37
Forensk Science International, 56 (1992) 37 - 43 Elsevier Scientific Publishers Ireland Ltd.
A FATAL CASE OF POISONING WITH CANTHARIDIN
A. POLETTINP’, 0. CRIPPAa, A. RAVAGLIb and A. SARAGONIC Vhair of Fortmsic Toxicolqy, Institute of Legal Medicine, University of Patia, Medicine Service and ‘Pathobgy Service, G.B. Morgagni Hospita& ForU (Italy)
Pavia, *Legal
(Received January 22nd, 1992) (Revision received March 27th, 1992) (Accepted May 19th, 1992)
Summary A case of fatal poisoning due to voluntary ingestion of cantharides powder for aphrodisiac purposes is reported. Clinical history, autopsy and analytical findings are described. Blood and urine samples collected during the 30 h of survival, as wel1 as the cantharides product, were analyzed by gas chromatography-mass spectrometry. On the basis of the percentage of the active principle measured in the powder, an ingested dose of 26-45 mg of cantharidin could be estimated. Key words: Poisoning; trometry
Cantharidin;
Ingestion;
Bioanalysis;
Gas Chromatography;
Mass Spec-
Introduction Since ancient times, cantharides (the blister beetle Cunthuris vesicatoria) are alleged to be aphrodisiacs. The crude drug, consisting of powdered dried insects, has a highly irritant action and, if swallowed, produces congestion of the urethra1 mucosa, which may result in priapism in men and pelvic congestion in women [ll. The toxic principle is cantharidin (hexahydro-3ao,7acY-dimethyl-4/3,7/3-epoxyisobenzofuran-l,ô-dione), which the crude drug contains in concentrations ranging from 0.6% to 5.4% [2,3] and whose lethal dose in man is estimated to be between 10 and 60 mg [4]. NO information about the kinetics and the metabolic fate of cantharidin can be found in the literature. Fatalities in humans, due to voluntary or accidental ingestion of cantharides, or of other cantharidin-yielding beetles, are seldom reported [5- 91; however, some non-fata1 cases of intoxication are referred to [lO- 141. The analysis of cantharidin in biological specimens is accomplished by high pressure liquid chromatography, with previous derivatization 131, or by gas chromatography (GC) [8,15-191. Most recently, high resolution GC, coupled with flame ionization detection [8,16,17], or with mass spectrometry (MS) [8,X3,19], was the technique of choice. Besides some papers dedicated to the analysis of urine and tissues of animals (horses, sheep) which ingested alfalfa hay 0379-0738/92/$05.00
0 1992 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
38
contaminated with blister beetles [18,20], there is a paucity of data regarding the concentration of cantharidin in the blood and urine of intoxicated humans [8,9]. The present paper concerns a case of poisoning due to voluntary ingestion of cantharides powder for aphrodisiac purposes leading to death, despite intensive care. We analysed samples of biological fltids collected during the 30 h of surviva1 after the ingestion. A sample of the powder swallowed by the victim was also available for analysis. Case
report
A 38-year-old trade agent took a cup of tea laced with three teaspoonsful of cantharides powder, in order to draw some aphrodisiac effects. Almost immediately, he felt burnings at the tongue and the pharynx, intense disphagia and sialorrhea. A few minutes later, retrosternal pyrotic pain, gastric spasm and vomiting joined. About 1 h after the ingestion of the tea, he was hospitalized. At the admission, he was lucid and co-operative, with intact sensorium and spontaneous and regular breathing. The blood pressure was 130/70 mmHg; the heart rate was 100 beatslmin. He presented the above-mentioned symptomatology and severe caustic lesions at the mouth and the pharynx. Some clear urine was spontaneously voided. The biochemical parameters already indicated renal damage in progress. Early oral therapy with a demulcent drink was unsuccessful, owing to the difficulty of deglutition. A 2h charcoal hemoperfusion could not relieve the toxic syndrome. Continuous fluid infusion failed to maintain the circulation. The patient became progressively anuric and comatose, with ingravescent biochemical signs of renal and hepatic damage and finally developed a strong tendency to bleeding. Despite the intensive treatment, he collapsed and died about 30 h after the ingestion of the poison. At the autopsy, the most significant findings were the necrotic-hemorragie lesions at the mucosa of the oral cavity, pharynx, oesophagus and, to a lesser extent,.of the stomach and duodenum. Moreover, a severe nephrotic picture was observed. Materials and Methods Biologica samples
The biological samples available for the toxicological analyses consisted of: -
-
specimens of whole blood, collected at 10, 20 and 30 h after the ingestion of the cantharides powder (the patient died a few minutes after the collection of the 30-h sample); specimens of a few milliliters of hematic urine, collected by catheter at 6, 10, 20 and 30 h; an unweightable amount of vomit, emitted at 12 h.
