Mushroom Poisoning.

BACKGROUND: Poisonous mushrooms are eaten by mushroom hunters out of ignorance, after misidentification as edible mushrooms, or as a psychoactive drug. Mushroom poisoning commonly leads to consultation with a poison information center and to hospitalization. METHODS: This review is based on pertinent publications about the syndromes, toxins, and diagnostic modalities that are presented here, which were retrieved by a selective search in PubMed. It is additionally based on the authors' longstanding experience in the diagnosis and treatment of mushroom intoxication, expert consultation in suspected cases, macroscopic identification of wild mushrooms, and analytic techniques. RESULTS: A distinction is usually drawn between mushroom poisoning with a short latency of less than six hours, presenting with a gastrointestinal syndrome whose course is usually relatively harmless, and cases with a longer latency of six to 24 hours or more, whose course can be life-threatening (e.g., phalloides, gyromitra, orellanus, and rhabdomyolysis syndrome). The DRG diagnosis data for Germany over the period 2000-2018 include a total of 4412 hospitalizations and 22 deaths due to the toxic effects of mushroom consumption. 90% of the fatalities were due to the death cap mushroom (amatoxins). Gastrointestinal syndromes due to mushroom consumption can be caused not only by poisonous mushrooms, but also by the eating of microbially spoiled, raw, or inadequately cooked mushrooms, or by excessively copious or frequent mushroom consumption. CONCLUSION: There are few analytic techniques available other than the qualitative demonstration of amatoxins. Thus, the diagnosis is generally made on the basis of the clinical manifestations and their latency, along with meticulous history-taking, assisted by a mushroom expert, about the type(s) of mushroom that were consumed and the manner of their preparation.

GC/MS based identification of skunk spray maliciously deployed as "biological weapon" to harm civilians.

Our laboratory has been asked to elucidate the origin of a strong "toxic smell" present in a prominent politician's office, private house and motorcar. This stinky and pungent atmosphere has caused serious nausea and vomiting to several individuals. Urine samples were collected from the persons presenting symptoms of nausea for toxicological analysis. Drops, paper and cotton swabs of an oily liquid found at the implicated places were submitted by police to our laboratory for investigation. Methanol extracts of the drops were acetylated for gas chromatography/mass spectrometry (GC/MS) analysis in the electron impact mode; the cotton and paper swabs were analysed using headspace-gas chromatography/mass spectrometry (HS-GC/MS). The GC/MS analysis of the acetylated methanol extracts revealed that the major peaks of the chromatogram could be attributed to 2-methylquinoline, to 2-quinolinemethanethiol, to S-2-quinolinemethyl thioacetate, to 2-phenylethanethiol, to bis(E)-2-butenyl disulphide and to bis(3-methylbutyl) disulphide. Several volatile sulphur-containing compounds have been identified with the HS-GC/MS system. Detailed examination of the spectra as well as GC/MS analysis of commercially available skunk secret allowed us to relate the identified compounds to those present in the defence spray of skunks. No health sequels were observed for any of the persons implicated in this case.

Temporal variations of concentrations of currently used pesticides in the atmosphere of Strasbourg, France.

Atmospheric samples have been collected in Strasbourg between April 18 and May 29, 2007 and were analyzed for 71 current-use pesticides, of which 38 were detected. Average concentrations ranged from 0.09 ng m(-3) for Fenarimol to 110.42 ng m(-3) for Dimethachlor, which was slightly higher than the concentrations reported from other, comparable agricultural regions. Significant temporal variations were observed for 30 pesticides, and for most of them it could be shown that these were linked to time, temperature or atmospheric pressure. In several cases this helped to identify pesticide application just before or at the beginning of the sampling period, or ongoing treatment. Humidity, in contrast to previous reports, could not be linked to these variations. For the other 8 pesticides, only very little temporal variations were observed. Generally, these concentrations were low (less than 1 ng m(-3)), and it was assumed that they are not in use in Alsace at present.

Internet suicide guidelines: report of a life-threatening poisoning using tobacco extract.

