SSADH deficiency in an Italian family: a novel ALDH5A1 gene mutation affecting the succinic semialdehyde substrate binding site

SSADH deficiency (SSADHD) is a rare autosomal recessively inherited metabolic disorder. It is associated with mutations of ALDH5A1 gene, coding for the homotetrameric enzyme SSADH. This enzyme is involved in γ-aminobutyric acid (GABA) catabolism, since it oxidizes succinic semialdehyde (SSA) to succinate. Mutations in ALDH5A1 gene result in the abnormal accumulation of γ-hydroxybutyrate (GHB), which is pathognomonic of SSADHD. In the present report, diagnosis of SSADHD in a three-month-old female was achieved by detection of high levels of GHB in urine. Sequence analysis of ALDH5A1 gene showed that the patient was a compound heterozygote for c.1226G > A (p.G409D) and the novel missense mutation, c.1498G > C (p.V500 L). By ALDH5A1 gene expression in transiently transfected HEK293 cells and enzyme activity assays, we demonstrate that the p.V500 L mutation, despite being conservative, produces complete loss of enzyme activity. In silico protein modelling analysis and evaluation of tetramer destabilizing energies suggest that structural impairment and partial occlusion of the access channel to the active site affect enzyme activity. These findings add further knowledge on the missense mutations associated with SSADHD and the molecular mechanisms underlying the loss of the enzyme activity.

Forensic toxicology findings in deaths involving gamma-hydroxybutyrate

Concentrations of the illicit drug gamma-hydroxybutyrate (GHB) were determined in femoral venous blood and urine obtained at autopsy in a series of GHB-related deaths (N = 49). The analysis of GHB was done by gas chromatography after conversion to gamma-butyrolactone and quantitation of the latter with a flame ionization detector. The cutoff concentration of GHB in femoral blood or urine for reporting positive results was 30 mg/L. The deceased were mainly young men (86%) aged 26.5 +/- 7.2 years (mean +/- SD), and the women (14%) were about 5 years younger at 21.4 +/- 5.0 years. The mean, median, and highest concentrations of GHB in femoral blood (N = 37) were 294, 190, and 2,200 mg/L, respectively. The mean urine-to-blood ratio of GHB was 8.8, and the median was 5.2 (N = 28). In 12 cases, the concentrations of GHB in blood were negative (<30 mg/L) when the urine contained 350 mg/L on average (range 31-1,100 mg/L). Considerable poly-drug use was evident in these GHB-related deaths: ethanol (18 cases), amphetamine (12 cases), and various prescription medications (benzodizepines, opiates, and antidepressants) in other cases. Interpreting the concentrations of GHB in postmortem blood is complicated because of concomitant use of other psychoactive substances, variable degree of tolerance to centrally acting drugs, and the lack of reliable information about survival time after use of the drug.

A validated SPME-GC–MS method for simultaneous quantification of club drugs in human urine

A solid-phase microextraction-gas chromatographic-mass spectrometric (SPME-GC-MS) method has been developed and validated for measuring four club drugs in human urine. These drugs include gamma-hydroxybutyrate (GHB), ketamine (KET), methamphetamine (MAMP), and methylenedioxymethamphetamine (MDMA). These drugs are referred to as 'club drugs' because of their prevalence at parties and raves. Deuterium labeled internal standards for each of the four drugs was included in the assay to aid in quantitation. The drugs were spiked into human urine and derivatized using pyridine and hexylchloroformate to make them suitable for GC-MS analysis. The SPME conditions of extraction time/temperature and desorption time/temperature were optimized to yield the highest peak area for each of the four drugs. The final SPME parameters included a 90 degrees C extraction for 20min with a 1min desorption in the GC injector at 225 degrees C using a splitless injection. All SPME work was done using a 100microm PDMS fiber by Supelco. The ratio of pyridine to hexylchloroformate for derivatization was also optimized. The GC separation was carried out on a VF-5ht column by Varian (30m, 0.25mm i.d., 0.10microm film thickness) using a temperature program of 150-270 degrees C at 10 degrees C/min. The instrument used was a ThermoFinnigan Trace GC-Polaris Q interfaced with a LEAP CombiPal autosampler. The data was collected by using extracted ion chromatograms of marker m/z values for each drug from the total ion chromatograms (TIC) (full scan mode). Calibration curves with R(2)>0.99 were generated each day using the peak area ratios (peak area drug/peak area internal standard) versus concentration. The validated method resulted in intra-day and inter-day precision (% R.S.D.) of less than 15% and a % error of less than 15% for four concentrations in the range of 0.05-20microg/mL (MAMP) and 0.10-20microg/mL (GHB, KET, and MDMA). This method has the advantage of an easy sample preparation with acceptable accuracy and precision for the simultaneous quantification of these four drugs of abuse and shows no interference from the urine matrix.