The cantharides powder ingested by the decedent was a brown coarse powder containing smal1 translucent flakes.
39
Extraction procedures
Each specimen required a different extraction procedure. The vomit was only subjected to qualitative analysis, owing to its minimum amount. Al1 the other samples were subjected to quantitative analysis. Blood
To 0.5 ml of blood, 100 ng of internal standard (benzophenone, 0.01 mg/ml in methanol), 0.1 ml of concentrated hydrochloric acid and 1 ml of acetonitrile were added. After vortexing (1 min) and centrifuging (1000 x g, 5 min), the supernatant was collected and passed through an Extrelut column (2 g). Fifteen minutes later the column was eluted with dichloromethane and the first 5 ml were collected and concentrated to about 50 ~1under a nitrogen flow. A volume of 2 ~1 was injected in the gas chromatograph. The reference sample consisted of blank whole blood (0.5 ml) spiked with 200 ng of cantharidin (0.01 mg/ml, in methanol).
To 0.5 ml of urine 100 ng of the internal standard, 0.05 ml of concentrated hydrochloric acid and 5 ml of n-hexane were added. The sample was vortexed and the organic layer, collected after centrifugation, was concentrated to about 100 pl. A volume of 1 ~1was injected in the gas chromatograph. Two reference samples were prepared by spiking blank urine samples with 750 and 400 ng of cantharidin, respectively. vomìt
The test tube containing traces of vomit was washed with bidistilled water (3 x 1 ml), which was then subjected to the same extraction procedure used for urine. Cantharides powokr
A 50-mg quantity of the cantharides powder was extracted with a chloroform solution of the internal standard (benzophenone, 0.1 mg/ml). After vortexing (5 min) and filtration through a paper filter, the organic solution was diluted 1:lO with chloroform and 0.5-~1 vols. were injected in the gas chromatograph. The cahbrator was a solution of cantharidin (0.1 mg/ml) and benzophenone (0.1 mglml) in chloroform. The analysis was done in triplicate. Analysìs
The gas chromatograph was a Hewlett-Packard 5890A, equipped with a HP 5970 mass selective detector and a HP 59970 MS Chemstation. The fused silica capillary column (HP Ultra 2, 12 m x 0.2 mm internal diameter) was coated with SE-54 (0.33 Pm film thickness). The column temperature was programmed from 70°C to 290°C at 2O’Clmin (1.5 min initial isotherm and 3.5 min final isotherm). The injector (splitless, 1.5 min) was maintained at 250°C and the interface at 280°C. The carrier gas was helium, flowing at 0.8 ml/min. For identification purposes, in the case of vomit, urine and powder, the detector operated in full scan mode @om mix 35 to mlz 210). Quantitative analyses
40 TABLE 1 BLOOD AND URINE CONCENTRATIONS
OF CANTHARIDIN
Time (h)
Blood (mg/l)
Urine (mg/I)
6 10 20 30
0.29 0.18 0.15
2.35 1.12 0.59 0.38
Ion
182.00
amu.
