60 ng/mg. The results confirm that by using a cut-off value of the sum of FAEE > 1 ng/mg and/or a positive EtG result in hair, excessive alcohol consumption can be identified using hair analysis. However, no significant correlation between the EtG and FAEE concentrations in the positive cases could be shown. Segmental analysis of some of the specimens did not reveal the same distribution for EtG compared to FAEE in hair, and no chronological accordance compared to the self-reported alcohol consumption could be observed for both parameters. These different results of both methods are discussed in terms of differences between EtG and FAEE in mechanism of formation and incorporation into hair and elimination from hair.

Determination of drugs of abuse in bovine dentin using liquid chromatography-electrospray ionization tandem mass spectrometry.

Drugs deposited in human teeth are well preserved; the spectrum of toxicological investigations may therefore be supplemented by an analysis method for drugs in teeth. A liquid chromatography-electrospray ionization tandem mass spectrometry assay for the detection and quantification of basic drugs of abuse in bovine dentin samples was developed and validated. The drugs and metabolites amphetamine, methamphetamine, methylenedioxymethylamphetamine, methylenedioxyethylamphetamine, codeine, morphine, cocaine and benzoylecgonine were extracted from 50 mg ground dentin powder by ultrasonication for 60 min in methanol 3 times. The extracts were analyzed on a triple-quadrupole mass-spectrometer in multiple reaction monitoring mode. The method was validated and proved to be accurate, precise, selective, specific and stable with good linearity within the calibration range and a lower limit of quantification of 10 to 20 pg/mg. To artificially load bovine dentin samples with drugs, the natural process of de- and remineralization in the oral cavity was mimicked by a pH-cycling experiment. The artificially drug-loaded dentin samples showed drug concentrations of 20 to 80 pg/mg. The method can be applied in further in vitro experiments as well as in post-mortem cases, especially where limited sample tissue is available.

Fatal doxepin intoxication--suicide or slow gradual intoxication?

The differentiation of intoxication courses is one of the most difficult challenges for forensic pathologists and toxicologists. The case of a 52-year-old female inpatient of a psychiatric clinic with multiple medications who died from doxepin intoxication is reported. Concentrations of doxepin metabolites and isomers, pharmacokinetic modelling and genotyping of the doxepin-metabolizing cytochrome P450 (CYP) enzymes led to the following conclusion: the lethal doxepin concentration of 2100 ng/mL was more likely to have been reached due to drug interactions and genetic peculiarities leading to a reduction of the metabolic capacity and not by an acute (suicidal) overdose.

Identification of the major urinary metabolites in man of seven synthetic cannabinoids of the aminoalkylindole type present as adulterants in 'herbal mixtures' using LC-MS/MS techniques.

Herbal mixtures, such as 'Spice', containing cannabimimetic compounds are easily available on the Internet and have become increasingly popular among people having to undergo urine drug testing, as these compounds are not detected by current immunochemical tests. For analysis of urine samples, knowledge of the main metabolites is necessary as the unchanged compounds are usually not found in urine after consumption. In this paper, the identification of the major metabolites of the currently most common seven synthetic cannabinoids is presented. Urine samples from patients of psychiatric facilities known to have consumed synthetic cannabinoids were screened by LC-MS/MS and HR-MS/MS techniques, and the major metabolites for each of the following synthetic cannabinoids were identified by their enhanced product ion spectra and accurate mass measurement: JWH-018, JWH-073, JWH-081, JWH-122, JWH-210, JWH-250 and RCS-4. The major metabolic pathway is monohydroxylation either at the N-alkyl side chain, the naphthyl moiety or the indole moiety. In addition, metabolites with carboxylated alkyl chains were identified for some of the compounds. These results facilitate the design of urine screening methods for detecting consumption of synthetic cannabinoids.

Complex suicide by ethanol intoxication and inhalation of fire fumes in an old lady: interdisciplinary elucidation including post-mortem analysis of congener alcohols.