GHB urine concentrations after single-dose administration in humans

Gamma-hydroxybutyric acid (GHB) is used as an illicit drug and is implicated in drug-facilitated sexual assault, but it also has some therapeutic uses. Detection of GHB in urine is important for forensic testing and could be of clinical benefit in overdose management. Urine GHB concentration-time profiles have not been well-characterized or correlated with doses used therapeutically. GHB levels were measured by gas chromatography-mass spectrometry in urine collected over 24 h from 16 adults administered single doses of 50 mg/kg GHB (Xyrem) alone and combined with 0.6 g/kg ethanol. Peak GHB urine concentrations averaged 150-200 mg/L and occurred in the 0-3 h urine collection. Significant variability in GHB urine levels between individuals was observed. Caucasians had lower urine concentrations than other races/ethnicities (p = 0.03). Men had lower GHB levels than women in the first 3 h after dosing (p = 0.038). Coingestion of ethanol did not significantly affect renal clearance of GHB, but urine GHB concentrations were lower in the first 3 h when ethanol and GHB were coingested (p = 0.039). At a proposed cut-off of 10 mg/L to distinguish endogenous versus exogenous GHB levels, 12.5% of the samples collected from 3 to 6 h, 81.3% of samples collected from 6 to 12 h, and 100% of urine specimens collected from 12 to 24 h were below this level. We conclude that the detection time for GHB in urine may be shorter than the previously reported 12-h window in some people taking therapeutic doses of GHB.

Further evidence of in vitro production of gamma-hydroxybutyrate (GHB) in urine samples

This study was designed to supplement previous studies that documented in vitro production of gamma-hydroxybutyrate (GHB) in urine samples. Urine samples were provided by subjects who reported that they had never used GHB (n=31). The specimens were stored under standard conditions of refrigeration (5 degrees C) without any preservatives added. All specimens were repeatedly analyzed for the presence of endogenous GHB over a 6-month period using a previously reported headspace GC-MS method. Significant elevations in GHB were observed in many of the urine samples as storage time increased. As a result, the in vitro production of GHB may increase the apparent GHB concentrations in urine during storage. This potential for an artificial increase in GHB concentration must be appreciated when establishing the threshold between endogenous and exogenous concentrations of GHB.

Therapeutic concepts in succinate semialdehyde dehydrogenase (SSADH; ALDH5a1) deficiency (gamma-hydroxybutyric aciduria). Hypotheses evolved from 25 years of patient evaluation, studies in Aldh5a1-/- mice and characterization of gamma-hydroxybutyric acid pharmacology