2.0E5
from
D-40:C A
1
2.0E5
1.5E5
1 .5E5
1.0E5 5.0E4
Ion 2.0E5
2 /
1.0E5
/
182.00
E
amu.
from
D-40:C
B
i
5.0E4
2.0E5 1.5E5 1.0E5 5.0E4
Ion
182.00
amu.
from
D-40:C
2.0E5 1.5E5 1.0E5 5.0E4 7.5 Time
8.0 (min.
1
Fig. 1. Gas chromatogram (A) obtained from the urine sample collected at 6 h and mass spectrum (B) of the peak identified as cantharidin.
41
in blood, urine and powder were performed monitoring the following ions of the electron impact (EI) maas spectra: mlz 79, 96 and 128 for cantharidin; mlz 105, 152 and 182 for the internal standard. Results and Discussion
Blood and urine concentrations of cantharidin measured at 6, 10,20 and 30 h after ingestion are summarized in Table 1. The poison was also detected in the vomit collected at 12 h. The percentage of cantharidin in the powder averaged 1.3%.
Figure 1 shows the gas chromatogram of the urine sample collected 6 h after the ingestion of the poison (A) and the mass spectrum of the peak identified as cantharidin (B). Figure 2 gives the GC-MS responses for (A) the urine sample collected at 30 h, (B) a blank urine sample spiked with 0.4 mg/l of cantharidin and (C) a blank urine sample. According to the available information, the ingested dose of cantharides powder was estimated in the range 2 - 3.5 g (approximately the weight of three teaspoonsful of powder), corresponding to 26-45 mg of cantharidin. These
86
Scan :
1.5E5
: u
1.0E5
5
5.0E4
L
(7.358
min)
of
LI-40:CAN-UR /
128
100
120
0
40
B
60
80
MassYCharge TIC
of
D-40:
CAN-UR-8.
D
0
1 .0E6: 8.0E5:
4.0E5, 2.0E5:
1
9 :0 Time
(min.
>
Fig. 2. Reconstructed ion chromatograms (mlz 128 and 182 added) obtained from (A) urine sample collected at 20 h, (B) a blank urine sample spiked with 0.4 mg/l of cantharidin and (C) a blank urine sample. Peaks: 1 = cantharidin; 2 = internal standard.
values are in good agreement with the estimated lethal dose of cantharidin in man: 10 - 60 mg [4]. The quantitative analysis of cantharidin in biological fluids revealed that considerable amounts of the unmodified compound were stil1 detectable 30 h after the ingestion, i.e. a few minutes before death. At this time, in fact, less than 50% of the poison detected at 10 h had been eliminated from the blood. Whether the observed slow removal of the poison may be ascribed to its own persistance in the tissues, or to the hepatic and renal failure only, is not known, due to the lack of information about both the kinetics and the metabolism of cantharidin. Post mortem blood concentrations of 0.11 mg/l and of 0.072 mg/l were detected in two reported lethal poisonings [8,9]. Chen et al. [8], in particular, refer a case showing some similarities with the one described here. Two days after the ingestion of an infusion of over 200 dried insects (Mylabrk phakratu) in an attempt to induce abortion, a woman died, despite appropriate intensive treatment. Ante mortem levels of cantharidin in blood and urine were 0.27 and 4.45 mg/l, respectively. The post mortem blood leve1 was 0.11 mg/l and the liver concentration was 1.24 mg/kg. The case described here stresses the lethal risk connected to the ingestion of cantharides powder in view of the high toxicity and the variable percentage of its active principle. As regards the use of cantharidin for the enhancement of sexual activity, the sale in many sex-shops of pseudo-pharmaceutical products (as drops, ointments and capsules) supposedly containing cantharidin, gives credit to the alleged aphrodisiac properties of this compound. Though cantharidin is usually contained in these products in homeopathie dilutions, their foreseeable lack of activity could induce someone to turn to the more potent cantharides powder to obtain the desired effect. References 1 2 3
