A lethal case involving purple drank and Kratom

Aim

To report a case of death related to the consumption of purple drank and mitragynine. Case history: a 19-year-old man, with a history of depression, was found dead, sitting on his bed. His mother had taken him to the emergency services the previous evening for observation because he was not in a normal state. The investigation revealed a history of morphine, cannabis, ketamine, prazepam and hallucinogenic mushroom use. The cause of death is undetermined. Hospital and autopsy samples are sent to our forensic laboratory.

Method

A systematic toxicological analysis was carried out on biologicals fluids taken in hospital (blood and urine), as well as on the autopsy samples (blood, urine, gastric fluid and hair). Samples of blood, urine and gastric fluid were analysed by untargeted UPLC-QTOF for general screening after a protein precipitation using ice-cold acetonitrile. Targeted confirmation assays were also performed on blood and urine by UPLC-MS/MS after either a liquid-liquid extraction, a solid-phase extraction or a protein precipitation. Deuterated analogues are used for the quantification of blood samples. After washing, segmenting, pulverisation and extraction steps, the hair sample was analysed by untargeted UPLC-QTOF for general screening and targeted UPLC-MS/MS for confirmation assays.

Results

Our analyses pointed out infra-therapeutic (cranial) blood concentrations of ketamine (166 ng/mL) and mirtazapine (18 ng/mL), therapeutic blood concentrations of citalopram (111 ng/mL), pipamperone (188 ng/mL) and mitragynine (53 ng/mL), and a supra-therapeutic blood concentration of nordiazepam (1019 ng/mL). Moreover, codeine was measured in potentially lethal blood concentration (8695 ng/mL) together with promethazine, in a toxic blood concentration at the time of death (321 ng/mL). Hair analysis highlighted a chronic consumption of all these products over the last 10 months: ketamine > 5000 pg/mg, mirtazapine 36 to 104 pg/mg, citalopram 65 to > 250 pg/mg, pipamperone 285 to 7091 pg/mg, mitragynine 6 to 23 pg/mg, nordiazepam 902 to > 2500 pg/mg, codeine > 1250 pg/mg, promethazine 1798 to > 5000 pg/mg.

Conclusion

The diverted use of codeine in combination with promethazine, both found in the present case, is known as “purple drank”. This is a hallucinogenic cocktail that was made popular through American rappers and their social networks since years 2010. Acute intoxication may led to respiratory depression, drowsiness and even delirium. Chronic use carries the risk of dependence and even psychosis.

Mitragynine is the main alkaloid found in the leaves of mitragyna speciosa, a Southeast Asian plant known as “Kratom”. Its leaves are orally ingested, either directly (chewed or powdered) or indirectly (infused). It is used in high doses for its opium-like effects. In low doses, it has stimulant effects similar to those of the coca plant. It can also be used for opiate withdrawal.

The easy access to this type of products for young consumers is problematic. Although this case of death cannot be directly attributed to Kratom consumption, it demonstrates the value of using a good untargeted screening to start toxicological investigations with, and also developing specific LC-MS quantitative confirmatory methods.