We overview the pathophysiological bases, clinical approaches and potential therapeutic options for succinate semialdehyde dehydrogenase (SSADH; EC1.2.1.24) deficiency (gamma-hydroxybutyric aciduria, OMIM 271980, 610045) in relation to studies on SSADH gene-deleted mice, outcome data developed from 25 years of patient evaluation, and characterization of gamma-hydroxybutyric acid (GHB) pharmacology in different species. The clinical picture of this disorder encompasses a wide spectrum of neurological and psychiatric dysfunction, such as psychomotor retardation, delayed speech development, epileptic seizures and behavioural disturbances, emphasizing the multifactorial pathophysiology of SSADH deficiency. The murine SSADH-/- (e.g. Aldh5a1-/-) mouse model suffers from epileptic seizures and succumbs to early lethality. Aldh5a1-/- mice accumulate GHB and gamma-aminobutyric acid (GABA) in the central nervous system, exhibit alterations of amino acids such as glutamine (Gln), alanine (Ala) and arginine (Arg), and manifest disturbances in other systems including dopamine, neurosteroids and antioxidant status. Therapeutic concepts in patients with SSADH deficiency and preclinical therapeutic experiments are discussed in light of data collected from research in Aldh5a1-/- mice and animal studies of GHB pharmacology; these studies are the foundation for novel working approaches, including pharmacological and dietary trials, which are presented for future evaluation in this disease.

[Qualitative and quantitative gamma-hydroxybutyrate analysis]

Gamma-hydroxybutyrate (GHB) is a naturally occurring compound present in the brain and peripheral tissues of mammals. It is a minor metabolite and precursor of gamma-aminobutyric acid (GABA). Just as GABA, GHB is believed to play a role in neurotransmission. GHB was first synthesized in vitro in 1960, when it revealed depressive and hypnotic effects on the central nervous system. In 1960s it was used as an anaesthetic and later as an alternative to anabolic steroids, in order to enhance muscle growth. However, after it was shown that it caused strong physical dependence and severe side effects, GHB was banned. For the last fifteen years, GHB has been abused for its intoxicating effects such as euphoria, reduced inhibitions and sedation. Illicitly it is available as white powder or as clear liquid. Paradoxically GHB can easily be manufactured from its precursor gamma-butyrolactone (GBL), which has not yet been banned. Because of many car accidents and criminal acts in which it is involved, GHB has become an important object of forensic laboratory analysis. This paper describes gas and liquid chromatography, infrared spectroscopy, microscopy, colourimetry and nuclear magnetic resonance as methods for detection and quantification of GHB in urine and illicit products.

Distribution of GHB in tissues and fluids following a fatal overdose

Gamma-hydroxybutyrate (GHB) is encountered in biological specimens as an endogenous neuromodulator, recreational drug, or therapeutic agent. Clinically, the drug is useful for the treatment of cataplexy. Illicit doses are typically 2-4 g, and the onset of action is rapid, occurring 15-30 min following oral ingestion. Dose-dependent effects include drowsiness, euphoria, dizziness, vomiting, respiratory depression, coma, and death. GHB was isolated from biological samples using a simple liquid-liquid extraction. The trimethylsilyl derivative (GHB-di-TMS) was analyzed using gas chromatography-mass spectrometry with positive chemical ionization. Deuterated internal standard and selective ion monitoring were used throughout. We report a GHB fatality involving a 35-year-old male who was partying with friends. Subjects at the party ingested unknown quantities of wine and GHB. A female companion at the party reported seeing the male alive before she herself passed out. She awoke to find the decedent cold and stiff. Postmortem specimens were submitted for comprehensive toxicology testing. No alcohol or common drugs of abuse were detected. A targeted analysis revealed GHB in urine, brain, vitreous fluid, femoral blood, heart blood, and liver at concentrations of 1665 mg/L, 102 mg/kg, 48 mg/L, 461 mg/L, 276 mg/L, and 52 mg/kg, respectively. Concentrations of the drug in urine and vitreous fluid are important in death investigations because of significant postmortem production of GHB in blood specimens. The cause of death was attributed to GHB intoxication, and the manner of death was accidental.