BACKGROUND: Severe nicotine intoxication occurred in a patient after ingestion of a tobacco extract made from a recipe found on a freely available Internet site. OBJECTIVES: To determine the levels of nicotine and cotinine in the plasma of a patient who tried to commit suicide by drinking a highly concentrated tobacco extract. CASE REPORT: A 67-year-old man tried to commit suicide by following guidelines found on an Internet site. He soaked 300 grams of tobacco for 3 days in water, evaporated most of the extract, and drank the rest of it. He felt sick immediately, with the following signs: respiratory depression, hypothermia, hypersalivation, bradycardia, and myoclonic jerks. Soon after the ingestion he vomited most of the extract. Toxicological analysis revealed potentially life-threatening nicotine and cotinine serum concentrations. Surprisingly, nicotine peak levels (322 microg/L) and cotinine peak levels (9092 microg/L) were reached more than 3 h after ingestion of the extract. Estimated nicotine and cotinine half-lives were 200 min and 1185 min, respectively. Treatment consisted of gastric lavage, ventilation, and monitoring of vital functions. The patient recovered and was discharged from the Emergency Department 4 days later without sequelae. CONCLUSION: Nicotinergic intoxication is not always easy to recognize, and without clues from the patient and the toxicologic analysis, might well have been missed in the present case.

Time resolved analysis of risperidone and 9-hydroxy-risperidone in hair using LC/MS-MS.

Risperidone (RSP) is a second generation anti-psychotic drug used for the treatment of schizophrenia and anxiety disorders. In the last decades, clinical applications of hair analysis have received an increasing attention, because of its wide surveillance window. In this work, we describe a simple and fast method for detection and quantification of RSP and its major metabolite, 9-OH-risperidone (9-OH-RSP), in human hair. The validated method (cv of interday precision, intraday precision and accuracy<15%, r(2) of the calibration curves>0.98, limit of detection (LOD) was 0.90 pg/mg hair (RSP) and 1.52 pg/mg hair (9-OH-RSP), the lower limit of quantification (LLOQ) were 1.8 and 4.56 pg/mg, respectively, extraction yield were 86.9% for RSP and 86.7% for 9-OH-RSP) was successfully applied to quantify both substances in the hair of psychiatric patients treated with RSP. After washing, pulverisation, incubation in an ultrasound bath and liquid/liquid extraction of the hair samples, quantification was performed using LC/MS-MS in selected reaction monitoring mode with methaqualone as internal standard. Concentrations for RSP and its major metabolite ranged from 36 to 4765 pg/mg and from 14 to 57 pg/mg, respectively in the different hair segments. These preliminary results indicate a better relationship between the administered dose and hair concentration for 9-OH-RSP than for the parent drug. Furthermore, the RSP/9-OH-RSP ratio varied from 1 to 83.

Determination of hydroxylated metabolites of polycyclic aromatic hydrocarbons in human hair by gas chromatography-negative chemical ionization mass spectrometry.

The study describes the determination of mono-hydroxylated polycyclic aromatic hydrocarbons (OH-PAHs), metabolites of PAHs, in human hair. Twelve selected OH-PAHs from two to four rings, generally determined in urine analysis, were investigated as markers of human exposure to PAHs. Following hydrolysis of hair specimens of 50-300 mg with 1M NaOH, OH-PAHs were extracted using dichloromethane and submitted to an optimized derivatization with (2S,4R)-N-heptafluorobutyryl-4-heptafluorobutoyloxy-prolyl chloride. Compounds were then analyzed using gas chromatography-negative chemical ionization mass spectrometry (GC-NCIMS). The average inter-day and intra-day variability was 12% and 17%, respectively. The average recovery was 52% and the limits of detection and quantification ranged from 20 and 66 pmol/g for 1-OH-phenanthrene (i.e., 3.9 and 12.8 pg/mg) to 311 and 1030 pmol/g for 2-OH-benzo(c)phenanthrene (i.e., 75.9 and 251 pg/mg). The influence of hair washing with water as decontamination step, and enzymatic treatment (beta-glucuronidase) to hydrolyze conjugated derivatives were also tested. The application of the developed method to the analysis of 30 hair specimens (17 from non-smoker and 13 from smoker volunteers) demonstrated inter-individual qualitative and quantitative variations. According to the easiness of hair sampling and based on the extended detection windows provided by hair analysis, this method is proposed as a new promising tool for the assessment of human chronic exposure to PAHs.

Ethyl glucuronide determination: head hair versus non-head hair.

