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Illegal drugs are becoming a public health problem in African cities. In 2021, Bombé, a new drug of unknown composition, caused an outbreak of neuro-psychiatric symptoms in Kinshasa. Bombé was rumored to be based on ground catalytic exhausts stolen from cars. The chemical composition of six samples of Bombé obtained from different neighborhoods in Kinshasa was determined by triple quad liquid chromatography-mass spectrometry/mass spectrometry with confirmation by quadrupole time-of-flight mass spectrometry. Metals were determined by inductively coupled plasma-mass spectrometry, and polycyclic aromatic hydrocarbons were measured by gas chromatography-mass spectrometry. Analysis of the Bombé samples revealed that it contained heroin (2–12% of the total area under the curve of the samples) and opioid derivatives, plus paracetamol (33–72%), caffeine (17–26%), and also benzodiazepines (5/6 samples) and cyproheptadine (2/6 samples). The concentrations of neurotoxic metals were unremarkable. The median (range) concentrations of manganese and lead were 9.4 µg/g (range 3–334 μg/g) and 0.36 µg/g (range 0.1–3.12 μg/g), respectively. All polycyclic aromatic hydrocarbons were below the level of detection (<0.10 µg/g). Thanks to international collaboration, Bombé was documented to be a heroin-based drug and its alleged origin from catalytic exhausts was not substantiated. The local human expertise and technical capacity for undertaking toxicological analyses should be increased in Africa. [ABSTRACT FROM AUTHOR]

Tramadol-attributed toxicity may involve opioid-like, serotoninergic, and noradrenergic mechanisms. We investigated the mechanisms of toxicity in a massive tramadol ingestion case by examining serial clinical, imaging, electroencephalography, pharmacokinetics, and genotyping data. A 32-year-old female who presumably ingested 9000 mg sustained-release tramadol was found comatose without hypoglycemia, bradypnea, hypotension, marked hypoxemia or seizures. She developed eyelid myoclonus and non-reactive mydriasis. Electroencephalogram showed non-reactive encephalopathy. MRI showed extensive brain injury. Despite supportive care and ventricular derivation, brain death occurred on day 12. Plasma concentrations of tramadol and metabolites were measured using a liquid chromatography–tandem mass spectrometry assay. Genotyping for the presence of metabolizing cytochrome P450 (CYP) gene polymorphisms was performed. Plasma concentrations of tramadol and metabolites were extremely high (∼70-fold the therapeutic concentrations) and slowly decreased during the first ∼146 h post-admission, possibly due to prolonged gastrointestinal absorption. Elimination half-lives were 2–3-fold longer than usual values. The patient was an intermediate CYP2D6 metabolizer with decreased CYP3A4 and CYP2B6 activities. Clinical and electroencephalographic data did not support the hypotheses of opioid or serotoninergic toxicity nor prolonged/repeated seizures. Based on serial imaging showing progressive extension of ischemic edema in the context of prolonged high plasma concentrations, we hypothesized a cerebral vasospasm as mechanism of injury. Massive tramadol ingestion with prolonged high plasma concentrations can result in severe brain injury, possibly involving vasospasm. [ABSTRACT FROM AUTHOR]

There is a strong need for a reliable marker of harmful alcohol consumption to identify injured patients that can benefit from alcohol interventions, and blood phosphatidyl ethanol (PEth) has not previously been tested on this population. This study aims to compare the performance of blood PEth concentration, blood alcohol concentration (BAC) and the Alcohol Use Disorders Identification Test Consumption (AUDIT-C) for the screening of alcohol misuse in trauma patients. Prospective cross-sectional study of 238 adult patients presenting in the emergency department with any type of trauma. PEth concentration was determined in whole blood by high-performance liquid chromatography with tandem mass spectrometry. Consent, AUDIT-C score and demographic data were obtained. The sample consisted of majority male (67.6%), single (46.2%) and employed (66%) patients. The most common type of trauma was traffic collision (63.9%). The mean age was 41.7 years. We found a significant correlation between PEth levels with AUDIT-C score (Spearman's r = 0.654; p <.0001). PEth had an area under the ROC curve of 0.885 to detect hazardous alcohol consumption (AUDIT-C score ≥ 6) and PEth ≥23.9 ng/mL cutoff point provided 91.2% of sensitivity and 78.4% of specificity. Twelve patients reported alcohol abstinence, but had quantifiable levels of PEth. PEth levels and AUDIT-C score had a moderate correlation in our population. PEth was useful to identify 12 cases of underreporting of alcohol consumption habits. PEth shows promising results, but more research is needed to identify the best screening tool for alcohol misuse in trauma patients. [ABSTRACT FROM AUTHOR]

