Syrian rue seeds interacted with acacia tree bark in an herbal stew resulted in N,N-dimethyltryptamine poisoning.

Introduction: Illicit substance use is an increasing problem all over the world, especially in adolescents and young adults. It is a challenge to make a definitive diagnosis of a specific substance in a poisoning case without toxicology laboratory confirmation. We confirmed the presence of N,N-dimethyltryptamine (DMT) by liquid chromatograph tandem mass spectrometer (LC/MS/MS) in biologic samples from two patients who presented with signs and symptoms consistent with sympathomimetic toxicity following the consumption of an herbal stew. Case: Two patients consumed an herbal stew together developed DMT poisoning from the interaction between Syrian rue seeds containing alkaloids with monoamine oxidase inhibitor (MAOI) activity and Acacia tree bark containing DMT. Patients' blood and spot urine was analyzed by LC/MS/MS which revealed the presence of DMT (case 1 urine: 1206 ng/mL, serum: 25 ng/mL; case 2 urine: 478 ng/mL, serum: undetectable) and harmaline (case 1 urine: 1564 ng/mL, serum: 3.3 ng/mL; case 2 urine: 1230 ng/mL, serum: undetectable). Discussion: The diagnosis of DMT poisoning is confirmed by the presence of DMT and harmaline in patients' serum and urine. Case 1 exhibited more severe signs and symptoms (e.g., altered consciousness, rhabdomyolysis, and elevated liver enzyme) than case 2. This may be explained by the presence of psychoactive DMT levels in the blood of case 1 whereas DMT was undetected in the blood of case 2. Conclusions: Consumption of an herbal stew composed of Syrian rue seeds and Acacia tree bark may be equivalent to taking a combination of DMT and MAOI, which may precipitate a sympathomimetic syndrome. Physicians should be aware that unusual clinical presentations may be the result of drug-drug interactions from a mixed herbal preparation.

Ayahuasca Exposure: Descriptive Analysis of Calls to US Poison Control Centers from 2005 to 2015.

BACKGROUND: Ayahuasca is a hallucinogenic plant preparation which usually contains the vine Banisteriopsis caapi and the shrub Psychotria viridis. This tea originates from the Amazon Basin where it is used in religious ceremonies. Because interest in these religious groups spreading as well as awareness of use of ayahuasca for therapeutic and recreational purposes, its use is increasing. Banisteriopsis caapi is rich in ß-carbolines, especially harmine, tetrahydroharmine and harmaline, which have monoamine oxidase inhibiting (MAOI) activity. Psychotria viridis contains the 5HT2A/2C/1A receptor agonist hallucinogen N,N-dimethyltryptamine (DMT). Usual desired effects include hallucination, dissociation, mood alteration and perception change. Undesired findings previously reported are nausea, vomiting, hypertension, and tachycardia. METHODS: All human exposure calls reported to the American Association of Poison Controls Centers' (AAPCC) National Poison Data System (NPDS) between September 1, 2005 and September 1, 2015 were reviewed. Cases were filtered for specific plant derived ayahuasca-related product codes. Abstracted data included the following: case age and gender, exposure reason, exposure route, clinical manifestations, treatments given, medical outcomes and fatality. RESULTS: Five hundred and thirty-eight exposures to ayahuasca botanical products were reported. The majority of the calls to poison control centers came from healthcare facilities (83%). The most common route of exposure was ingestion. Most cases were men (437, 81%, 95% CI 77.7% - 84.3%). The median age was 21 (IQR 18-29). Most exposures were acute. Three hundred thirty-seven (63%) were reported to have a major or moderate clinical effect. The most common clinical manifestations reported were hallucinations (35%), tachycardia (34%), agitation (34%), hypertension (16%), mydriasis (13%) and vomiting (6%). Benzodiazepines were commonly given (30%). There were 28 cases in the series who required endotracheal intubation (5%). Four cases were reported to have had a cardiac arrest and 7 a respiratory arrest. Twelve cases had a seizure. Reports of exposures called to poison centers appeared to increase during this period based on annual estimates. Three fatalities were reported. CONCLUSIONS: Ayahuasca use appears to be rising in the United States based on calls to poison control centers. While most use is reported to be safe and well tolerated, with possible beneficial effects, serious and life threatening adverse manifestations are possible. Most of the exposures reported to poison control centers were young people, more likely to be men and already in a healthcare facility. Further research, which includes comprehensive drug testing, will be needed to better identify the risks and effects of ayahuasca use.