4 5 6 7 8 9 10 11
A.G. Vult.0 and P.A.G.M. de Smet, Drugs used in non-orthodox medicine. In M.N.G. Dukes (ed.), MeyWs Side Effects of Drugs, 11th edn., Elsevier, Amsterdam, 1988, p. 1022. Martivw!u.b,The Extra Pharmacopoeia, 29th edn., J.E.F. Reynolds (ed.), The Pharmaceutical Press, London, 1989, p. 1554. A.C. Ray, S.H. Tamuhnas and J.C. Reagor, High pressure liquid chromatographic determination of cantharidin, using a derivatization method in specimens from animals acutely poisoned by ingestion of blister beetles, Epicauta lemniscata. Am. J. Vet. Res., 40 (1979) 498 - 504. Clurìce’s Isolutian and Zclent$ìcatti of Drugs in PharmocaLttials, Body Fluids and Postmortem Material, 2nd edn., The Pharmaceutical Press, London, 1986, pp. 425-426. L.C. Nickolls and D. Teare, Poisoning by cantharidin. Br. Med. J., 2 (1954) 1384-1386. J.D. Craven and A. Polak, Cantharidin poisoning. Br. Med. J., 2 (1954) 1386 - 1388. M.M.L. Dérobert and R. Le Breton, Intoxication aiguë par ingestion de poudre de cantharides. Ann. Mdd. Lbg., 3’7 (1957) 41-42. K. Cheng, H. Lee, S.F.B. Shum and C.P.D. Yip, A fatahty due to the use of cantharides from Mylabrk phalerata as an abortifacient. Med. Sci. Law, 30 (1990) 336 - 340. H.K. Hundt, J.M. Steyn and L. Wagner, Post-mortem serum concentration of cantharidin in a fataI case of cantharides poisoning. Hum. Ezp. Toxicol., 9 (1990) 35-40. Wertelecki, T.J. Vietti and P. KuIapongs, Cantharidin poisoning from ingestion of a “blister beetle”. Pediatrics, 39 (1967) 287-289. A.J. Presto and E.C. Muecke. A dose of spanish fly. J. Am. Med. Assoc., 214 (1970) 591-592.
43 12 13 14
15
16 17 18 19 20
R.D. Rosin, Cantharides intoxication. Br. Med. J., 4 (1967) 33. J. Harrisberg, J.C. Desem, L. Cohen, J. Tamlett and F.J. Milne, Cantharidin poisoning with neurological complications. 5’. Afr. Med. J., 65 (1984) 614-615. W. Tenschert, T. Behrenbeck, N. Rolf, J. Ahlmann, B. Winterberg, J. Heepe, A.E. Lison and H. Zumkley, Cantharidin poisoning. Transitory impairment of kidney function and hemorrhagic cystitis. Forkxhr. Med., 105 (1987) 686 - 688. F. Martens, M. Martens, T. Soylemezoglu and A. Heyndrickx, Determination of cantharidin in urine by nitrogen flame ionisation detection, gas liquid chromatography and mass fragmentography. Proceedings of the Centenn~ Meeting of tb International Association of Forensic Totiobgists, Ghent, Belgium, August 26-28, 19’76, p. 14. F. Mari, E. Bertol, 1. Volpato, M. Tosti and G. Orralesi, The detection of cantharidin in biological specimens. J. Anal. TokcoL, 3 (1979) 264-265. J.E. Carrel, Quantitative determination of cantharidin in biological materials using capillary gas chromatography with flame ionization detection. J. Chromatogr., 342 (1985) 411-415. A.C. Ray, L.O. Post and J.C. Reagor, GC-MS confirmation of cantharidin toxicosis due to ingestion of blister beetles. Vet. Hum. Toxicol., 22 (1980) 398-399. J.M. Steyn and H.K.L. Hundt, Gas chromatographic-mass spectrometric method for the quantitation of cantharidin in human serum. J. Chromatogr., 432 (1988) 177- 184. A.C. Ray, L.O. Post, J.M. Humt, W.C. Edwards and J.C. Reagor, Evaluation of an analytical method for the diagnosis of cantharidin toxicosis due to ingestion of blister beetles (Epicauta kmniscata) by horses and sheep. Am. J. Vet. Res., 41 (1980) 932-933.