The illegal market of counterfeit and falsified medicines and supplements containing unlabeled pharmaceuticals is expanding worldwide. They are usually referred to by the term "performance and image enhancing drugs" (PIEDs) and are mainly steroids, stimulants, hormones, and drugs for erectile dysfunction. PIEDs are easily accessible through the online or black markets. We analyzed over 400 such medicines confiscated in Italy in the period 2017–2019, to determine their composition. Confiscated products were analyzed by gas chromatography/mass spectrometry and liquid chromatography/high-resolution mass spectrometry, in order to ascertain their composition and to evaluate the correspondence between what was declared on the label and the actual content, or to identify unknown products. The most commonly found substance was anabolic steroids, found in 64% of products, with 11% containing hormone modulators, 6% stimulants, 6% sexual enhancers (mainly sildenafil) and other drugs, including thyroid hormones, melanin stimulators, and vitamins. These substances were often in mixtures. The products were often mislabeled, containing contaminants in addition to the drug declared, or consisted of a drug completely different from the one reported on the label. Fifteen percent of products had a qualitative composition completely different from that declared, while 10% of products showed cross-contamination with other drugs, mainly testosterone esters, probably due to the presence of residues of other drugs in the production line. In addition, 11% of products were not labeled, so their purported composition was unknown. PIEDs pose a threat to public health. The main risks are related to the intrinsic toxicity of the substances found, especially when taken without a therapeutic indication. Another issue is related to the mislabeling of the fake medicines, and the poor-quality standard of counterfeit product preparation, with additional risks of the presence of other toxic ingredients or microbial contamination. The use of counterfeit products is a public health concern, as it constitutes a high risk for consumer health. It is mainly caused by the uncontrolled use of steroids, stimulants, sexual enhancers, and other medicaments, without medical indication or supervision, with variable and unknown compositions and doses, as well as other contaminants as a result of the absence of good manufacturing practices. [ABSTRACT FROM AUTHOR]

Introduction: The jequirity bean (Abrus precatorius) seed contains abrin, a toxalbumin, that irreversibly binds the 60-s ribosomal subunit inhibiting protein synthesis. Neurologic manifestations of ingestions are rare. Case details: We present a case of a 20-year-old man with 24 h of vomiting, diarrhea and 2 h of hematemesis and hematochezia. He admitted to purchasing 1000 jequirity beans online, crushing and ingesting them 26 h prior to presentation in a suicide attempt. Over the next 2 days, he developed hallucinations, incomprehensible mumbling and grunting, disconjugate gaze with abnormal roving eye movements and a left gaze preference with his right eye deviated medially. There was a fine tremor of the upper extremities and he had brief episodes of choreoathetoid movements of his legs. A head CT was normal with no cerebral edema. He progressed to minimally responsive to noxious stimuli, and was unable to converse or follow commands and displayed increased choreoathetoid movements of his extremities. An electroencephalogram (EEG) showed only mild background slowing. Magnetic resonance imaging (MRI) was performed showing bilaterally symmetric signal abnormalities in the basal ganglia, brainstem, corpus callosum and corona radiata with diffuse leptomeningeal enhancement. The patient developed a tonic–clonic seizure followed by pulseless electrical activity, from which he was resuscitated. He was provided comfort care and died just under 5 days after his ingestion. Results: Urine analysis using liquid chromatography coupled to tandem mass spectrometry was positive for 8.84 ng/ml of l-abrine (4.96 ng l-abrine/mg creatinine) 61 h after admission to the hospital (approximately 87 h post-ingestion). Serum concentrations for l-abrine and ricinine were both below the limits of detection. Discussion: Ingestion of 1000 crushed jequirity beans purchased on the internet resulted in progressive encephalopathy and death. [ABSTRACT FROM AUTHOR]

Objective: Use of the New Psychoactive Substance (NPS) methiopropamine was first reported in 2011, but there are limited data on its acute toxicity. We report 11 patients presenting with analytically confirmed methiopropamine use. Methods: Adults presenting to 26 hospitals in the UK with severe acute toxicity after suspected NPS use were recruited from March 2015 to April 2018. Clinical features were recorded and biological samples analysed using tandem mass spectrometry. Results: Methiopropamine was detected in 11 of 414 patients, with the last detection in August 2016. It was the only substance detected in one patient; other substances detected included other NPS in nine and conventional drugs of misuse in five. Common features included tachycardia (10/11), agitation (7/11), confusion (7/11), reduced level of consciousness (5/11), hallucinations (5/11) and a raised creatine kinase (7/11). The median length of hospital stay was 17 hours; ten were discharged without sequelae and one was transferred for in-patient psychiatric treatment. Conclusions: Methiopropamine was only detected during 2015 and 2016; most patients had other drugs detected, particularly other NPS. Raised CK was common but it is not possible to determine the degree to which this and other features could be contributed to by co-use of other substances. [ABSTRACT FROM AUTHOR]