"Herbal seizures"--atypical symptoms after ibogaine intoxication: a case report.

INTRODUCTION: Misuse of various new psychotropic substances such as ibogaine is increasing rapidly. Knowledge of their negative side effects is sparse. CASE PRESENTATION: We present a case of intoxication with the herbal substance ibogaine in a 22-year-old white man. After taking a cumulative dose of 38 g (taken in two doses), he developed visual memories, nausea and vomiting. He developed a generalized tonic-clonic seizure with additional grand mal seizures. He was treated with midazolam and levetiracetam. Extended drug screenings and computed tomography and magnetic resonance imaging findings were all negative. CONCLUSIONS: Knowledge of the side effects of ibogaine has mainly come from reports of cardiovascular complications; seizures are rarely mentioned and experimental findings are inconsistent. It seems that ibogaine acts like a proconvulsive drug at high doses.

Pre-treatment of BALB/c mice with a centrally acting serotonin antagonist (cyproheptadine) reduces mortality from Boophone disticha poisoning.

INTRODUCTION: Crude extracts of Boophone disticha are used in Southern African traditional medical practice for the management of various illnesses and conditions and have also been abused for their claimed euphoric and hallucinogenic effects. Unfortunately, ingestion of Boophone disticha has resulted in toxicity and death. The results of a recent acute toxicity study in a rat model insinuated that central nervous system (CNS) serotonin overdrive could be the cause of toxicity in B. disticha poisoning. The present work sought to test that hypothesis by investigating whether pre-treatment of B. disticha poisoned BALB/c mice with the CNS acting serotonin antagonist, cyproheptadine, has a dose-dependent protective effect on toxicity and mortality. METHODS: A hydroethanolic extract of B. disticha was used in all the experiments. Five groups each with 10 animals were constituted as follows; a negative control group (received 10 ml/kg Normal Saline), a positive control group (received 375 mg/kg of the B. disticha extract), and three test groups each receiving 10 mg/kg, 15 mg/kg and 20 mg/kg cyproheptadine intraperitoneally 15 minutes before oral gavage administration of 375 mg/kg B. disticha extract respectively. The Functional Observational Battery was used to evaluate neurobehavioral and physiological changes resulting from toxicity of the plant extract. The mice were then placed in an open field for another five minutes and the number of rearings and border crossings were counted and recorded. Gait abnormalities, involuntary motor movements, mobility, arousal and stereotypical behavior were also scored according to predefined criteria. All open field investigations were recorded electronically using a LABTEC Webcam(®) and results were later analysed and recorded by one of the group members. All results were entered on data collection forms. Time to death (survival time) was considered as the time period from dosage with Boophone disticha to time of death. The study follow up period was 7 days and those mice that were alive at the end of the 7 day follow-up period were considered as having survived the poisoning episode. The Kaplan Meier plot and Log-rank test were used to compare differences in mortality and median time to death for mice in the 5 treatment groups. RESULTS: We found that cyproheptadine pre-treatment led to a dose-dependent decrease in mortality from 80% in the group not pre-treated with cyproheptadine, to 30% in the 15 and 20 mg/kg cyproheptadine pre-treated groups (n = 10 per group, p < 0.05). There was also a dose-dependent increase in median survival times amongst the groups (p < 0.0001). Pre-treatment with cyproheptadine also resulted in a decrease of other toxic symptoms associated with Boophone disticha. CONCLUSIONS: We conclude that cyproheptadine has a dose-dependent protective effect on mortality and toxicity produced by exposure to Boophone disticha in our mouse model of toxicity.

Salvia divinorum: exposures reported to a statewide poison control system over 10 years.