Forensk Science International, 56 (1992) 37 - 43 Elsevier Scientific Publishers Ireland Ltd.
A FATAL CASE OF POISONING WITH CANTHARIDIN
A. POLETTINP’, 0. CRIPPAa, A. RAVAGLIb and A. SARAGONIC Vhair of Fortmsic Toxicolqy, Institute of Legal Medicine, University of Patia, Medicine Service and ‘Pathobgy Service, G.B. Morgagni Hospita& ForU (Italy)
Pavia, *Legal
(Received January 22nd, 1992) (Revision received March 27th, 1992) (Accepted May 19th, 1992)
Summary A case of fatal poisoning due to voluntary ingestion of cantharides powder for aphrodisiac purposes is reported. Clinical history, autopsy and analytical findings are described. Blood and urine samples collected during the 30 h of survival, as wel1 as the cantharides product, were analyzed by gas chromatography-mass spectrometry. On the basis of the percentage of the active principle measured in the powder, an ingested dose of 26-45 mg of cantharidin could be estimated. Key words: Poisoning; trometry
Cantharidin;
Ingestion;
Bioanalysis;
Gas Chromatography;
Mass Spec-
Introduction Since ancient times, cantharides (the blister beetle Cunthuris vesicatoria) are alleged to be aphrodisiacs. The crude drug, consisting of powdered dried insects, has a highly irritant action and, if swallowed, produces congestion of the urethra1 mucosa, which may result in priapism in men and pelvic congestion in women [ll. The toxic principle is cantharidin (hexahydro-3ao,7acY-dimethyl-4/3,7/3-epoxyisobenzofuran-l,ô-dione), which the crude drug contains in concentrations ranging from 0.6% to 5.4% [2,3] and whose lethal dose in man is estimated to be between 10 and 60 mg [4]. NO information about the kinetics and the metabolic fate of cantharidin can be found in the literature. Fatalities in humans, due to voluntary or accidental ingestion of cantharides, or of other cantharidin-yielding beetles, are seldom reported [5- 91; however, some non-fata1 cases of intoxication are referred to [lO- 141. The analysis of cantharidin in biological specimens is accomplished by high pressure liquid chromatography, with previous derivatization 131, or by gas chromatography (GC) [8,15-191. Most recently, high resolution GC, coupled with flame ionization detection [8,16,17], or with mass spectrometry (MS) [8,X3,19], was the technique of choice. Besides some papers dedicated to the analysis of urine and tissues of animals (horses, sheep) which ingested alfalfa hay 0379-0738/92/$05.00
0 1992 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
38
contaminated with blister beetles [18,20], there is a paucity of data regarding the concentration of cantharidin in the blood and urine of intoxicated humans [8,9]. The present paper concerns a case of poisoning due to voluntary ingestion of cantharides powder for aphrodisiac purposes leading to death, despite intensive care. We analysed samples of biological fltids collected during the 30 h of surviva1 after the ingestion. A sample of the powder swallowed by the victim was also available for analysis. Case
report
A 38-year-old trade agent took a cup of tea laced with three teaspoonsful of cantharides powder, in order to draw some aphrodisiac effects. Almost immediately, he felt burnings at the tongue and the pharynx, intense disphagia and sialorrhea. A few minutes later, retrosternal pyrotic pain, gastric spasm and vomiting joined. About 1 h after the ingestion of the tea, he was hospitalized. At the admission, he was lucid and co-operative, with intact sensorium and spontaneous and regular breathing. The blood pressure was 130/70 mmHg; the heart rate was 100 beatslmin. He presented the above-mentioned symptomatology and severe caustic lesions at the mouth and the pharynx. Some clear urine was spontaneously voided. The biochemical parameters already indicated renal damage in progress. Early oral therapy with a demulcent drink was unsuccessful, owing to the difficulty of deglutition. A 2h charcoal hemoperfusion could not relieve the toxic syndrome. Continuous fluid infusion failed to maintain the circulation. The patient became progressively anuric and comatose, with ingravescent biochemical signs of renal and hepatic damage and finally developed a strong tendency to bleeding. Despite the intensive treatment, he collapsed and died about 30 h after the ingestion of the poison. At the autopsy, the most significant findings were the necrotic-hemorragie lesions at the mucosa of the oral cavity, pharynx, oesophagus and, to a lesser extent,.of the stomach and duodenum. Moreover, a severe nephrotic picture was observed. Materials and Methods Biologica samples
The biological samples available for the toxicological analyses consisted of: -
-
specimens of whole blood, collected at 10, 20 and 30 h after the ingestion of the cantharides powder (the patient died a few minutes after the collection of the 30-h sample); specimens of a few milliliters of hematic urine, collected by catheter at 6, 10, 20 and 30 h; an unweightable amount of vomit, emitted at 12 h.
