Journal of Analytical Toxicology, Vol. 29, November/December 2005
[CaseReport
A Fatal Intoxication Following the Ingestion of
5-Methoxy-N,N-Dimethyltryptamine in an
Ayahuasca Preparation*
Jason Sklerov 1, Barry tevine 1,2,*, Karla A. Moore 2, Theodore King2, and David Fowler 2
I Division of Forensic Toxicology, Office of the Armed Forces Medical Examiner, 1413 Research Blvd., Rockville, Maryland
20850 and 2Office of the Chief Medical Examiner, State of Maryland, III Penn St., Baltimore, Maryland 21201
The ayahuasca brew is commonly prepared with the leaves of
I Abstract
A case of a 25-year-old white male who was found dead the
morning after consumingherbal extracts containing ~carholines
and hallucinogenictryptamines is presented. No anatomic cause of
death was found at autopsy. Toxicologicanalysisof the heart blood
identified N,N-dimethyltryptamine (0.02 mg/L), 5-methoxy-N,Ndimethyltryptamine (1.88 rag/L), tetrahydroharmine (0.38 rag/t),
harmaline (0.07 mg/L), and harmine (0.17 mg/L). All substances
were extracted by a single-stepn-butyl chloride extraction
following alkalinization with borate buffer. Detection and
quantitation was performed using liquid chromatographyelectrospray massspectrometry. The medical examiner ruled that
the causeof death was hallucinogenic amine intoxication, and the
manner of death was undetermined.
Introduction
Ayahuasca, also commonly known as yagg, hoasca, and
daime, refers to a decoction of the woodyvines of Banisteriopsis
caapi. The extract is prepared as a tea formulation, usually with
additional plant material containing psychoactive drugs.
Ayahuasca has a long history of use in various South American
medical and sacramental practices, and its use has expanded
into North America and Europe in recent years (1). The foundation of the ayahuasca beverage is the [3-carboline alkaloids:
harmine, harmaline, and tetrahydroharmine (THH) found in
B. caapi. Harmine and harmaline are competitive, reversibleinhibitors of monoamine oxidase type-A (MAO),whereas THH is
believed to inhibit presynaptic serotonin uptake (2). Harmine,
harmaline, and B. caapi extract have also demonstrated increased dopamine release in vitro (3). The harmala alkaloids
themselves have mild sedative effects, possibly through interaction with the benzodiazepine receptor (4).
* Disclaimer: The opinions or assertions contained herein are the private views of the authors
and are not to be construed as official or as reflecting the views of the Department of Defense
or of the Army, Navy, or Air Force.
t Author to whom correspondence should be addressed: Office of the Chief Medical Examiner,
111 Penn St., Baltimore, MD 21201.
838
Psychotriaviridis, which contains the U.S. Drug Enforcement
Administration Schedule I hallucinogen N,N-dimethyltryptamine (DMT), although nicotine, cocaine, atropine, and
other alkaloid combinations have been described (5). Hallucinogenic drugs are generally composed of two groups:
phenethylamines and indoleamines. DMT is the prototypical
drug of the tryptamine subgroup of the indoleamine hallucinogenic drug group. Other tryptamine derivativesthat have
been identified as hallucinogenic drugs include 5-methoxy-~methyltryptamine, ~-methyltryptamine, 5-methoxy-N,N-DMT
(5-MeO-DMT), N,N-diethyltryptamine, N,N-dipropyltryptamine, and 5-methoxy-N,N-diisopropyltryptamine.All of
these compounds have high affinityfor the serotonin 5-HT2 receptors; hallucinogenic potency is well correlated with the relative affinity of these compounds for the 5-HT2 receptor (6).
DMT and its analogues are metabolized by MAO in the liver.
When it is administered orally, first pass metabolism prevents
significant absorption of DMT. However,when taken as part of
an ayahuasca beverage, the presence of the harmala alkaloids
significantlyreduces the first-pass metabolism of DMT.As a resuit, more DMT is free to circulate to the central nervous
system where it binds to serotonergic receptors and exerts its
psychedelic effects (7). The onset of action of an ayahuasca
preparation is between 35 and 40 rain with effects felt for up to
3 or 4 h (8-10). Subjectiveeffectshave been reported to include
nausea, dose-dependent visual and auditory perception
changes, personal psychological introspection, increased alertness and stimulation, and changes in gauging the passing of
time (7,9,11). Cardiovascular effects have included moderate
increases in systolic/diastolic blood pressure and heart rate
(7,11) with only diastolic increases significant over placebo
(7).
