Portal de Periódicos da CAPES

“Pressed” Etizolam

2021; Elsevier BV; Volume: 232; Linguagem: Inglês

10.1016/j.jpeds.2020.12.075

1097-6833

Jennifer S. Love, John A. Thompson, B. Zane Horowitz,

Forensic Toxicology and Drug Analysis

Three boys, aged 6, 9, and 10 years, presented to the emergency department (ED) with altered mental status after eating Pez candy. Their mother had left the boys under an aunt's supervision at approximately 8:30 AM on the day of symptom onset. She returned home at 10:45 AM to find them "drowsy and wobbly." The aunt also had altered mental status, and she owned the candy container. On arrival to the ED, the patients were sleepy, drooling, mydriatic, and ataxic. All 3 patients received naloxone without mental status improvement. One child had detectable benzodiazepines on a qualitative ED urine drug screen. Two patients became somnolent over 2 hours, and the ED team considered intubating them for airway protection. The pills brought to the ED were brightly colored and unlabeled and resembled Pez candy (Figures 1 and 2). In consultation with the toxicologist, 2 of the patients were given 0.2 mg of flumazenil, leading to improved mental status. These patients were transferred by air transport to the pediatric intensive care unit (PICU) for monitoring. They received additional doses of flumazenil before transport and during transport to the PICU. They were discharged from the PICU after 72 hours observation. The third patient was admitted to the local hospital for monitoring and was discharged after 24 hours. Gas chromatography-mass spectroscopy of 1 patient's urine sample detected etizolam.Figure 2Additional etizolam pills obtained from patients.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Designer benzodiazepines, including etizolam, are being increasingly detected in the US.1Carpenter J.E. Murray B.P. Dunkley C. Kazzi Z.N. Gittinger M.H. Designer benzodiazepines: a report of exposures recorded in the National Poison Data System, 2014-2017.Clin Toxicol. 2019; 57: 282-286Crossref Scopus (20) Google Scholar Etizolam is a thienodiazepine, a short-acting benzodiazepine derivative prescribed in Japan, Italy, and India for anxiety and sleep disorders. Etizolam is illegal in the US but easily purchased on the "dark web."2Shapiro A.P. Krew T.S. Vazirian M. Jerry J. Sola C. Novel ways to acquire designer benzodiazepines: a case report and discussion of the changing role of the internet.Psychosomatics. 2019; 60: 625-629Crossref PubMed Scopus (5) Google Scholar Etizolam was the fourth most commonly detected benzodiazepine on forensic testing in 2019, accounting for nearly 6% of submitted samples.3US Drug Enforcement Administration, Diversion Control DivisionNational Forensic Laboratory Information System: NFLIS-Drug 2019 Annual Report.https://www.nflis.deadiversion.usdoj.gov/DesktopModules/ReportDownloads/Reports/NFLIS-Drug-AR2019.pdfDate: 2019Google Scholar Previous reports have noted counterfeit benzodiazepines pressed to imitate the structure of prescription benzodiazepines.4Arens A.M. Van Wijk X.M.R. Vo K.T. Lynch K.L. Wu A.H.B. Smollin C.G. Adverse effects from counterfeit alprazolam tablets.JAMA Intern Med. 2016; 176: 1554-1555Crossref PubMed Scopus (58) Google Scholar, 5Blumenberg A. Hughes A. Reckers A. Ellison R. Gerona R. Flualprazolam: report of an outbreak of a new psychoactive substance in adolescents.Pediatrics. 2020; 146: e20192953Crossref PubMed Scopus (8) Google Scholar, 6Jurásek B. Čmelo I. Hájková K. Kofroňová E. Kuchař M. Counterfeit benzodiazepines—a phantom menace.Int J Clin Pract. 2020; 74: e13575Crossref PubMed Scopus (2) Google Scholar This case is unique, because etizolam was disguised as a known candy. To date, no reports have described designer benzodiazepines disguised as a commercial food product. In this case, drug concealment efforts resulted in a significant toxicologic exposure in children.