BACKGROUND: Salvia divinorum, a hallucinogenic herb, has in recent years become popular among teenagers and young adults. Salvia is presently marketed as a "legal" alternative to other drugs of abuse, but little is known about the clinical toxicity of this substance. OBJECTIVES: The purpose of this study is to describe the clinical and demographic features of this emerging substance of recreational abuse using data obtained from the records of a poison control center. METHODS: We performed retrospective review of exposures to the herbal hallucinogen Salvia divinorum as reported to the California Poison Control System (CPCS) over the last 10 years. Demographic and clinical data were collected and compiled from the computerized records of the CPCS for the search terms "salvia" and "sage." RESULTS: There were 37 exposures to S. divinorum and 96 exposures to non-hallucinogenic Salvia species. Eighteen (49%) of the exposures were to S. divinorum alone. Intentional Salvia exposures resulted in a variety of neurologic, cardiovascular, and gastrointestinal effects. Notably, the use of concomitant substances of abuse was associated with a high rate of complications and psychomotor disturbances. CONCLUSIONS: Intentional use of S. divinorum, whether alone or in combination with alcoholic beverages and other drugs, causes neurologic, cardiovascular, and gastrointestinal effects. This poison-center-based review helps to characterize the clinical toxicity of S. divinorum, but more clinical and pharmacologic research is warranted for this rapidly emerging substance of abuse.

Bioanalytical and clinical evaluation of 103 suspected cases of intoxications with psychoactive plant materials.

INTRODUCTION: Problems associated with the increasing abuse of plant-derived psychoactive substances have recently attracted attention. This study involved bioanalytical and clinical examinations of intoxication cases suspected to be linked to such plant materials. METHODS: Urine samples were collected at emergency wards in Sweden from patients who either admitted or were suspected of ingestion of psychoactive plant materials. The bioanalytical investigation employed a liquid chromatography-tandem mass spectrometry multicomponent method covering 10 plant-derived substances (atropine, dimethyltryptamine, ephedrine, harmaline, harmine, ibogaine, lysergic acid amide, psilocin, scopolamine, and yohimbine) and a gas chromatography-mass spectrometry method for asarone. Routine testing for illicit drugs was also performed. RESULTS: Over a 4-year period, 103 urine samples collected from mainly young people (age range 13-52 years, median 19) were studied. Among 53 cases where ingestion of any of the 11 plant-derived substances covered in this study was admitted or suspected, 41 (77%) could be confirmed bioanalytically. Nine of the 11 substances tested for were detected, the exceptions being ibogaine and yohimbine. Psilocin, originating from ingestion of hallucinogenic mushrooms, was the most frequent drug accounting for 54% of the cases. The most common means of drug acquisition (56%) was purchase over the Internet. CONCLUSION: The patients using psychoactive plant materials were mainly young and commonly used the Internet for drug acquisition. Having access to bioanalytical methods for detection of plant-derived psychoactives is therefore considered important, when providing clinical toxicology service.

Sudden death associated with intravenous injection of toad extract.

A 24-year-old male died suddenly following the intravenous injection of what was believed to be the ring-derivate amphetamine 'ecstasy' (MDMA). Toxicological analyses of the victim's blood and the injected material, however, failed to reveal MDMA, but showed instead low levels of bufotenine, a tryptamine derivative alkaloid found in the secretions of various toads. In addition, resibufogenin, cinobufagin and bufalin, bufadienolides that are also found in toad venom, were identified in the injected material. While these substances also occur in certain South American plants, the finding of paracetamol, promethazine and diclofenac would be in keeping with ingredients found in the traditional Chinese herbal product Chan Su that derives from the skin glands and secretions of toads and that is often adulterated with standard pharmaceutical drugs. This case demonstrates the problems that users and sellers may encounter from the unknown composition of street drugs and herbal medicines, and the danger that may be incurred from the injection of such materials. It also shows the difficulties that may be associated with attempting to identify low levels of organic toxins in postmortem specimens necessitating a targeted screening approach guided by information obtained at the death scene.

[Intoxication with henbane]. / Intoksikacija bunikom.

Henbane, Hyoscyamus niger, is a hallucinogenic plant, widely spread and easy accessible, which contains anticholinergic substances. Ingestion, intentional or accidental, can provoke serious worsening of psychophysical state and can cause even death. Intoxication resembles the one with atropine. Symptoms like mydriasis, tachycardia, arrhythmia, agitation, convulsion and coma can appear. Diagnosis is made by clinical symptomatology and history. Therapeutic acts include stomach lavage, supportive therapy and physostigmine as a specific antidote. Prognosis is usually good.

Collective poisoning with hallucinogenous herbal tea.