We report a fatal case involving the recreational administration of an ayahuasca-like preparation containing 5-MeODMT. Quantitative measurements of 5-MeO-DMT, DMT,
harmine, harmaline, and THH are reported for postmortem
samples. 5-MeO-DMT has been reported to have greater potency than DMTwhen smoked (12). Presumably this translates
Reproduction(photocopying)of editorial contentof this journal is prohibitedwithout publisher'spermission.
Journal of Analytical Toxicology, Vol, 29, November/December 2005
to an equivalent potency difference when both are administered
orally in combination with a monoamine oxidase inhibitor.
This premise was advanced by the self-experimentation reported by Ott (8), which showed oral activity of 5-MeO-DMTat
lower doses than DMTwhen in the presence of identical harmaline doses.
Case History
A 25-year-old white male went camping with family and
friends in a national park. According to these individuals, he
drank some type of "herbal tonics" and went to sleep. He was
found dead the next morning. Subsequent investigation indicated that the decedent ingested a preparation from a South
American tree bark, "ooasca"(sic), and approximately 4 h later,
he ingested tryptamines.
An autopsy was performed the day after the body was discovered. External examination identified the presence of lividity
that was fixed on the posterior surface of the body, except in
areas exposed to pressure. The body was in full rigor. No
remarkable external findings were noted. Internal examinations, both gross and microscopic, were unremarkable except
for some tissue congestion and edema. Specimens were sent to
the laboratory for toxicologic analysis.
Experimental
Materials
DMT was obtained from the Drug Enforcement Administration central laboratory (Atlanta, GA). 5-MeO-DMT was
purchased over the internet from JMAR Chemical Corporation. Harmine hydrochloride, ammonium formate, 5-fluorotryptamine, and sodium borate decahydrate were obtained
from Sigma-Aldrich (St. Louis, MO). Harmaline hydrochloride was purchased from Acros Organics (Morris Plains, NJ),
and sodium borohydride was purchased from Fisher Scientific (Pittsburgh, PA).All solvents were high-performance liquid
chromatography (HPLC) grade and were purchased from
Fisher Scientific.
column compartment, diode-array detector (DAD), and fraction collector. An isocratic mobile phase of 25% acetonitrile,
75% 0.02M ammonium formate was used at a flow rate of 0.8
mL/min. The separation column was a Phenomenex ProdigyODS (150 x 4.6 mm, dp = 5 IJm) maintained at 35~ Timebased collections of the tetrahydroharmine peak were made,
and fractions were pooled after each injection. Pooled fractions
were alkalinized with ammonium hydroxide and extracted
into n-butyl chloride. The solvent was evaporated, and the
crystals were assayed for purity using the aforementioned
HPLC-DAD apparatus. The chromatographic purity of the
tetrahydroharmine was 87.4%, and its identity was verified
using the full scan mass spectrometry parameters listed
herein.
Sample preparation
Blood (central and peripheral), urine, gastric contents, bile,
kidney, brain, and liver were collected at autopsy and stored,
unpreserved, at-15~ Standard curves were prepared in blood
and urine at 0.010, 0.025, 0.050, 0.10, 0.50, 1.0, and 2.5 mg/L
for DMT,5-MeO-DMT,and harmine. Separate standard curves
were prepared for THH and harmaline due to the lower purity
of these standard reference materials.
A 5-fluorotryptamine internal standard was prepared at a
concentration of 0.01 mg/mL in methanol. One-milliliter volumes of blood, urine, bile, and gastric were initially assayed,
but final quantitation was based on respective dilutions of
each. Tissue samples (0.5 g) were homogenized in 3 mL of
saturated sodium borate buffer using a Brinkmann PT3000
tissue homogenizer (Westbury, NY). One-milliliter aliquots of
homogenate were extracted.
Samples and/or their dilutions were added to clean, labeled
16 x 100-mm tubes, and 2 mL saturated sodium borate was
added. Fifty microliters of the 5-fluorotryptamine internal
standard solution was added to each tube along with 2 mL of
n-butyl chloride. The tubes were capped and mixed for 10 min
on an orbital mixer. After centrifuging the tubes for 10 min at
3500 rpm, the solvent was transferred to 10-mL conical tubes,
a drop of 1% HCI in methanol was added, and the extracts
were evaporated to dryness under nitrogen at 40~ The sample
residue was reconstituted with 100 ~L of HPLC mobile phase
(75% 0.02M ammonium formate/25% acetonitrile) and transferred to autosampler vials. Two microliters was injected for
analysis.