INTRODUCTION: In previous studies, hair analysis of ethyl glucuronide (EtG), a non-volatile, water-soluble, direct metabolite of ethanol, was shown to be adequate for the detection of social and chronic excessive alcohol consumption. As in some cases scalp hair is not available, the analysis of hair from alternative anatomical sites becomes of interest. AIMS: In this study, hair samples from head, beard, chest, armpit, stomach, pubis, arms and legs from 32 subjects were analyzed when available, in order to compare the EtG concentrations and to study if the cut-offs used for head hair could be used for non-head hair. METHODS: EtG was determined by GC/MS in negative chemical ionization mode using EtG-d5 as internal standard, after extraction by solid phase extraction using Oasis MAX columns and pentafluoropropionic anhydride (PFPA) derivatization. RESULTS: The results showed that in the cases of negative findings in head hair (EtG < 7 pg/mg), in 7 out of 12 cases negative results could also be found in non-head hair. The five others were positive, due to a positive EtG finding in pubic hair. In 20 cases of positive EtG results for head hair, in all cases positive results could also be found in non-head hair. CONCLUSIONS: In conclusion, although preliminary results indicate a clear trend regarding the accordance between EtG results in head hair and non-head hair, interpretation of non-head hair results remains to be carefully done for pubic hair, for which often higher concentrations have been found.

Comparison of MTBSTFA and BSTFA in derivatization reactions of polar compounds prior to GC/MS analysis.

In this study, MTBSTFA and BSTFA, which are among the preferred derivatization reagents for silylation were both tested on derivatization of six different groups of polar chemicals to get information about usefulness in terms of sensitivity and specificity of both reagents. Tested compound groups were nitrophenols and methoxyphenols, sterols and sugars, dicarboxylic acids and hydroxylated polycyclic aromatic hydrocarbons. It was found that MTBSTFA-derivates produce characteristic fragmentation patterns presenting mainly the fragments [M](+), [M-57](+) and [M-131](+), of which [M-57](+) is generally dominant on the mass spectrogram. BSTFA-derivates mainly show the fragments [M](+), [M-15](+) and [M-89](+) whereof the molecular ion [M](+) is generally dominant. It was also found that steric hindrance and molecular mass play a very important role in the choice of the best suited derivatization reagent: compounds with sterically hindered sites derivatized with MTBSTFA produce very small analytical responses or no signal at all, and compounds with high molecular mass produce no characteristic fragmentation pattern when derivatization is performed with BSTFA. It was also found that MTBSTFA-derivatization facilitates separation of isomer analytes, suggesting its choice in combination to semi-polar columns, whilst BSTFA seems better for sterically hindered compounds. Findings were confirmed with applications of both reagents to biological and environmental matrices (urine and atmospheric aerosols).

Back to the roots of modern analytical toxicology: Jean Servais Stas and the Bocarmé murder case.

In 1850 the Belgian Count Hypolyte Visart de Bocarmé was accused of having killed his brother-in-law Gustave Fougnies by poisoning with nicotine. Bocarmé had isolated nicotine from tobacco leaves (Nicotiana tabacum). J. S. Stas (1813-1891) was committed expert and managed to convince the poisoner. He was the first scientist to deproteinize organ tissues by alcohol and could successfully identify nicotine after diethyl ether extraction from the victim's organs. During court trial this identification was challenged by his mentor M. J. B. Orfila from Paris, who had stated 3 years before, that it would never be possible to isolate and identify organic poisons from organ tissues.

Was a child poisoned by ethanol? Discrimination between ante-mortem consumption and post-mortem formation.

The presence of ethanol in human specimens collected during autopsies is generally considered as an indication of recent ante-mortem alcohol consumption. The interpretation of the results may however be impaired by post-mortem formation of ethanol when microorganisms capable of fermentation of glucose to ethanol are present. Since the distribution in the different fluids and tissues remains contentious to conclude on the origin of the detected ethanol, the determination of specific metabolites of ethanol such as ethyl glucuronide (EtG) may be performed to discriminate between exogenous (ante-mortem) and endogenous (post-mortem). Toxicological analysis of specimens from the autopsy of a child aged 14 months displayed a high concentration of ethanol in blood and tissues. In order to discriminate between ante-mortem alcohol administration and post-mortem formation, the presence of microorganisms capable of ethanol production was checked by fermentation tests and the liver was tested for the presence of EtG and compared with a positive control. Fermentation tests displayed in the blood of the deceased the presence of the bacterial strain Lactococcus garvieae capable of producing ethanol from glucose. The absence of EtG in the liver of the deceased compared to the high level (19.56 mug/g) detected in the positive control's liver is a further indication that the ethanol detected in the body of the deceased is of post-mortem origin.

Efavirenz in human breast milk, mothers', and newborns' plasma.

