Altered mental status and end organ damage associated with the use of gacyclidine: a case series

INTRODUCTION

Over the past decade, there has been a sharp increase in the number of newly identified synthetic drugs. These new drugs are often derivatives of previously abused substances but have unpredictable toxicity. One of these drugs is gacyclidine, a derivative of phencyclidine (PCP). Gacyclidine has been studied as a neuroprotective agent in trauma and as a therapy of soman toxicity. There are no previous reports of its use as a drug of abuse.

CASE REPORTS

During a two-month period in the summer of 2013, a series of patients with severe agitation and end-organ injury were identified in an urban academic Emergency Department (ED). A urine drug of abuse screen was performed on all patients, and serum samples were sent for comprehensive toxicology analysis. A total of five patients were identified as having agitation, rhabdomyolysis, and elevated troponin (Table 1). Three of the five patients reported use of methamphetamine, and all five patients had urine drug screens positive for amphetamine. Comprehensive serum analysis identified methamphetamine in three cases, cocaine metabolites in one case, and a potential untargeted match for gacyclidine in all five cases. No other drugs of abuse were identified.

DISCUSSION

This is the first series of cases describing possible gacyclidine intoxication. The possible source of the gacyclidine is unknown but it may have been an adulterant in methamphetamine as all patients who were questioned reported methamphetamine use. These cases highlight the importance of screening for new drugs of abuse when patients present with atypical or severe symptoms. Gacyclidine has the potential to become a drug of abuse both by itself and in conjunction with other agents and toxicity from gacyclidine can be severe. It is the role of the medical toxicology field to identify new agents such as gacyclidine early and to attempt to educate the community on the dangers of these new drugs of abuse.

Pharmacokinetics of reduced iso-α-acids in volunteers following clear bottled beer consumption

Reduced iso-α-acids (reduced IAA) consisting of the rho-, tetrahydro- and hexahydro-IAA groups (RIAA, TIAA and HIAA, respectively) are ingredient congeners specific to beer and generally found in clear and also occasionally green bottled beer. Concentrations of reduced IAA were determined in the blood and urine of five volunteers over 6h following the consumption of small volumes of beer containing each of the reduced IAA. The reduced IAA were absorbed and bioavailable with peak concentrations at 0.5h followed by a drop of generally fivefold by 2h. Preliminary pharmacokinetics of these compounds in humans shows relatively small inter-individual differences and an estimated short half-life varying between ∼38 and 46min for the three groups. Comparison of RIAA analyte ratios within the group indicate that some analytes eliminate relatively faster than others and the formation of metabolite products was observed. Preliminary urine analysis showed only unmodified RIAA analytes were detectable throughout 6h and suggests extensive phase I metabolism of TIAA and HIAA analytes. In authentic forensic casework where clear or green bottled beers are consumed, the identification of reduced IAA groups may provide a novel method to target ingredient congeners consistent with beer ingestion and suggest the type of beer consumed.

Manifestation of hawkinsinuria in a patient compound heterozygous for hawkinsinuria and tyrosinemia III

Mutations in the gene for 4-hydroxyphenylpyruvic acid dioxygenase (HPD) cause either autosomal recessive tyrosinemia type III or autosomal dominant hawkinsinuria. We report a 6-month-old Indian infant who is compound heterozygous for both alleles and who has hawkinsinuria but not tyrosinemia type III based on biochemical investigations. The HPD gene was directly sequenced in the proband and both parents. The mechanistic model of the enzymatic function was built using the known structure of rat HPD. We identified a novel hawkinsinuria mutation, Asn241Ser, and a known tyrosinemia type III mutation, Ile335Met, in trans configuration. The structural analysis of the active site revealed that the IIe335Met mutation is situated in the close vicinity of one of the two highly conserved Phe rings which stack with the phenol ring of the substrate. The Asn241Ser mutation is situated further away from the 4-hydroxyphenylpyruvate binding pocket. Assuming that Asn241Ser causes hawkinsinuria, we propose positioning the dioxygen molecule in the HPD-catalyzed reaction as a novel role for the Asn residue. The IIe335Met allele is equivalent to a null mutation while the Asn241Ser allele results in a partially active enzyme with an uncoupled turnover causing hawkinsinuria.