Fatal 5-APB and 5-APDB overdose: A case report with clinical, analytical and forensic documentation

Abstract

Objective 5-APB and 5-APBD belong to the benzofuran group of new psychoactive substances (NPS). Used for their entactogen and stimulant properties, benzofurans are related to phenethylamines and displayed sympathetic activity, with possible neurologic and cardiovascular complications [1] . We describe a fatal poisoning with 5-APB and 5-APDB as the only drugs involved. Case history A 25-year-old woman, with history of recreative ecstasy abuse, was referred to an emergency department (ED) after a malaise during a party. Her medical condition abruptly worsened with tonico-clonic seizure followed by a first resuscitated cardiorespiratory arrest. In intensive care unit, there was a major hemodynamic instability with hypotension and she experienced recurrent episodes of ventricular fibrillation with iterative cardiac arrests. She eventually died a few hours after admission in ED. According to friends, she consumed Ecstasy during the party. The autopsy showed non-specific signs of asphyxia, signs of multi-organ failure and of hemodynamic shock, without revealing any previous condition that may have contributed to the fatality. Cardiac/femoral blood, urine, vitreous humor, bile, gastric content and hair were collected for toxicological forensic analysis. Methods Immunoassay for amphetamine, methamphetamine, cocaine, opiates and cannabinoids was performed on urine. Identification and quantification of major amphetamine derivatives in blood was performed by GC-MS. General unknown screening (GUS) was performed on blood and gastric contents by GC-MS and LC-DAD after liquid-liquid extraction. 5-APB and 5-APDB were quantified in blood by GC-MS/MS, using MDA-d5 as internal standard, after assay validation for linearity, selectivity, limits of detection, precision and accuracy at 3 concentration levels. Blood ethanol/other volatile compounds analysis was performed on HS-GC-FID. Results Urine immunoassay was positive for amphetamine, but confirmation analysis for major amphetamine derivatives was negative. An APB isomer was detected on GUS by GC-MS. It was identified as 5-APB studying urine metabolites. A 2nd compound, 5-APDB, was highlighted in urine, with confirmation after 5-APDB commercial standard injection. 5-APB and 5-APDB respective peripheral blood/urine concentrations were as follows: 1429/34,469\xa0ng/mL and 111/3770\xa0ng/mL. No other drugs/toxins, including ethanol or volatile compounds, have been identified. Conclusion As far as we know, this is the first reported case with no other compound detected but benzofurans 5-APB and 5-APDB. The latter, suspected by McIntyre et al. [2] was formally identified without ruling out the hypothesis of a 5-APB metabolite or a synthesis/conditioning impurity.