Coma, Seizures, Atrioventricular Block, and Hypoglycemia in an ADB-FUBINACA Body-Packer

Abstract

Background: Synthetic Cannabinoid (SC) intoxication has become difficult to diagnose and manage in the United States in part due to varying clinical effects within this heterogeneous group of compounds. Case Report: A 38 year-old male was admitted with altered mental status and bradycardia. He demonstrated progressive encephalopathy, seizure activity, second degree atrioventricular (AV) block, type I, respiratory failure, hypotension, hypothermia, and hypoglycemia. A computed tomography (CT) abdomen and pelvis revealed multiple packages in the patient’s stomach and rectum. Multiple attempts at gastrointestinal decontamination were unsuccessful. On hospital day eight the patient developed hypertensive emergency and was taken to the operating room for exploratory laparotomy. Twenty-two poorly wrapped packages were removed from the bowel. Post-operatively the patient demonstrated both generalized and focal seizure activity. His mental status slowly returned to baseline over the period of about one week and he was ultimately discharged without neurological sequelae after one month. Analysis of patient serum, urine, and plant matter from packages identified cannabis and 2.N-(1-amino-3,3-dimethyl-1-oxobutan-2-yl)-1-(4-fluorobenzyl)-1H-indazole-3-carboxamide (ADB-FUBINACA). Why should an emergency physician be aware of this?: The case presented demonstrates the suspected toxidrome associated with severe ADB-FUBINACA intoxication including mental status depression, bradycardia, autonomic instability, seizure, hypoglycemia, and hypothermia. Although the patient had simultaneous exposure to cannabis, his constellation of symptoms is not consistent with cannabis intoxication. A previous animal model supports the potential of this specific SC to cause the reported toxidrome.

Body packer syndrome

“…[ 1 2 ] The most common drugs involved in body packing are cocaine and heroin. [ 3 4 5 ] In our case, the drug smuggled was found to be morphine. History is usually unreliable in these patients.…”

Functional evaluation of carboxy metabolites of synthetic cannabinoid receptor agonists featuring scaffolds based on L‐valine or L‐tert‐leucine

“…ADB‐FUBINACA ( 20 ) intake has led to multiple severe intoxications . In a fatal case reported in the USA, related to the intake of compound 20 , a concentration of 7.3 ng/mL (19.1 nM) was detected in postmortem blood .…”

“…An EC 50 value of 3.45 nM (1.96-6.14) was determined for compound 14 (Table 1) ADB-FUBINACA (20) intake has led to multiple severe intoxications. [59][60][61] In a fatal case reported in the USA, related to the intake of compound 20, a concentration of 7.3 ng/mL (19.1 nM) was detected in postmortem blood. 61 In a nonfatal case, an even higher serum concentration of 15.6 ng/mL (41 nM) was determined after intake of ADB-FUBINACA (20) by ingesting two drops of e-cigarette fluid.…”

Overview of Synthetic Cannabinoids ADB-FUBINACA and AMB-FUBINACA: Clinical, Analytical, and Forensic Implications

“…Several clinical cases have shown that acute administration of ADB-FUBINACA and AMB-FUBINACA contributes to serious adverse effects and fatalities [2][3][4][5]60,61,67]. In each case described, the drugs were confirmed analytically by testing the consumed product and/or the consumers' urine or blood.…”

“…Of note, there are other reports that also document strokes of possible cardioembolic origin after consuming products containing SCs [93][94][95]. In the following year, Nacca et al [61] described a case in New York involving a 38-year-old male who was hospitalised with altered mental status and bradycardia. Later, the patient showed progressive encephalopathy and seizures accompanied by autonomic instability, respiratory failure, type-I second-degree atrioventricular block, hypotension, hypothermia, and hypoglycaemia, so a computed tomography scan was performed, detecting several broken packages in the stomach and rectum.…”