An 88-year-old woman committed suicide by drinking a toxic amount of highly concentrated alcohol and setting two rooms of her flat on fire. As there was not enough oxygen, the fire went out, however. At autopsy, no thermal lesions were found on the body, but soot depositions in the airways and a COHb value of 14% pointed to the inhalation of fire fumes. The ethanol concentration in femoral blood was 6.62 per mille. The gastric mucosa was fixed by the ingested alcohol and showed hardly any autolytic changes despite a post-mortem interval of five days. Congener analysis of the gastric contents and the femoral blood indicated the uptake of a fruit distillate or its foreshot.

Selective detection of phosphatidylethanol homologues in blood as biomarkers for alcohol consumption by LC-ESI-MS/MS.

A new validated method for the quantitation of the abnormal phospholipid phosphatidylethanol (PEth)--a biomarker for ethanol uptake--has been developed by LC-ESI-MS/MS following miniaturised organic solvent extraction and reversed phase chromatography with phosphatidylbutanol (PBut) as internal standard. PEth homologues with two fatty acid substituents-PEth 18:1/18:1, PEth 16:0/16:0-were determined in post-mortem blood collected from heavy drinkers at autopsy and also in whole blood samples from a volunteer after a single 60 g-dose of ethanol. Furthermore, PEth 18:1/16:0 or its isobaric isomer PEth-16:0/18:1 was detected. In comparison to previous high-performance liquid chromatography (HPLC) methods with evaporative light scattering detection (ELSD), the LC-MS/MS-method is more sensitive--with a limit of detection below 20 ng/ml--and more selective for single PEth homologues, while ELSD has been used for detection of the sum of PEth homologues with approximately 10 times less sensitivity. LC-MS/MS enables monitoring of PEth homologues as biomarkers for harmful and prolonged alcohol consumption as with HPLC/ELSD earlier, where PEth is measurable in blood only after more than 50 g ethanol daily intake for more than 2 weeks. Because of its higher sensitivity, there is a potential to detect single heavy drinking by LC-MS/MS, when PEth is formed in very low concentrations. This opens a new field of application of PEth to uncover single or multiple heavy drinking at a lower frequency and with a larger window of detection in blood than before by HPLC/ELSD or by use of other direct markers, e.g. ethyl glucuronide or ethyl sulfate.

Fatty acid ethyl esters in hair as markers of alcohol consumption. Segmental hair analysis of alcoholics, social drinkers, and teetotalers.

BACKGROUND: Fatty acid ethyl esters (FAEEs) are products of nonoxidative ethanol metabolism. After incorporation in hair, they should be suitable long-term markers of alcohol abuse. METHODS: Hair samples from 19 alcoholics in a treatment program, 10 fatalities with verified excessive alcohol consumption, 13 moderate social drinkers who consumed up to 20 g ethanol/day, and 5 strict teetotalers were analyzed in 1-12 segments for four FAEEs (ethyl myristate, ethyl palmitate, ethyl oleate, and ethyl stearate) by external degreasing with n-heptane, extraction with a dimethyl sulfoxide-n-heptane mixture, headspace solid-phase microextraction of the extracts, and gas chromatography-mass spectrometry with deuterated internal standards. The n-heptane washings were analyzed in the same way for FAEEs from the hair surface. RESULTS: The sum of the four ester concentrations in hair calculated for the proximal 0-6 cm segment was 2.5-13.5 ng/mg (mean, 6.8 ng/mg) for the fatalities, 0.92-11.6 ng/mg (mean, 4.0 ng/mg) for 17 of the alcoholics in treatment, 0.20-0.85 ng/mg (mean, 0.41 ng/mg) for the moderate social drinkers, and 0.06-0.37 ng/mg (mean, 0.16 ng/mg) for the teetotalers. In almost all cases the segmental concentrations increased from proximal to distal. There was no agreement between the self-reported drinking histories of the participants and the FAEE concentrations along the hair length. Ethyl oleate was the dominant ester in all samples. CONCLUSIONS: FAEEs are deposited in hair mainly from sebum. Despite large individual differences, FAEE hair concentrations can be used as markers for excessive alcohol consumption with relatively high accuracy.