The cantharides powder ingested by the decedent was a brown coarse powder containing smal1 translucent flakes.
39
Extraction procedures
Each specimen required a different extraction procedure. The vomit was only subjected to qualitative analysis, owing to its minimum amount. Al1 the other samples were subjected to quantitative analysis. Blood
To 0.5 ml of blood, 100 ng of internal standard (benzophenone, 0.01 mg/ml in methanol), 0.1 ml of concentrated hydrochloric acid and 1 ml of acetonitrile were added. After vortexing (1 min) and centrifuging (1000 x g, 5 min), the supernatant was collected and passed through an Extrelut column (2 g). Fifteen minutes later the column was eluted with dichloromethane and the first 5 ml were collected and concentrated to about 50 ~1under a nitrogen flow. A volume of 2 ~1 was injected in the gas chromatograph. The reference sample consisted of blank whole blood (0.5 ml) spiked with 200 ng of cantharidin (0.01 mg/ml, in methanol).
To 0.5 ml of urine 100 ng of the internal standard, 0.05 ml of concentrated hydrochloric acid and 5 ml of n-hexane were added. The sample was vortexed and the organic layer, collected after centrifugation, was concentrated to about 100 pl. A volume of 1 ~1was injected in the gas chromatograph. Two reference samples were prepared by spiking blank urine samples with 750 and 400 ng of cantharidin, respectively. vomìt
The test tube containing traces of vomit was washed with bidistilled water (3 x 1 ml), which was then subjected to the same extraction procedure used for urine. Cantharides powokr
A 50-mg quantity of the cantharides powder was extracted with a chloroform solution of the internal standard (benzophenone, 0.1 mg/ml). After vortexing (5 min) and filtration through a paper filter, the organic solution was diluted 1:lO with chloroform and 0.5-~1 vols. were injected in the gas chromatograph. The cahbrator was a solution of cantharidin (0.1 mg/ml) and benzophenone (0.1 mglml) in chloroform. The analysis was done in triplicate. Analysìs
The gas chromatograph was a Hewlett-Packard 5890A, equipped with a HP 5970 mass selective detector and a HP 59970 MS Chemstation. The fused silica capillary column (HP Ultra 2, 12 m x 0.2 mm internal diameter) was coated with SE-54 (0.33 Pm film thickness). The column temperature was programmed from 70°C to 290°C at 2O’Clmin (1.5 min initial isotherm and 3.5 min final isotherm). The injector (splitless, 1.5 min) was maintained at 250°C and the interface at 280°C. The carrier gas was helium, flowing at 0.8 ml/min. For identification purposes, in the case of vomit, urine and powder, the detector operated in full scan mode @om mix 35 to mlz 210). Quantitative analyses
40 TABLE 1 BLOOD AND URINE CONCENTRATIONS
OF CANTHARIDIN
Time (h)
Blood (mg/l)
Urine (mg/I)
6 10 20 30
0.29 0.18 0.15
2.35 1.12 0.59 0.38
Ion
182.00
amu.
