Description of a fatal case of aconite poisoning after ingestion of leaves of Aconitum napellus, documented by the dosages of 3 aconite alkaloids on various matrices in a deceased patient.

After accidental ingestion of aconite plant as a Couscouil salad, a 78-years-old man with non-insulin-dependent diabetes mellitus, and his wife felt buccal paraesthesia and numbness. Quickly, these symptoms become widespread. The man finally admitted in reanimation unit where he developed cardiovascular decompensation on acute arrhythmia and deceased. To confirm the aconite toxidrome, several samples were collected from the wife and the deceased patient.

Large screenings of drugs and toxics were performed on blood samples. An aconite specific and sensitive LCMSMS (3200 QTrap, ABSciex) method was developed to determine aconite alkaloids aconitine (A), hypaconitine (H) and mesaconitine (M). Clinical and autopsy samples were analysed after precipitation with methanol [1Grossenbacher F., et al. L’Aconit, la « reine des poisons » : suicide-mode d’emploi des plantes toxiques sur Internet Toxicol Anal Clin 2017 ;  29 : S56-S57 [inter-ref]

Cliquez ici pour aller à la section Références, 2Strzelecki A., et al. Acute toxic herbal intake in a suicide attempt and fatal refractory ventricular arrhythmia Basic Clin Pharmacol Toxicol 2010 ;  107 : 698-699 [cross-ref]

Cliquez ici pour aller à la section Références]. Bile and urine were hydrolysed before extraction. The limit of quantitation was 1ng/mL for A, H and M.

The toxicological findings were only amiodarone, lidocaine (intensive care) and metformin in non-toxic level in the fatal case. Aconitine was the only alkaloid found in all samples, with traces only for the wife. Measured concentrations in autopsy samples are presented in Table 1.

The concentration of A measured in peripheral blood was higher than those reported in other aconitine-related deaths [2Strzelecki A., et al. Acute toxic herbal intake in a suicide attempt and fatal refractory ventricular arrhythmia Basic Clin Pharmacol Toxicol 2010 ;  107 : 698-699 [cross-ref]

Cliquez ici pour aller à la section Références], even if the digestive absorption might have not been finished. The heart/peripheral concentrations ratio is about 3, which is in accordance to the heart accumulation and the cardiotoxicity of the compound. The concentrations of A in spleen, lung and heart were similar (about 4-fold the peripheral blood). In contrast, diffusion in skeletal muscle was close to blood distribution (34.2ng/mL). Both diffusion in brain and vitreous humor represented half of blood. Unchanged and conjugated A forms seemed to be low compared to the blood concentrations and the other published cases despite liver and kidney distributions, suggesting a potential renal impairment during resuscitation cares. As another French intoxication case, H and M were not found, may be because of a lack of these compounds in the French species of Aconite. Blood A concentration above 30ng/mL seems to be lethal even with appropriate cares.

In France, toxicological investigation should focus only on A in peripheral blood, and if not available postmortem distribution must be taken into account. Vitreous humor could have an interest.