Case report: Another death associated to γ-hydroxybutyric acid intoxication.

We report a fatal γ-hydroxybutyric acid (GHB) intoxication of a forty-year old man. According to an acquaintances' statement, the deceased had drunk a beverage containing GHB approximately five hours before he was found. Postmortem GHB concentrations were determined using gas chromatography coupled to single quadrupole mass spectrometry after simple protein precipitation with methanol and derivatization with BSTFA (1% TMCS). Concentrations in body fluids and tissues of the deceased were as follows: cardiac blood 384 mg/L, femoral blood 358 mg/L, urine 864 mg/L, brain tissue 211 mg/kg, liver tissue 201 mg/kg, kidney tissue 492 mg/kg, bile 334 mg/L and gastric content 2025 mg/L. In an exhibit (liquid in a plastic bottle found next to the decedent) analyzed 29 days after the intake 27.6 g/L GHB were found with an increasing content during storage depending on the pH of the liquid (17 months after the intake: 70.0 g/L GHB and 121.2 g/L after adjusting the exhibit to a pH of 10 before extraction). GHB concentrations in head hair of the deceased (overall length approx. 4 cm, measured in segments of 0.5 cm) were measured using liquid chromatography coupled to triple quadrupole mass spectrometry. Concentrations in unwashed and washed hair samples were 91.9-174 ng/mg and 49.2-134 ng/mg, respectively. All cut-off values for postmortem matrices generally used for the identification of an exogenous GHB intake, which are further discussed within this publication, were exceeded. A lethal GHB intoxication can be assumed by a combination of toxicological findings, police investigations and exclusion of other causes of death.

Fatal Combination with 3-Methylmethcathinone (3-MMC) and Gamma-Hydroxybutyric Acid (GHB).

We reported the case of 69-year-old man who was discovered dead at a friend's home. 3-Methylmethcathinone (3-MMC) and poppers (alkyl nitrites) were found at the scene by the police. Autopsy specimens including peripheral and cardiac blood, urine, gastric content, bile and hair were sent to our laboratory to document a possible death involving abuse of drugs. Routine toxicological analysis was performed with gas chromatography with flame ionization detection (GC-FID), high performance liquid chromatography-diode array detection (HPLC-DAD), headspace gas chromatography-mass spectrometry (HS-GC-MS), gas chromatography-mass spectrometry (GC-MS) and liquid chromatography-mass spectrometry (LC-MS)-MS. After liquid-liquid extraction at alkaline pH, 3-MMC was identified with GC-MS (to allow the discrimination with 4-MMC) and quantified with ultra-performance liquid chromatography-mass spectrometry (UPLC-MS)-MS with the two following transitions: m/z 178.1 > 160 and 178.1 > 144.9. Gamma-hydroxybutyric acid (GHB) was analyzed by GC-MS for fluids and GC-MS-MS for hair. Toxicological analysis in peripheral blood revealed the presence of 3-MMC (0.33 mg/L), pseudoephedrine (0.03 mg/L) and GHB (576 mg/L). These molecules have also been found in other post-mortem fluids. Furthermore, testing for "poppers" by HS-GC-MS was negative. Hair analysis, without segmentation, demonstrated the presence of 3-MMC (206.7 ng/mg), pseudoephedrine (0.16 ng/mg) and GHB (96.3 ng/mg) and suggested a repeated consumption of these substances. However, one cannot exclude contamination by sweat during the agony period. Toxicological post-mortem results suggest a fatal combination of 3-MMC and GHB. Despite his age, the decedent was known to abuse drugs.

Drug facilitated sexual assault with lethal outcome: GHB intoxication in a six-year-old girl.

A very serious case of DFSA (drug facilitated sexual assault) is presented, in which a six-year-old girl died following sedation with γ-hydroxybutyric acid (GHB). She had been sexually abused by a relative. Samples of cardiac blood, bile, vitreous humour, liver, kidney, brain tissues and hair were analysed by a LC-MS/MS method. The following GHB concentrations were determined: cardiac blood: 150 mg/l; bile: 292mg/l; vitreous humour: 58mg/l; liver: 100 mg/kg; kidney: 124.5 mg/kg, brain: 110 mg/kg. Very high GHB levels were found in the proximal part of the hair sample (about 40.9 ng/mg). In distal segments of hair - up to 12 cm distant from the hair scalp - GHB concentrations were higher than the overall found endogenous range of 2-3 ng/mg. Police investigations revealed that the uncle had also administered GHB to the older half-sister. Therefore, a sample of her hair was analysed accordingly, but unremarkable results were obtained. Comparing our toxicological results with police investigations and the offender's statements it can be assumed that the 6-year-old girl had ingested GHB. By exclusion of other causes of death a lethal intoxication with GHB could be confirmed.

