X-amin Your Water!

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X-aminYourWater!

• A Toxicology Case Study

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Case History

• A 20-year-old female presented to ER confused and
  unresponsive to commands
• History revealed that patient had attended a
  nightclub and consumed several glasses of water,
  after which she appeared drunk
• Physical examination revealed hyperthermia,
  increased blood pressure, and elevated heart rate
• Urine specimen sent to Toxicology lab for analysis

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Questions to Consider

• What common club drugs might the patient have
  encountered in this situation?
• What method can be used in the Toxicology Lab to
  reliably screen for drugs in urine?
• What role does a Medical Technologist in the
  Toxicology Lab play in the care of this patient?

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Urine Drug Screen
Toxi-Lab

• Urine screening is performed using the ToxiLab
  Drug Detection System
• Utilizes thin-layer chromatography to identify
  over 700 substances in biological fluids

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Toxi-Lab? Procedure
The extracted drugs are concentrated onto discs
of chromatographic media though evaporation.
Drugs are extracted from the patient urine sample
using various organic solvents and buffers.
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Toxi-Lab? Procedure, cont.
The patient discs are then placed onto the center
of the Toxi-Lab? chromatogram.
Developing solution (ethyl acetate, methanol,
water, ammonium hydroxide) is added to the
chromatography jar.
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Toxi-Lab? Procedure, cont.
Drugs are drawn up through the chromatogram,
carried by the developing solution in the bottom
of the jar.
Drugs are fixed onto the chromatogram with
formaldehyde fumes
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Stage I

• Chromatogram is dipped in sulfuric acid
• Drugs are visualized as they develop color at
  their migration points
• Concentrated and dilute patient extraction are in
  left center and right center lanes respectively
• Colorful spots on sides of chromatogram are known
  drugs incorporated into the chromatogram for
  reference

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Stage II

• Chromatogram is dipped in deionized water
• Colors from the previous stage are rinsed away,
  leaving behind a new color pattern

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Stage III
Mercury Vapor UV Lamp

• Chromatogram placed under UV light to visualize
  fluorescence pattern of the drugs

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Stage IV

• Chromatogram is dipped in Dragendorffs Reagent
  (iodine bismuth subnitrate, potassium iodide)
• Certain drugs take up this stain
• The typical color seen is brown, but can range
  from rose to blue-grey

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Toxi?-Lab Interpretation

• The location and color of the patient spots
  from each stage of the procedure are marked in
  pencil on the Toxi-Lab worksheet.
• Recall, the color spots on the sides of each
  chromatogram are known drugs incorporated into
  the chromatogram for reference.

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Toxi?-Lab Interpretation

• Each stage of the Toxi?-Lab
  procedure is compared to pictures in a library
  (compendium) of known drugs
• The Med Tech examines the color and location of
  each spot to make a presumptive drug match
• This method takes skill and practice the colors
  are not always straightforward and drugs may
  overlap

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Toxi?-Lab Interpretation

• The Medical Technologist determined that two
  suspected drugs were present
• MDM - Methylenedioxymethamphetamine
• DXM - Dextromethorphan

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Interpretation Stage I
Patient Sample
Known DXM from Library
Known MDM from Library
dark blue
orange (hidden)
dark blue
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Interpretation Stage II
Patient Sample
Known DXM from Library
Known MDM from Library
brown
tan
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Interpretation Stage III
Patient Sample
Known DXM from Library
Known MDM from Library
dark absorbing spot
Orange center, yellow-green halo
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Interpretation Stage IV
Patient Sample
Known DXM from Library
Known MDM from Library
brown
brown
brown
(overlapping)
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Confirmatory Testing

• Drugs detected by the screen are confirmed with
  analysis by the combined Gas Chromatograph (GC) /
  Mass Spectrometer (MS)
• GC/MS detects the individual molecules of the
  drug.

A Medical Technologist injecting the extracted
sample into the GC/MS.
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Confirmatory Testing

• The Medical Technologist then compares the
  molecular pattern (or mass spectrum) to a
  computerized database of known spectra to
  identify the unknown substances in the urine
  sample.

A Med Tech performs confirmatory analysis using
the GC/MS.
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Mass Spectrum of MDMA
Patient Sample
Known MDM
Molecular Weight 279
Base Peak 144
Its a match!
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Final Report

• Methylenedioxymethamphetamine (MDM/MDMA)
• a.k.a. Ecstasy, X, Adam
• Sympathomimetic structure closely resembles
  neurotransmitters dopamine and norepinephrine
  (adrenaline) which acts as a stimulant
• Adverse effects hallucination, hyperthermia,
  anxiety, confusion, irreversible neural damage,
  death

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Final Report - continued

• Dextromethorphan (DXM)
• Antitussive - main ingredient in cough
  suppressants such as Nyquil and Robitussin
• Adverse effects of large doses hallucination,
  dizziness, confusion, depressed respiration,
  numbness, tremors, irregular heartbeat, death
• Used as a filler in drugs such as Ecstasy and
  heroin

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Patient Outcome

• Patient admitted to hospital for observation of
  heart rate and other symptoms
• Benzodiazepine, a sedative to relieve anxiety
  brought about by MDMA, was administered
• Patient recovered the following day
• Ecstacy was most likely slipped into the
  patients drink at the nightclub

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Role of the Medical Technologist

• DETECT Preliminary Toxi?-Lab screen
• IDENTIFY Confirmatory Gas Chromatography/Mass
  Spectrometry
• REPORT Aids physician in administering
  appropriate treatment

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Summary

• Patient presented in a confused, unresponsive
  state after dancing and consuming water at a
  nightclub
• Toxi?-Lab drug screen on urine revealed possible
  MDM/MDMA and DXM intoxication, also known as
  common club drugs
• Identification confirmed by GC/MS
• Patient treated accordingly and released

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References

• Ansys Technologies, Inc. Toxi-Lab Thin Layer
  Chromatography Products. http//www.ansysinc.com/
  toxi.html
• Hartstra, J. Computer-aided identification of
  toxicologically relevant substances by means of
  multiple analytical methods. University Library
  of Groningen. 1997. www.ub.rug.nl/eldoc/dis/scie
  nce/j.hartstra
• Toxi-Lab A Drug Detection System Instruction
  Manual, Varian, Inc. Proficiency Critique, Lot
  21201. 12-15-02.

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Credits

• This case study was prepared by
• Christina Pienkos, MT(ASCP) while she
• was a Medical Technology student in the 2004
  Medical Technology Class at
  William Beaumont
  Hospital, in Royal Oak, MI.