Case

A healthy 47-year-old man presented to his Canadian FP worried that he had been robbed at a bus terminal after vacationing in Bogotá, Colombia, 6 days previously. The patient was amnestic for approximately 12 hours during and after the event. He was able to successfully board a bus despite his state and after returning home and becoming aware of his surroundings, he noted he was missing an estimated $250 in cash and his cell phone. He had no signs of physical or sexual assault; however, he felt disoriented and confused, was unable to concentrate, and suffered from marked xerostomia.

Upon his return to Canada he discussed the event with his family, who believed he might have been exposed to burundanga (scopolamine). As he still felt unwell he presented to his physician with questions about scopolamine toxicity and long-term effects. Urine toxicology screening and drug screening for scopolamine and flunitrazepam were performed. Test results were negative, and the patient returned for follow-up 2 days later to monitor his symptoms, according to advice from poison control. Poison control indicated that there would be no benefit from dialysis but that there might be a role for activated charcoal and lavage within hours of scopolamine ingestion.⁶ Given that he presented days after exposure, no additional intervention was offered.

At follow-up, the patient’s neurologic examination findings were normal. He was alert and oriented, with a blood pressure of 110/68 mm Hg. He experienced palpitations and lethargy for 3 days and shakiness that lasted for a week after exposure, and he continued to have permanent anterograde amnesia for the 12-hour period around the exposure, but fully recovered to his previous level of functioning.

Discussion

Scopolamine and other plant derivatives are potential drugs of abuse for both recreational and criminal purposes. In our case, the patient suspected scopolamine was the causative agent, as it is commonly used in Colombia and his symptoms matched what would be expected from such intoxication. We cannot discern whether he was given a mixture of psychoactive drugs and their specific doses; however, his symptoms were mostly anticholinergic and were not severe enough to require intervention.

Extensive review of the MEDLINE and EMBASE databases, with search terms criminal, poisoning, intoxication, and scopolamine, revealed 40 documented cases of intentional and unintentional poisoning with scopolamine, although accurate information on this intoxication is difficult to ascertain.² In one case, a 28-year-old woman was poisoned by an elegantly dressed man. She subsequently cashed her pay cheque and gave the money to him.² In a meditation session, 30 people were intentionally poisoned and many required supportive therapy.⁷ In another case, a 19-year-old man intentionally ingested an unknown quantity of D stramonium seeds to experience their hallucinogenic effects and was found dead.⁸ Increasing misuse has led to prohibition by law in certain regions of planting certain species of plants that produce potentially lethal toxins.⁹

Scopolamine is tasteless and odourless and can be administered through oral, dermal, intravenous, or inhalation routes.¹⁰ Intoxication presents clinically as tachycardia, palpitations, dry mouth, flushed skin, blurred vision, urinary retention, disorientation, confusion, insomnia, and severe anterograde amnesia.^2,11,12 After scopolamine is orally ingested, most of it is excreted unchanged in the urine within 12 hours, which explains the challenge in obtaining a positive urine toxicologic result, as laboratory tests are usually done more than 12 hours after ingestion.² Toxic doses vary greatly among individuals and children are very susceptible, with less than 10 mg leading to death.⁷ In addition, a combination of tropane alkaloids can have a synergistic action and might lead to death.

In Canada, scopolamine can be purchased without a prescription and comes in 2 commercial preparations: the Transderm-V patch and Buscopan. One case report revealed a substitution error by a pharmacist that led to hyoscine hydrobromide overdose. The patient involved experienced long-lasting effects including decreased ability to concentrate and memory disturbances.¹³ Further, there has been an increase in poisoning caused by scopolamine disguised and sold as flunitrazepam tablets.¹⁴ This increase has been explained by the lower availability and higher production costs of flunitrazepam.¹⁴

We recognized that our patient described the anticholinergic toxidrome expected in scopolamine intoxication; he was reassured that scopolamine does not have a long half-life and that even high doses leave the body in 3 to 4 days. This patient fully recovered from his symptoms and was educated on safety precautions when traveling to countries that commonly use scopolamine as a predatory drug.

Conclusion

As clinicians, we encourage that when patients present to their FPs with unknown drug intoxication, the common standard of care be applied. However, if screening results are negative and there is no identifiable cause of the symptoms, the patient should be educated on possible scopolamine intoxication, particularly if that patient presents with an anticholinergic toxidrome and traveled to a country that uses scopolamine for recreational and predatory purposes. This case describes suspected toxic alkaloid poisoning managed in primary care. It is important to become educated about the toxicities and potential risks associated with criminal and recreational use of scopolamine.