In this case, we describe a false-positive opiate immunoassay urine screen after diphenhydramine (DPH) overdose with quantitative confirmatory testing. Our case suggests that the high DPH concentration triggered a false positive methadone and opiate result on the Siemens Vista opiate urine immunoassay screen. Keywords: False positive; rapid urine drug screen; opiate; diphenhydramine EN False positive rapid urine drug screen opiate diphenhydramine 1073 1074 2 10/12/22 20220901 NES 220901 Introduction Rapid urine drug screens are commonly used as a qualitative screening tool to detect drugs of abuse. [Extracted from the article]

Context: In the recent years, there have been an increasing number of new psychoactive substances (NPS) available through marketing and sale on the Internet. The stimulant 3,4-methylenedioxypyrovalerone (MDPV) is a potent dopamine reuptake inhibitor, which can cause serious intoxications requiring intensive care and even fatality. This report from the STRIDA project presents the prevalence, laboratory results, and clinical features in a series of intoxications involving MDPV over a 5-year period.Study design: Observational case series of consecutive patients with admitted or suspected intake of NPS presented at hospitals in Sweden from 2010 to 2014.Patients and methods: Blood and/or urine samples were collected from intoxicated patients with admitted or suspected intake of NPS presenting at hospitals over the country. Analysis of NPS was performed by a liquid chromatography–tandem mass spectrometry multicomponent method. Clinical data were collected when caregivers consulted the Swedish Poisons Information Centre and also retrieved from medical records. The severity of poisoning was graded retrospectively using the poisoning severity score.Results: During the 5-year study period, the number of MDPV-related inquiries to the Poisons Information Centre was 662 out of a total ∼4500 suspected NPS-related inquiries (∼15%), and 201 analytically confirmed MDPV intoxications were enrolled in the study. The study period covered the period when the use of MDPV in Sweden was at its peak and also the decline to an almost zero level. The age range of patients was 18–68 (mean 36, median 35) years, and 71% were males. The MDPV concentrations in serum ranged between 1.0 ng/mL and 1509 ng/mL (mean 63.6, median 20) and between 1.0 ng/mL and 81 000 ng/mL (mean 3880, median 1160) in urine. The urinary values were also creatinine corrected for variation in urine dilution, and the MDPV/creatinine ratio ranged between 0.10 ng/mmol and 2480 ng/mmol (mean 247, median 92.6). There was a statistically significant association between the serum MDPV concentration and the urinary MDPV/creatinine ratio, for 118 cases where both data were available (r = 0.764;p < 0.0001, Spearman’s rank correlation). In 30 (15%) cases, MDPV was the single psychoactive substance identified in the serum or urine specimens. In the other 171 cases, other psychoactive substances were detected together with MDPV. The additional substances (n = 61) comprised of both conventional drugs of abuse, other NPS (n = 39), pharmaceuticals, and ethanol. The cathinone-derivative alpha-pyrrolidinovalerophenone (α-PVP) was the most frequent other NPS, and was detected in 58 (29%) cases, followed by methylone in 14 (7%) cases. The main clinical manifestations reported in patients testing positive for MDPV included agitation, tachycardia (≥100/min), and hypertension (systolic blood pressure ≥140 mmHg), which were observed in 130 (67%), 106 (56%), and 65 (34%) cases, respectively. Other symptoms included hallucinations (n = 31, 16%), delirium (n = 29, 15%), hyperthermia (>39°C/102.4°F;n = 18, 10%), and rhabdomyolysis (n = 16, 8%). In MDPV intoxications with serum levels >100 ng/mL, the cases were graded as more severe and hyperthermia was less common. Conclusions: In a large number of analytically confirmed MDPV intoxications from mostly polydrug users, the urine and serum MDPV concentrations showed a high variability. The clinical features were consistent with a severe sympathomimetic toxidrome. The results also demonstrated that MDPV prevailed as a drug of abuse for a long time, after its classification as a narcotic substance and despite a high incidence of severe poisonings. [ABSTRACT FROM PUBLISHER]

In a 163-case series of VPD overdoses, severe valpromide poisoning has been associated with lower VPA concentrations in comparison to VPA concentrations resulting from VPA overdoses (above 200 I versus i 850 mg/L) [[3]]. To the Editor, Valpromide, a valproic acid (VPA)-derived amide, is used as antiepileptic and mood stabilizer drug. Valpromide (VPD) and valproic acid (VPA) concentrations following acute VPD overdose leading to delayed and prolonged coma. [Extracted from the article]