Sudden death associated with intravenous injection of toad extract

Abstract

A 24-year-old male died suddenly following the intravenous injection of what was believed to be the ring-derivate amphetamine ‘ecstasy’ (MDMA). Toxicological analyses of the victim's blood and the injected material, however, failed to reveal MDMA, but showed instead low levels of bufotenine, a tryptamine derivative alkaloid found in the secretions of various toads. In addition, resibufogenin, cinobufagin and bufalin, bufadienolides that are also found in toad venom, were identified in the injected material. While these substances also occur in certain South American plants, the finding of paracetamol, promethazine and diclofenac would be in keeping with ingredients found in the traditional Chinese herbal product Chan Su that derives from the skin glands and secretions of toads and that is often adulterated with standard pharmaceutical drugs. This case demonstrates the problems that users and sellers may encounter from the unknown composition of street drugs and herbal medicines, and the danger that may be incurred from the injection of such materials. It also shows the difficulties that may be associated with attempting to identify low levels of organic toxins in postmortem specimens necessitating a targeted screening approach guided by information obtained at the death scene.

Introduction

In our experience illicit drug administration by intravenous injection may cause death due to a variety of mechanisms including central respiratory depression and cardiotoxicity. Sedation and respiratory depression are most often due to opiate drugs such as heroin and morphine resulting in lethal cerebral hypoxia. The history from witnesses is often of prolonged and deep sleep with snoring after drug administration, followed by failure to rouse and eventually death [1]. Alternatively, intravenous administration of an opioid drug may result in rapid death; the drug may be self-administered or used in a homicide. Amphetamines and other psychostimulants, such as cocaine, may also be injected and may cause hyperpyrexia or have a direct cardiotoxic action [2]. These drugs may also impair reflexes or lead to increased risk taking, both of which may predispose to traumatic deaths. Injected drugs may have an additive or synergistic effect with other drugs or alcohol that may have been previously or concurrently taken. The combined effects of a variety of drugs may also result in death from aspiration of gastric contents if emesis is stimulated and swallowing mechanisms are impaired.

Occasionally a case of witnessed intravenous drug administration occurs that is followed by collapse and rapid death where routine toxicological evaluation does not reveal common drugs of abuse. The details of such a case are reported involving the self-administration of what was thought by the user to be a ring derivative amphetamine.