When the patients have recovered, they report that they took 25-B after purchasing it on the Internet from another country. The drug had arrived by mail as a cardboard strip, presumably blotter paper for oral or sublingual administration.

Discussion

The NBOMe class of compounds has recently emerged as novel synthetic drug of abuse. In November 2013, the Department of Justice temporarily placed 25B-NBOMe in Schedule I of the Controlled Substances Act, along with 25I-NBOMe and 25C-NBOMe.⁵

Pharmacologically, 25B-NBOMe is an agonist of the 5-HT2A serotonin receptor.⁵ Our patients exhibited symptoms consistent with serotonin syndrome. An elevated WBC was noted with more severe symptoms.

Review of the literature shows limited information describing the clinical course in the emergency department. Toxicology journals report the case of a 19-year-old male with confirmed 25-B overdose who exhibited grand mal seizure activity, fever, sinus tachycardia, dilated pupils, erythema, and purpuric rash.⁶ The most common reported symptoms of acute 25I-NBOMe intoxication are tachycardia, agitation, hallucinations, hypertension, and seizures.⁷ Other reported symptoms include violent behavior, hyperpyrexia, clonus, an elevated WBC count, elevated creatine kinase, metabolic acidosis, and renal failure.8-10 Additionally, Poklis et al. report persistent seizure activity and resultant rhabdomyolysis, requiring sedatives and skeletal muscle blocking agents.⁷ Three deaths resulting from 25I-NBOMe toxicity have been reported in the medical literature, and in each, the decedents exhibited delirious or erratic behavior.^7,11 Dangerous behavior directly contributed to one death as the decedent appeared to have fallen from an apartment balcony.⁷ Forensic pathologic study in two cases revealed nonfatal injuries, leaving open the possibility of death from pharmacologic effects.¹¹

The patients described in this report improved with symptomatic treatment. One was given benzodiazepines for agitation. There are no antidotes available for 25B-NBOMe or similar compounds. Pharmacologically based therapies may be considered, but efficacy of 5-HT2A antagonists such as cyproheptadine is inconclusive.^12,13 Accidental NBOMe consumption is possible with intended LSD intoxication.^2,14

Complete the CME activity.

Mr. Su is in the department of otolaryngology, head and neck surgery, at Mount Sinai Beth Israel and a research associate at the Thyroid, Head and Neck Cancer Foundation, both in New York. Dr. Baker is in the department of emergency medicine Pali Momi Medical Center in Aiea, Hawaii. Dr. Baraff is with the emergency medicine center at David Geffen School of Medicine at the Universitycof California, Los Angeles.

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