An incident wherein more than 30 people were poisoned with a herbal infusion during a meditation session is described. The clinical features observed were hallucinations, aggression, agitation, amnesia, mydriasis, dry skin, tachycardia, hyperthermia, hypotension, collapse, coma and respiratory depression. All patients recovered, although mechanical ventilation was required in some instances. A portion of the herbal infusion was found to contain atropine (hyoscyamine), scopolamine (hyoscine), harmine, and other alkaloids. The estimated ingested doses (free bases) were atropine 4 mg, harmine 27 mg, and scopolamine 78 mg. The mean concentrations in 21 serum samples obtained approximately 6h after ingestion of the infusion were atropine 5 ng/ml, harmine 8 ng/ml, and scopolamine 13 ng/ml.

[A case of datura stramonium poisoning--general problems of differential diagnosis]. / Csattanómaszlag-mérgezés esete--a differenciáldiagnózis gyakorlati kérdései.

In past year drug abuse becomes more and more general in Hungary. In addition to consume traditional drugs, other substances are used frequently too. One of them is the Datura stramonium, which contains alkaloids (mostly atropine), and can result in hallucinations. Therefore Datura stramonium is seemingly becoming popular as a hallucinogenic drug. The consumption of any part of the plant causes atropine intoxication, thus anticholinergic delirium. Differential diagnosis of Datura intoxication can be difficult in the everyday medical practise. In our paper the symptomatology, diagnosis, differential diagnosis, and therapy of Datura intoxication are discussed and we report one of our cases.

Banisteriopsis caap: acao alucinogena e uso ritual / Banisteriopsis caap: hallucinogenic action and ritual use

Atualmente, um crescente interesse nas praticas rituais indigenas, as quais se utilizavam de plantas com o intuito de se comunicarem com o mundo espiritual tem sido observado. No Brasil, as ceitas religiosas Uniao do Vegetal (UDV) e Santo Daime, frequentemente, fazem uso do cha, preparado a partir das plantas Banisteriopsis caap e Psychotria viridis...

Mass ingestion of Jimson Weed by eleven teenagers.

Jimson Weed is a naturally occurring plant which is commonly ingested for its hallucinogenic properties. This paper is a case report summarizing 11 cases of patients, ages 13-21 years, who presented to our emergency department following oral ingestion of large quantities of Jimson Weed pods and seeds. Toxicity following ingestion is due to an atropine-containing alkaloid contained throughout the plant and concentrated in the seeds. Signs and symptoms ranged from asymptomatic mydriasis and tachycardia to severe agitation, disorientation, and hallucinations. Nine of the eleven patients were admitted for observation. There were no deaths associated with these ingestions and none of the patients required physostigmine for reversal of severe anticholinergic symptoms. This paper also includes an historical overview of Jimson Weed, its physiologic effects, the epidemiological data, and a treatment summary.

Accidental ingestion of jimsonweed by an adolescent.

Ingestion of jimsonweed can result in hallucinations. Despite this side effect, the differential diagnosis of jimsonweed toxicity can be difficult, in part, because routine drug screens do not detect this agent. Such a delay in diagnosis not only postpones treatment but may also result in the patient's death. Treatment involves gastric lavage, followed by supportive care. Life-threatening cases entail the cautious use of physostigmine salicylate.

[Poisoning with Jimson weed. Five cases treated with physostigmine]. / Forgiftning med piggeple. Fem tilfeller behandlet med fysostigmin.

During the autumn of 1995, the National Poisons Information Centre was contacted about several cases of poisoning with Jimson weed (Datura stramonium). Five cases are described here. Upon admission to hospital the patients had moderate to severe anticholinergic symptoms, such as mydriasis, sinus tachycardia, agitation, dry mouth, urine retention, fever, hypertension, hallucinations and seizures. Owing to their agitated behaviour, gastrointestinal decontamination was impossible. Repeated doses of physostigmine (2-3 mg) administered intravenously reversed the anticholinergic features without side-effects. In the most severe case, physostigmine was needed for 18 hours (total dose; 25.5 mg). The patients recovered in a day or two, but mydriasis persisted in many cases.

[Thorn apple poisoning]. / Doornappel-intoxicatie.

A 20-year-old man presented with signs of thornapple intoxication: restlessness, disorientation, hallucinations, euphoria, and furthermore dry and red skin and symmetrical dilation of the pupils. Thornapple intoxication mimics atropine intoxication. Thorn apples (Datura stramonium) are seemingly becoming popular as a hallucinogenic drug. When the symptoms are mild gastric lavage leaving active charcoal in the stomach afterwards will suffice. In case of severe symptoms treatment with physostigmine is indicated.