title: Case files of the University of Massachusetts fellowship in medical toxicology: lethal dose of opioids contained in an elastomeric capsule labeled as vancomycin.
abstract: A 67 year-old male presented to the emergency department with alteration in mental status. On arrival he had vital signs: pulse 110, BP 173/83, respiratory rate 4, oxygen saturation 57% and temperature 36.1 degrees Celsius. His past medical history included hypertension, vitamin B12 deficiency, hyperlipidemia, and recurrent cellulitis treated with vancomycin. The patient had no response to noxious stimuli, pinpoint pupils, and agonal respirations. Secondary to his wife's vehement denial that he had access to or history of using any narcotics, he was intubated after 2.2mg IV naloxone failed to reverse respiratory depression. Thirty minutes before presentation, however, he had received an intravenous infusion of vancomycin administered by his wife at home. The vancomycin, obtained from a home infusion medication supply company, was contained in one of five sealed elastomeric capsules delivered earlier that day. A qualitative comprehensive toxicology screen of urine for 1043 substances identified morphine, codeine, naloxone, lidocaine and caffeine. The original elastomeric container was not available for testing, but another container from the same delivery was submitted for testing to the state forensic laboratory. This intact container was labeled as Vancomycin 1g in 240mL of normal saline. The forensic laboratory confirmed that the alkaloidal contents of the elastomeric capsule were 10% codeine, 4.4% 6-monoacetyl morphine, and 84% morphine. No vancomycin was identified in the infusion bottles. The case was referred to the local police department and the state department of health drug control board. The home infusion company was also immediately notified to prevent similar occurrence.
  
  
  CONCLUSIONS
  We are reporting the first known case of opioid overdose from an adulterated elastomeric capsule that was labeled as containing an antimicrobial agent.
authors.affiliation: Department of Emergency Medicine, Division of Medical Toxicology, University of Massachusetts Medical School, Worcester, MA 01655, USA. jcourtn@gmail.com
authors.forename: James
authors.initials: J
authors.lastname: Courtney
authors.forename: Edward
authors.initials: E
authors.lastname: Boyer
mesh_terms: D000368:Aged; D000701:Analgesics, Opioid / Q000506:poisoning*; D000900:Anti-Bacterial Agents; D002214:Capsules; D004340:Drug Contamination; D004348:Drug Labeling; D004349:Drug Packaging; D003932:Heroin / Q000737:chemistry / Q000493:pharmacokinetics / Q000506:poisoning; D018718:Home Infusion Therapy; D006801:Humans; D008297:Male; D008508:Medication Errors; D012131:Respiratory Insufficiency / Q000139:chemically induced / Q000628:therapy; D014640:Vancomycin
chemical_list: D000701:Analgesics, Opioid; D000900:Anti-Bacterial Agents; D002214:Capsules; D014640:Vancomycin; D003932:Heroin