2.0E5
from
D-40:C A
1
2.0E5
1.5E5
1 .5E5
1.0E5 5.0E4
Ion 2.0E5
2 /
1.0E5
/
182.00
E
amu.
from
D-40:C
B
i
5.0E4
2.0E5 1.5E5 1.0E5 5.0E4
Ion
182.00
amu.
from
D-40:C
2.0E5 1.5E5 1.0E5 5.0E4 7.5 Time
8.0 (min.
1
Fig. 1. Gas chromatogram (A) obtained from the urine sample collected at 6 h and mass spectrum (B) of the peak identified as cantharidin.
41
in blood, urine and powder were performed monitoring the following ions of the electron impact (EI) maas spectra: mlz 79, 96 and 128 for cantharidin; mlz 105, 152 and 182 for the internal standard. Results and Discussion
Blood and urine concentrations of cantharidin measured at 6, 10,20 and 30 h after ingestion are summarized in Table 1. The poison was also detected in the vomit collected at 12 h. The percentage of cantharidin in the powder averaged 1.3%.
Figure 1 shows the gas chromatogram of the urine sample collected 6 h after the ingestion of the poison (A) and the mass spectrum of the peak identified as cantharidin (B). Figure 2 gives the GC-MS responses for (A) the urine sample collected at 30 h, (B) a blank urine sample spiked with 0.4 mg/l of cantharidin and (C) a blank urine sample. According to the available information, the ingested dose of cantharides powder was estimated in the range 2 - 3.5 g (approximately the weight of three teaspoonsful of powder), corresponding to 26-45 mg of cantharidin. These
86
Scan :
1.5E5
: u
1.0E5
5
5.0E4
L
(7.358
min)
of
LI-40:CAN-UR /
128
100
120
0
40
B
60
80
MassYCharge TIC
of
D-40:
CAN-UR-8.
D
0
1 .0E6: 8.0E5:
4.0E5, 2.0E5:
1
9 :0 Time
(min.
>
Fig. 2. Reconstructed ion chromatograms (mlz 128 and 182 added) obtained from (A) urine sample collected at 20 h, (B) a blank urine sample spiked with 0.4 mg/l of cantharidin and (C) a blank urine sample. Peaks: 1 = cantharidin; 2 = internal standard.
values are in good agreement with the estimated lethal dose of cantharidin in man: 10 - 60 mg [4]. The quantitative analysis of cantharidin in biological fluids revealed that considerable amounts of the unmodified compound were stil1 detectable 30 h after the ingestion, i.e. a few minutes before death. At this time, in fact, less than 50% of the poison detected at 10 h had been eliminated from the blood. Whether the observed slow removal of the poison may be ascribed to its own persistance in the tissues, or to the hepatic and renal failure only, is not known, due to the lack of information about both the kinetics and the metabolism of cantharidin. Post mortem blood concentrations of 0.11 mg/l and of 0.072 mg/l were detected in two reported lethal poisonings [8,9]. Chen et al. [8], in particular, refer a case showing some similarities with the one described here. Two days after the ingestion of an infusion of over 200 dried insects (Mylabrk phakratu) in an attempt to induce abortion, a woman died, despite appropriate intensive treatment. Ante mortem levels of cantharidin in blood and urine were 0.27 and 4.45 mg/l, respectively. The post mortem blood leve1 was 0.11 mg/l and the liver concentration was 1.24 mg/kg. The case described here stresses the lethal risk connected to the ingestion of cantharides powder in view of the high toxicity and the variable percentage of its active principle. As regards the use of cantharidin for the enhancement of sexual activity, the sale in many sex-shops of pseudo-pharmaceutical products (as drops, ointments and capsules) supposedly containing cantharidin, gives credit to the alleged aphrodisiac properties of this compound. Though cantharidin is usually contained in these products in homeopathie dilutions, their foreseeable lack of activity could induce someone to turn to the more potent cantharides powder to obtain the desired effect. References 1 2 3