BACKGROUND AND METHODS: Highly active antiretroviral therapy with efavirenz (EFV) has been prescribed to HIV-positive pregnant women in Rwanda (HIV status 1 and CD4 cell count > 350 cells/mm) during the last trimester of pregnancy and for 6 months after delivery. The EFV concentrations in maternal plasma, breast milk and in newborns' plasma of 13 women and their children between 6 weeks and 6 months post partum are reported. RESULTS: Results show a mean EFV plasma concentration of 6.55 mg/L in maternal plasma, 3.51 mg/L in skim milk, and 0.85 mg/L in infant plasma. Significant linear correlations between maternal plasma and skim milk (r = 0.8666, P < 0.0001) and between skim milk and infant plasma (r = 0.6646, P < 0.02) were found, but no significant correlation was observed between maternal and infant plasma concentrations (P > 0.05). CONCLUSIONS: After 6 months of breast-feeding, no child out of the 13 had been infected with HIV and all had good psychomotor and growth development. Our results suggest that EFV may be an alternative to nevirapine (NVP) during the third trimester of pregnancy and during the breast-feeding period. Further studies on larger groups of newborns will be necessary to get a better understanding of possible prophylactic protection of the newborns by highly active antiretroviral therapy with EFV given to the mothers.

Quantitative determination of ethyl glucuronide in sweat.

In this study, ethyl glucuronide (EtG), a specific metabolite of ethanol, was for the first time detected in sweat after alcohol consumption by human volunteers. Sweat was collected using a sweat patch (PharmChek). After collection, chemicals accumulated on the patch were extracted with water and extracts were purified by solid phase extraction. EtG was determined by gas chromatography with mass spectrometric detection in negative chemical ionization mode. In parallel, the amount of sodium deposited on the patch was determined by capillary electrophoresis and used as a correction factor to calculate the volume of sweat accumulated on the patch and, hence, the concentration of EtG in sweat. The EtG sweat concentration observed ranged from 1.7 to 103.0 microg/L for alcohol consumption from 38.0 to 154.6 g equivalent pure ethanol. No EtG was detected in subjects who did not consume alcohol. Our results demonstrate that after ethanol consumption, EtG is detectable in sweat collected using a sweat patch. The simultaneous determination of sodium allows the estimation of the volume of sweat accumulated on the patch and to calculate the concentration of EtG in sweat. This represents the first quantitative determination of a xenobiotic in sweat collected using a sweat patch. This study suggests that EtG determination in sweat could represent an interesting alternative to urine or serum analysis for the control of abstinence of patients included in treatment programs.

Determination of fentanyl in sweat and hair of a patient using transdermal patches.

Fentanyl is a synthetic opioid used to treat intense chronic pain. In this study, the authors report detection and quantification of fentanyl in sweat and hair of a patient receiving fentanyl (25 microg/h) via a transdermal therapeutic system (TTS) for 22 days. Sweat was collected using sweat patches every night on days 13-21 of the therapy, and hair was collected 12 weeks after the end of the treatment. Detection and quantification was performed with liquid chromatography-tandem mass spectrometry using electron spray ionization in selected reaction monitoring mode. Alfentanyl was used as internal standard for quantification in hair and in sweat. Sodium ions have been used as endogenous internal reference for determination of volume of sweat excreted on each patch. Results show presence of fentanyl in both matrices. Fentanyl concentrations in sweat varied from 0.17 to 1.02 ng/microL, and time-resolved segmented hair analysis showed a maximum fentanyl concentration of 0.48 ng/mg of hair during the period of the therapy.

Simultaneous enantioselective quantification of methadone and of 2-ethylidene-1,5-dimethyl-3,3-diphenyl-pyrrolidine in oral fluid using capillary electrophoresis.

A capillary electrophoresis method was developed for the enantioselective quantification of methadone (MTD) and its main metabolite, 2-ethylidene-1,5-dimethyl-3,3-diphenyl-pyrrolidine (EDDP). The enantiomers of MTD and EDDP were resolved by CE in 5min using 0.2% highly sulphated gamma-cyclodextrins as chiral selectors and a 50mM phosphate solution at pH 4.5 as background electrolyte. The optimized method was applied and validated for oral fluid testing. Linear relationships were obtained for MTD enantiomers in the range of 8.1-625ng/mL and in the range of 7.6-500ng/mL for EDDP enantiomers. The detection limits ranged from 2.3 to 2.4ng/mL, whereas the limits of quantification ranged from 7.6 to 8.1ng/mL. Intra- and inter-assay precision and accuracy were acceptable, respectively. The method was applied to the analyses of 60 oral fluid specimens obtained from patients enrolled in a MTD maintenance programme. Our data pointed out that higher concentrations of (R)-MTD and the enantioselective excess of (S)-EDDP in OF may reflect the free fraction of MTD and EDDP enantiomers in plasma.

Influence of bleaching on the enantiomeric disposition of amphetamine-type stimulants in hair.

