Fatal 251-NBOMe Intoxication: A New Recreational Risk

Abuse of synthetic drugs is an emerging trend in substance abuse. Identification of exposure to such chemicals is often difficult due to the paucity of specific laboratory assays. One such group of compounds is the 2C class of phenethylamines that include 2-(4-lodo-2, 5-dimethoxyphenyl)-N-I[(2-methyoxyphenyl)methyl]ethanamine, known as 251-NBOMe or the street names “Smiles” and “N-Bomb.” This family of compounds consists of relatively new synthetic drugs, a two-carbon substitute of phenethylamine, which is a highly potent serotonin receptor 2A(5-HT2A) agonist. There are limited data on 251-NBOMe poisoning. We report a 17-year-old girl with mood disorders who died following 251-NBOMe ingestion, revealing its lethality. She presented in status epilepticus shortly after ingesting a substance on a blotter paper at a concert. She then acutely developed hyperthermia, metabolic acidosis, rhabdomyolysis, elevated transaminases, acute kidney injury, hypokalemia, hypocalcemia, and irreversible cerebral edema, and was declared brain dead on hospital day seven. Specific toxicological testing revealed exposure to 251-NBOMe from antemortem whole blood liquid chromatography/time-of-flight mass spectrometry at concentrations above 0.25 ng/mL. We suggest that the patient died from fulminant serotonin syndrome following acute 251-NBOMe intoxication with a possible contribution from chronic lithium therapy.