4 5 6 7 8 9 10 11
A.G. Vult.0 and P.A.G.M. de Smet, Drugs used in non-orthodox medicine. In M.N.G. Dukes (ed.), MeyWs Side Effects of Drugs, 11th edn., Elsevier, Amsterdam, 1988, p. 1022. Martivw!u.b,The Extra Pharmacopoeia, 29th edn., J.E.F. Reynolds (ed.), The Pharmaceutical Press, London, 1989, p. 1554. A.C. Ray, S.H. Tamuhnas and J.C. Reagor, High pressure liquid chromatographic determination of cantharidin, using a derivatization method in specimens from animals acutely poisoned by ingestion of blister beetles, Epicauta lemniscata. Am. J. Vet. Res., 40 (1979) 498 - 504. Clurìce’s Isolutian and Zclent$ìcatti of Drugs in PharmocaLttials, Body Fluids and Postmortem Material, 2nd edn., The Pharmaceutical Press, London, 1986, pp. 425-426. L.C. Nickolls and D. Teare, Poisoning by cantharidin. Br. Med. J., 2 (1954) 1384-1386. J.D. Craven and A. Polak, Cantharidin poisoning. Br. Med. J., 2 (1954) 1386 - 1388. M.M.L. Dérobert and R. Le Breton, Intoxication aiguë par ingestion de poudre de cantharides. Ann. Mdd. Lbg., 3’7 (1957) 41-42. K. Cheng, H. Lee, S.F.B. Shum and C.P.D. Yip, A fatahty due to the use of cantharides from Mylabrk phalerata as an abortifacient. Med. Sci. Law, 30 (1990) 336 - 340. H.K. Hundt, J.M. Steyn and L. Wagner, Post-mortem serum concentration of cantharidin in a fataI case of cantharides poisoning. Hum. Ezp. Toxicol., 9 (1990) 35-40. Wertelecki, T.J. Vietti and P. KuIapongs, Cantharidin poisoning from ingestion of a “blister beetle”. Pediatrics, 39 (1967) 287-289. A.J. Presto and E.C. Muecke. A dose of spanish fly. J. Am. Med. Assoc., 214 (1970) 591-592.
43 12 13 14
15
16 17 18 19 20
R.D. Rosin, Cantharides intoxication. Br. Med. J., 4 (1967) 33. J. Harrisberg, J.C. Desem, L. Cohen, J. Tamlett and F.J. Milne, Cantharidin poisoning with neurological complications. 5’. Afr. Med. J., 65 (1984) 614-615. W. Tenschert, T. Behrenbeck, N. Rolf, J. Ahlmann, B. Winterberg, J. Heepe, A.E. Lison and H. Zumkley, Cantharidin poisoning. Transitory impairment of kidney function and hemorrhagic cystitis. Forkxhr. Med., 105 (1987) 686 - 688. F. Martens, M. Martens, T. Soylemezoglu and A. Heyndrickx, Determination of cantharidin in urine by nitrogen flame ionisation detection, gas liquid chromatography and mass fragmentography. Proceedings of the Centenn~ Meeting of tb International Association of Forensic Totiobgists, Ghent, Belgium, August 26-28, 19’76, p. 14. F. Mari, E. Bertol, 1. Volpato, M. Tosti and G. Orralesi, The detection of cantharidin in biological specimens. J. Anal. TokcoL, 3 (1979) 264-265. J.E. Carrel, Quantitative determination of cantharidin in biological materials using capillary gas chromatography with flame ionization detection. J. Chromatogr., 342 (1985) 411-415. A.C. Ray, L.O. Post and J.C. Reagor, GC-MS confirmation of cantharidin toxicosis due to ingestion of blister beetles. Vet. Hum. Toxicol., 22 (1980) 398-399. J.M. Steyn and H.K.L. Hundt, Gas chromatographic-mass spectrometric method for the quantitation of cantharidin in human serum. J. Chromatogr., 432 (1988) 177- 184. A.C. Ray, L.O. Post, J.M. Humt, W.C. Edwards and J.C. Reagor, Evaluation of an analytical method for the diagnosis of cantharidin toxicosis due to ingestion of blister beetles (Epicauta kmniscata) by horses and sheep. Am. J. Vet. Res., 41 (1980) 932-933.