The aim of this work was to study the influence of hair bleaching on the enantiomeric ratios of amphetamine-type stimulants (ATS), including amphetamine, methamphetamine, 3,4-methylenedioxyamphetamine, 3,4-methylenedioxymethamphetamine and 3,4-methylenedioxyethylamphetamine. Hair specimens from 14 STA users were treated with a commercial bleaching product during 40 min. After alkaline digestion and solid-phase extraction of bleached and non-bleached hair, the STA enantiomers were derivatised with an in-house synthesised chiral reagent, the (2S,4R)-N-heptafluorobutyryl-4-heptafluorobutoyloxy-prolyl chloride. The diastereoisomers were quantified by GC/MS-NCI. The results showed that the concentrations of all enantiomers decreased in bleached hair in comparison with the non-treated hair (median values between 20 and 39%). The enantiomeric ratios of the STA in bleached hair were not significantly different from those determined in non-treated hair. Our findings pointed out that bleaching treatments decrease concentrations of STA in hair without influencing their enantiomeric ratios.

Formation of scopolamine from N-butyl-scopolammonium bromide in cigarettes.

Scopolamine (hyoscine) is a naturally occurring alkaloid found in solonacea, the so-called "night shade" plants. Therapeutic applications of scopolamine are in ophthalmology to cause mydriasis and for the prevention of motion sickness, among others. It is known to induce hallucinogenic effects at a high dose. The N-butyl bromide derivative of scopolamine, available commercially as Buscopan, is commonly used as an antispasmotic. The possibility of forming scopolamine from N-butyl-scopolammonium bromide when burning cigarettes fortified with Buscopan was investigated based on a record of a prison inmate who claimed to experience hallucinations after smoking Buscopan. Liquid chromatography-tandem mass spectrometry in electrospray ionization mode was used to monitor the formation of scopolamine. Various series of eight cigarettes spiked with 10 mg of N-butyl-scopolammonium bromide with and without filters and in different smoking modes were investigated. The smoke of the burning cigarettes, the ashes, and the filter were analyzed for the presence of scopolamine. Scopolamine was detected in all cases.

Quantification of lorazepam and lormetazepam in human breast milk using GC-MS in the negative chemical ionization mode.

Lormetazepam (Loramet is a benzodiazepine mainly used as an hypnotic to treat insomnia. Lorazepam (Temesta) is used as an anxiolytic, tranquilizer, sedative, and anticonvulsant, and it is the major metabolite of lormetazepam. In this study, we designed a method to simultaneously detect and quantify these substances in human breast milk. Solid-phase extraction of 2 mL of milk was followed by derivatization with a trimethylsilyl reagent. Separation and detection was performed using gas chromatography coupled to mass spectrometry in the negative chemical ionization mode. Calibration curves were linear in the ranges of 10-200 and 1-20 ng/mL for lorazepam and lormetazepam, respectively. Limits of detection were estimated at 0.016 ng/mL for lormetazepam and 0.100 ng/mL for lorazepam. Our method was applied to real case samples from a woman receiving both benzodiazepines. Lorazepam concentrations varied from 55.3 to 123.1 ng/mL, and lormetazepam concentrations varied from 1.7 to 7.3 ng/mL.

Ethyl glucuronide concentration in hair is not influenced by pigmentation.

This work shows that the concentration of ethyl glucuronide (EtG) in hair, a marker for the evaluation of the alcohol consumption, is not influenced by the presence or absence of melanin. The results confirm that, unlike many other substances, the EtG determination in hair has not to take into account the hair colour for the correct interpretation of hair testing results.

Segmental determination of ethyl glucuronide in hair: a pilot study.

Ethyl glucuronide (EtG) is a minor metabolite of ethanol. Its detection in hair is more and more studied in both clinical and forensic context for the purpose of alcohol abuse monitoring. In this pilot study, hair specimens from 15 patients included in a treatment program after alcohol abuse cessation, were segmented and analyzed for EtG. The results were then compared to their self-reported past alcohol consumption and to their blood biomarkers values (GGT, MCV, ASAT, ALAT). EtG concentrations measured in hair varied from 8 to 261 pg/mg. The pattern of EtG concentration detected in the different hair segments matched with the drinking history of patients, displaying variations (increase and decrease) in alcohol consumption and also time of cessation. Results also demonstrated the existence of a significant correlation (r(p)=0.5357; p=0.0390) between EtG concentration in hair and the amount of alcohol intake. Variations in the EtG concentrations with respect to hair segments may provide an overview of the drinking history of patients. Moreover, EtG concentration in hair may help to estimate the daily alcohol intake.