(130) "Devil's Breath" Intoxication Presenting with Acute-Onset Psychosis and Self-Injurious Behavior: A Case Report and Review of Literature

Abstract: Background/Significance:

Non-pharmaceutical Scopolamine, widely known outside the scientific community as ‘Devil’s Breath’ or ‘Burundanga’ is a tropane alkaloid and muscarinic antagonist that is among the metabolites of plants from the Solanaceae family, which grow freely throughout much of South America (Sandia,2018). ‘Devil’s Breath’ is gaining a reputation in the media as the “world’s most dangerous drug." The anticholinergic intoxication that results is built on a synergistic but even more toxic mixture of the additional alkaloids in the plants. When an extracted powder from the plant is consumed, it can cause anterograde amnesia, cognitive inhibition, frightening hallucinations, agitation, and disorientation (Papoutis, 2010). Furthermore, effects can be long-lasting (Papoutis,2010; Sandia,2018). Recently, ‘Devil’s Breath’ has become a well-known practice across Latin American countries to incapacitate people for criminal gain. Here we report a case of a patient with suspected involuntary intoxication with non-pharmaceutical scopolamine, who was successfully treated with transdermal Rivastigmine.

Case:

Mr. V is a 52 year-old gentleman with no known psychiatric history, who presented to the ED due to self-inflicted lacerations and AMS. Initial workup, including toxicology screen and CT brain, was unremarkable. Psychiatry consultation was obtained for suicide attempt. The patient appeared to be suffering from a psychotic episode of acute onset, starting the morning after visiting a nightclub during a trip to the Dominican Republic. Both patient and his family were insistent that he unknowingly ingested some atypical substance of abuse while at the nightclub. On admission to the hospital 4 days after symptom onset, the patient exhibited anterograde amnesia of the event, confusion, paranoid delusions, as well as visual/auditory/tactile hallucinations. He was initiated on Risperidone 0.5 mgBID and was transferred to the Psychiatric Unit. Given the high clinical suspicion for scopolamine intoxication, and in consultation with regional poison control, the patient was administered Rivastigmine 4.6mg patch with successful resolution of psychosis.

Discussion:

‘Devil’s Breath’ intoxication is difficult to prove scientifically, as there is minimal data on methods of toxicological analysis, and therefore diagnosis relies heavily on the patients' stories to reach any conclusion. Furthermore, there is limited literature available on the clinical effectiveness of possible cholinesterase inhibitors as antidotes. One case series described successful use of transdermal patches of Rivastigmine in the treatment of ‘Devil’s Breath’ intoxication (Sandia,2018).

Conclusion:

While voluntary/involuntary intoxication with ‘Devil’s Breath’ is becoming a relatively frequent situation that's no longer confined to South America, little is known about the course of symptom development, identification, or treatment. Consultation-liaison Psychiatrists are well poised to identify and treat this medically unrecognized intoxication that presents with psychiatric symptoms.

References:

Papoutis etal.,Mass intoxication with Datura—case series and confirmation by analytical toxicology.ClinToxicol.2010;8:143-145.

Sandia et al.,Treating ‘Devil’s Breath’ intoxication:Use of Rivastigmine in six patients with toxic psychoses due to non-pharmaceutical scopolamine.J.Toxicol.Clin.Toxicol.,2018;6:4-7.