Preparation of tetrahydroharmine
The synthesis of THH was based on a previously reported
method (13). Harmaline HCI (500 rag) was added to 50 mL of
methanol in a 0~ ice bath. The methanol was acidified by the
addition of 4M HCI, and sodium borohydride was slowly added
until the solution turned pale yellow and gas was no longer
formed. After 30 rain, the solution was alkalinized (pH > 10)
by the addition of 1N NaOH. The solution was extracted twice
with 10 mL of n-butyl chloride, and the solvent was transferred to a 100-mL beaker to evaporate at room temperature.
The resulting crude tetrahydroharmine crystals were dissolved
in methanol, and 100-BL portions were injected into an Agilent 1100 HPLC (Palo Alto, CA). The instrument consisted of
a vacuum degasser, quaternary pump, well-plate autosampler,
Instrumentation
Biological extracts were analyzed using an Agilent 1100
LC-mass selective detector (SL) equipped with an orthogonal
electrospray ionization interface. Separation was performed
using an XTerra| MS-C18 column (100 x 3.0 mm, dp = 3.5 Bin,
Waters, Milford, MA) held at 35~ The mobile phase consisted
of 0.02M ammonium formate (75%) and acetonitrile (25%) at
a flow rate of 0.4 mL/min.
The positive, pseudomoIecular ions of DMT (m/z 189), 5MeO-DMT (m/z 219), 5-FT (ISTD, m/z 179), THH (m/z 217),
harmaline (m/z 215), and harmine (m/z 213) were formed by
electrospray ionization and selectively monitored for quantitation. Pneumatic-assisted nebulization utilized nitrogen at
839
Journal of Analyti( al Toxicology, Vol. 29, November/December 2005
30 psi, and 350~ nitrogen drying gas was used at a flow of 12
L/rain. Full scan mass spectra were also acquired at three separate capillary exit voltages (100, 150, 200V) over the mass
range m/z 100--400. The fragmentation patterns were compared to those of the drug standards for confirmatory identification.
Results
The heart blood and urine specimens from this case were
tested for volatile substances and therapeutic and abused drugs.
This included volatile testing for methanol, ethanol, acetone,
and isopropanol by headspace gas chromatography (GC);
~EG
M 6 1 ~ 219. E I I C ~ 1L'~'.219k'r
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M S I ~ 189. E I ~ : l I ~ . ' ~ . l l J S . 7
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-OMT
+
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,
MSCG 171. EJC:171k'~.lTY.7
~ G ( 3 l " t ~ E I O : 1YS.'r:. l"~m~?"
~.~. a.rr (mTD)
.
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+
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l~-5 D3 217. EIC=216.7:217.7
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-
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IV~i C~. Z17. EJI~:21 @7 ~ 17.T
2~ t2 .
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P~..~D~ Z I ~ . E ~ = 2 1 ~ . 7 ~ 1 5 - 7
M 3 D 3 21~. EJC::212.7:213.7
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acid/neutral drug testing by GC-nitrogen-phosphorus detection (NPD); alkaline drug testing by GC-NPD: morphine by
radioimmunoassay;and acetaminophen and salicylateby color
test. No ethanol or other volatile substances were detected in
the case. Diphenhydramine was detected in the urine; no
diphenhydramine was detected in the blood at a limit of quantitation of 0.05 mg/L. In addition, an unidentified peak was detected in both the blood and urine on the alkaline drug screen
that eluted around chlorpheniramine. Subsequent mass spectral analysis tentatively identified the substance as 5-MeODMT (14). This was verified when an authentic drug standard
was subjected to the same extraction, chromatographic, and
mass spectral conditions.
Table I lists the distribution of the tryptamines and [3-carbolines in the specimens, and Figure 1 shows representative
chromatograms of the heart blood
sample and a negative blood control.
Quantitative values were calculated by
multi-point, linear regression of the
peak-area ratio of individual compounds
to that of the 5-FT internal standard.
Regression lines for the five analytes'
standard curves were between 0.989
and 0.999. The limits of detection, quantitation, and linearity for all drugs were
0.005, 0.01, and 2.5 mg/L, respectively.
All of the analytes were identified in
the specimens except for DMT, which
was not present in the brain, kidney,
or liver. In samples where DMT and
5-MeO-DMT were both measured, 5MeO-DMTwas present at higher concentrations. THH was present in higher
amounts than both harmaline and
harmine in all samples with the exception of the gastric contents, where
the amount of harmine was 10-fold
greater than that of THH.
