Fatal Outcome Of Status Epilepticus, Hyperthermia, Rhabdomyolysis, Multi-Organ Failure, And Cerebral Edema After 25I-NBOMe Ingestion (P1.342)

A 17-year-old girl taking lithium and topiramate for mood disorders died after ingesting the designer drug 25I-NBOMe (street names "Smiles" and "N-Bomb") on blotter paper at a music concert. She presented with status epilepticus, then developed hyperthermia, metabolic acidosis, rhabdomyolysis, elevated transaminases, acute kidney injury, hypokalemia, and hypocalcemia. Irreversible cerebral edema led to brain death on hospital day 7. Antemortem whole blood testing confirmed 25I-NBOMe at concentrations above 0.25 ng/ml. The authors suggest death resulted from acute 25I-NBOMe ingestion combined with lithium, which has serotonergic effects, causing fatal serotonin syndrome, despite the lithium level being subtherapeutic at 0.34 mmol/L.

Study at a glance

Abstract

OBJECTIVE: To describe a fatal outcome due to ingestion of a new designer drug, 25I-NBOMe. BACKGROUND: Abuse of synthetic drugs has been on the rise, and many are sold over-the-counter as bath salts and fertilizer. Identification of the exposure to such chemicals is often difficult due to the paucity of available specific laboratory assays. 25I-NBOMe stands for 2-(4-Iodo-2,5-dimethoxyphenyl)-N-I[(2-methyoxyphenyl)methyl]ethanamine, whose street names include “Smiles” and “N-Bomb”. It is a relatively new synthetic drug, a 2 carbon substitute of phenethylamine which is a primarily a highly potent serotonin receptor (5-HT2A) agonist. There have been a limited number of case reports of 25I-NBOMe poisoning. To our knowledge most reported cases of 25I-NBOMe toxicity in the published scientific literature result in clinical recovery. DESIGN: Case Report. RESULTS: We report a case of a 17 year old girl who was taking lithium & topiramate for mood disorders who died following a 251-NBOMe ingestion, portraying the lethality of this drug admixture. She presented in status epilepticus shortly after ingesting an unknown substance on a blotter paper at a music concert. She then acutely developed hyperthermia, metabolic acidosis, rhabdomyolysis, elevated transaminases, acute kidney injury, hypokalemia and hypocalcemia. Subsequently, she developed irreversible cerebral edema and was declared brain dead on hospital day #7. Further specific laboratory testing revealed exposure to 25I-NBOMe from antemortem whole blood by liquid chromatography / time of flight-mass spectrometry at a concentrations above 0.25ng/ml. CONCLUSIONS: We suggest that the patient died due to acute 25I-NBOMe ingestion in combination with lithium even though the antemortem lithium concentration was 0.34mmol/L (therapeutic range 0.6 - 1.2mmol/L). This case describes a fatal serotonin syndrome caused by ingestion of 25I-NBOMe concomitantly with lithium which also has serotonergic effects. Disclosure: Dr. Umemura has nothing to disclose. Dr. Andrew has nothing to disclose. Dr. Jacobs has nothing to disclose. Dr. Giustini has nothing to disclose. Dr. Lewis has nothing to disclose. Dr. Hanowell has nothing to disclose. Dr. Filiano has nothing to disclose.