Intoxication of a Young Girl Reveals the Pitfalls of GHB Rapid Screening.

The authors discuss the case of a 14-year-old girl who was transferred to the ICU of our hospital with ethanol intoxication (3.3 g/L), loss of consciousness (E5M3V1), and severe amnesia on recovery that was suspected of gamma-hydroxybutyric acid (GHB) intoxication. STAT toxicology screening may be necessary, when sexual assault under GHB intoxication is suspected. Therefore, the initial analysis of a urine sample was performed with a new enzymatic assay analysis for GHB. The enzymatic assay reported a GHB concentration of 26 mg/L, which is above the cut-off value of 10 mg/L. This cut-off value is to differentiate endogenous and exogenous levels because low levels of GHB occur naturally in the body. However, confirmation of these results by gas chromatography, which is common practice to confirm a positive GHB, gave a negative result. This discrepancy is probably contributed to interference of ethanol with the assay. This is a substantial downside of the GHB rapid screening, since the combination of GHB and ethanol is common. It is therefore advised to confirm that the positive GHB results are lower than 50 mg/L by gas chromatography, when using the rapid screening. This way the false-positive results and consequent inappropriate social and legal actions may be avoided.

New "lethal highs": a case of a deadly cocktail of GHB and Mephedrone.

Drug scenes within several countries have changed in recent years to incorporate a range of licit psychoactive products collectively known as "legal highs": these in combination with substances already in use can cause major health problems and even death. Consumption of Gamma-hydroxybutyric acid (GHB) spread from 1980s to 2000s, when several nations have enacted laws that have made it illegal. Cases of GHB-caused or related deaths are often described in association with alcohol or traditional drugs (heroin, cocaine, amphetamine); few cases of acute lethal toxicity due to Mephedrone have been recently reported; we describe the first case of fatality due to concomitant consumption of GHB and Mephedrone. A 43 years old man died during a drugs-based party: the two substances were not detected at toxicological screening, but were identified by further analysis on the basis of circumstantial data reported by a survivor. Through our work we aim to bring to the attention in the emerging role of new drugs of abuse, and highlight problems in identifying these drugs with immunoassay screening test commonly used.

[First report of lethal gamma-hydroxybutyrate (GHB) intoxication after consumption of gamma-butyrolactone (GBL) in Lower Saxony]. / Erster Todesfall durch gamma-hydroxybuttersäure (GHB) nach Aufnahme von gamma-Butyrolacton (GBL) in Niedersachsen.

A 25-year-old drug addict died from an overdose of GBL after mistaking it for water in preparing a dilution. He realized his error and wrote a call for help in the chat room of a drug forum, so that we know the time, type and approximate amount of drug consumed. The deceased had written numerous contributions in this drug forum before, which provide further information on his drug habits and the duration of the abuse of GHB, GBL and other drugs. According to the Criminal Investigation Department of Lower Saxony, this is the first death due to GHB/GBL reported in Lower Saxony.

Acute poisonings treated in hospitals in Oslo: a one-year prospective study (I): pattern of poisoning.

OBJECTIVES: Prospective design is mandatory to study pattern of poisoning and suicidal intention of patients. MATERIAL AND METHODS: Prospective cross-sectional multi-center study of all patients contacting health care services because of acute poisoning during one year in Oslo, irrespective of intention. Data on the adult hospitalized patients (> or = 16 years) are presented here. RESULTS: Of a total of 3,775 such adult contacts (3,025 episodes), there were 947 (31 %) hospitalizations; annual incidence 1.9 (per 1,000) in males and 2.1 in females. Median age was 36 years (range 16-89); 54% females. Benzodiazepines (18%), ethanol (17%), paracetamol (12%), opioids (7%), and gamma hydroxybutyric acid (GHB) (7%) were most frequently taken. Patients stated suicidal intention in 29% of the admissions; physicians in 10%. CONCLUSION: Benzodiazepines and ethanol were the most common agents, but newer illicit drugs were frequent, especially GHB. Males often took ethanol and drugs of abuse; females often used prescription drugs with suicidal intention.