-
~. ....
,
.
.
.
~ ....
.
,
.
.
.
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~ ....
Time(rain)
Figure 1. Extracted ion chromatograms of the heart blood sample containing 5-MeO-DMT (1.88 mg/L),
DMT (0.02 mg/L), 5-FT (internal standard), THH (0.38 mg/L), harmaline (0.07 mg/L), and harmine
(0.17 llg/L/ (A) and a negative blood sample (B).
Discussion
To the authors' knowledge, this is the
only reported case of death following
Table I Toxicological Findings in the Presented Case
Substance
DMT
5-MeO DMT
Tetrahydroharmine
Harmaline
Harmine
* ND+ none detected.
840
Heart Blood
(mg/L)
PeripheralBlood
(mg/t)
Gastric
(mg/t)
Bile
(mg/L)
Brain
(mg/kg)
Kidney
(mg/kg)
Liver
(mg/kg)
Urine
(rag/L)
0.02
1.88
0.38
0.07
0.17
0.01
1.20
0.24
0.04
0.08
3.3
201.6
12.5
6.4
121.9
0.57
9.81
4.78
0.41
1.64
ND*
0.15
0.43
0.04
0.16
ND
22.8
6.89
2.24
0.74
ND
16.38
13.24
3.6
2.31
0.89
9.59
6.02
2.26
1.15
Journal of Analytical Toxicology, Vol. 29, November/December2005
ingestion of hallucinogenic tryptamines contained in an
ayahuasca preparation. Morano et al. (15) reported a fatal case
of ethyltryptamine intoxication in a 19-year-old female who
consumed a beer allegedly containing Ecstasy. The heart blood
concentration in this case was 5.6 mg/L. In addition, methamphetamine (0.12 rag/L) and amphetamine (0.05 rag/L) were
detected. Warren (16) presented an acute nicotine intoxication
resulting in death following ayahuasca ingestion during a
healing ritual. Harmine and harmaline presence were reported in the ayahuasca brew.
In addition to fatalities from these preparations, there have
also been several non-fatal intoxications from hallucinogenic
tryptamine use. Meatherall and Sharma (17) published a case
report of a 21-year-old male who ingested 5-methoxy-NjV-diisopropyltryptamine, also known as "Foxy."A urine concentration of 1.7 mg/L was measured. A metabolite, 5-methoxy-indoleacetic acid (1.3 rag/L) was also detected. Within 4 h of
oral ingestion, the hallucinations stopped and the patient was
discharged from the hospital. Another nonfatal case of 5methoxy-N,N-diisopropyltryptamine was reported by Vorce
and Sklerov (18); the urine concentration was 0.229 mg/L. In
addition, a monoisopropyl metabolite was tentatively identified.
A single case of intoxication in a 17-year-old college student
was reported after the ingestion of the extract of three
Peganum harmala seeds and a combined smoked and snorted
dose of 25-30 mg of 5-MeO-DMT (19). This was accompanied
by emesis, hyperthermia, increased heart rate, and rhabdomyolysis. However,in this case, only harmine and harmaline were
detected in urine.
Oral dosing of 15 volunteers with a traditional ayahuasca
preparation was reported by Callaway et al. (13). Average doses,
based on a 59-kg individual, were 28.8, 204, 24, and 128.4 mg
for DMT,harmine, harmaline, and THH, respectively.The DMT
plasma range reported for this trial was 0.011-0.025 mg/L,
which is similar to both central and peripheral values for this
case. Plasma carboline concentrations were given in the following ranges: THH, 0.049-0.134 rag/L; harmaline, <
0.001-0.009 mg/L; and harmine, 0.036-0.222 mg/L. The present case had all three alkaloids near or above these upper
ranges with the largest difference seen for THH. In this report,
the unknown interval between dosing and death and the large
concentrations found in both urine and gastric contents make
it impossible to put the values in any context of peak concentrations.
The medical examiner ruled that the cause of death in this
case was hallucinogenic amine intoxication, and the manner of
death was undetermined.
Acknowledgments
The authors would like to thank Dr. Jerry Zweigenbaum of
Agilent Technologies for the loan of the HPLC fraction collector.
This work was funded in part by the American Registry of
Pathology, Washington, D.C. 20306-6000.
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Manuscript received November 29, 2004;
revision received March 18, 2005.
841