[Study on determination and distribution of GHB in biological fluids and tissues of acute poisoned rats].

OBJECTIVE: e To investigate the distribution of GHB in biological fluids and tissues and provide methodand information for detcetion of GHB in Biological Fluids and Tissues METHOD The concentrations of GHB in Biological Fluids and Tissues were analyzed by gas chromatography-mass spectrometry; Two groups of rats were fed with 1000 mg/kg of GHB and were killed at 1 hour and 3 hours post dose, respectively. RESULTS GHB concentrations of the administrated groups distributed in a degressive order of urine, stomach, blood, intestine, kidney, lung, spleen, heart, liver and brain. CONCLUSION: Urine was the best specimen for the determination of GHB concentrations in biological fluids and tissues.

Study on determination and distribution of GHB in biological fluids and tissues of acute poisoned rats / 法医学杂志

OBJECTIVE@#e To investigate the distribution of GHB in biological fluids and tissues and provide methodand information for detcetion of GHB in Biological Fluids and Tissues METHOD The concentrations of GHB in Biological Fluids and Tissues were analyzed by gas chromatography-mass spectrometry; Two groups of rats were fed with 1000 mg/kg of GHB and were killed at 1 hour and 3 hours post dose, respectively. RESULTS GHB concentrations of the administrated groups distributed in a degressive order of urine, stomach, blood, intestine, kidney, lung, spleen, heart, liver and brain.@*CONCLUSION@#Urine was the best specimen for the determination of GHB concentrations in biological fluids and tissues.

[GHB, GBL and butanediol poisonings--a serious problem in Western Sweden]. / GHB-, GBL- och butandiolförgiftningar--ett allvarligt problem i Västsverige.

Acute poisoning with GHB (Gamma-hydroxybutyrate, Gamma-hydroxybutyric acid) has been an increasing medical and social problem during the last decade in Sweden, especially on the west coast. The number of poisonings decreased in the beginning of this millennium but has again increased during the last years. At the same time the number of seizures by the police has increased similarly as well as the number of drug-related deaths. During 2004 the number of GHB-abuse related deaths in western Sweden was seven, approximately the same figures as for heroin. Two other substances which are transformed to GHB in the human body, GBL (gamma-butyrolactone) and 1,4-butanediol, have during the last years presented themselves among the same users as for GHB. Since GBL and butanediol are not classified as illicit drugs the possibilities for the police force to intervene and capture the drugs are severely restricted. Intoxication by GBL and butanediol has shown to be as dangerous as intoxication by GHB. Acute intoxications and abuse of these drugs is still a serious medical and social problem. A legal classification of GBL and butanediol as narcotics appears to be medically motivated.

[Recognition and treatment of gamma hydroxybutyric acid poisoning]. / Herkenning en behandeling van hydroxyboterzuurintoxicaties.

The number of cases of gamma-hydroxybutyric acid (GHB) poisoning is increasing rapidly. The substance is becoming more and more popular as a party drug, while the users are often unaware of the potential dangers of GHB abuse. If a GHB overdose is treated properly and on time, the patient generally recovers completely within 6 hours. Preventing aspiration and the timely initiation of artificial respiration are particularly important.

Rave drugs: pharmacological considerations.

An increasingly prevalent component of today's adolescent and young adult culture are the rave or club drugs, such as Ecstasy, Rohypnol, gamma-hydroxybutyric acid, ketamine, Fry, lysergic acid diethylamide (LSD), and methamphetamine. Considering the incidence of accidental injury in this age group, young patients admitted to the operating room in emergency situations may be under the influence of one of these drugs. Each of these illicit drugs has distinct adverse physiological effects that may be compounded by the administration of anesthetic agents. Thus, it is important for the anesthetist to be cognizant of these drugs, their effects, and the potential risk factors they pose.