GC-MS-MS Determination of Gamma-Hydroxybutyrate in Blood and Urine

A gas chromatographic-tandem mass spectrometric (GC-MS-MS) method for determining trace concentrations of gamma-hydroxybutyrate (GHB) in blood and urine has been developed. Multiple reaction monitoring was used to detect parent and daughter ions of GHB, 233 and 147, respectively, following liquid-liquid extraction with acetonitrile and derivatisation with N,O-bis[trimethylsilyl]trifluoroacetamide (BSTFA). Deuterated GHB was used as an internal standard. The assay produced excellent linearity and sensitivity without conversion to gamma butyrolactone. The lower limit of quantitation (LLOQ) in 50 microL of sample was 2.5 microg/mL. The expanded uncertainty values for intra- and interassay results were +/- 0.097 and +/- 0.123 ng/mL at a confidence level of 95% for blood and urine, respectively. Endogenous concentrations of GHB were found to be in the range of 0.3 to 6 microg/mL in urine and 0.5 to 2.3 microg/mL in blood, confirming previously suggested cut-off values for forensic analysis.

Effects of drinking and smoking on endogenous levels of urinary γ-hydroxybutyric acid, a preliminary study

The aim of this study was to determine if the endogenous levels of gamma-hydroxybutyric acid (GHB) in urine were affected by drinking and smoking. Urine samples were obtained from 20 healthy volunteers (15 males, 21-45 years; 5 females, 22-24 years). This population included four average drinkers (males), 4 average smokers (males), and 12 nonsmokers/nondrinkers (seven males and five females). Urinary levels of GHB were measured by gas chromatography. No gender differences were observed in the urinary levels of endogenous GHB. The urinary levels of GHB in males were 0.52+/-0.37 microg/ml in smokers, 0.28+/-0.21 microg/ml in nonsmokers/nondrinkers, and 0.23+/-0.04 microg/ml in drinkers. Urinary GHB levels were measured three times a day for 5 consecutive days in a male from each group. Large intra-individual differences were observed over the 5-day period in a smoker and a nonsmoker/nondrinker. No significant changes in daily endogenous GHB levels were observed in a drinker during the period. Our preliminary results suggest that stimulatory effects of nicotine on the central nervous system (CNS) may result in an increase in nocturnal formation of GHB and the depressive effects of ethanol on the CNS may not affect, even may inhibit, nocturnal production of GHB.

A comprehensive study on the variations in urinary concentrations of endogenous gamma-hydroxybutyrate (GHB)

This study was designed to supplement previous attempts to establish an accurate range of normal endogenous gamma-hydroxybutyrate (GHB) concentrations in random antemortem urine samples. Furthermore, its purpose was to ascertain the effect of gender, race, age, medications, and select medical conditions on endogenous concentrations of GHB in urine and the proposed endogenous urinary GHB cutoff of 10 microg/mL. Urine samples (n = 207) were provided by subjects who reported that they had never used GHB. As part of the collection process, subjects also completed a short survey to collect information about gender, race, age, orally ingested medications, and select medical conditions. All specimens were analyzed in duplicate for the presence of endogenous GHB using a previously reported headspace gas chromatography-mass spectrometry method. The data were analyzed for tendencies among different population groups. GHB concentrations ranged from 0.00 to 2.70 microg/mL in all specimens, with a median concentration of 0.24 microg/mL. Males (n = 130) had an average endogenous GHB concentration of 0.27 microg/mL (0.00-2.70 microg/mL), whereas females (n = 77) averaged 0.29 microg/mL (0.00-0.98 microg/mL). Select medical conditions and participants' race, age ranges, and medications that were used within 48 h prior to collection were also evaluated. We believe this to be the most comprehensive study on endogenous GHB concentrations in urine to date. The results of this study will aid the interpretation of low GHB concentrations measured in urine samples, particularly in investigations of drug-facilitated crimes.

Effect of Genetically Caused Excess of Brain Gamma-Hydroxybutyric Acid and GABA on Sleep

BACKGROUND

Exogenous gamma-hydroxybutyrate (GHB) increases slow-wave sleep and reduces daytime sleepiness and cataplexy in patients with primary narcolepsy.

OBJECTIVE

To examine nighttime sleep and daytime sleepiness in a 13-year-old girl homozygous for succinic semialdehyde dehydrogenase (SSADH) deficiency, a rare recessive metabolic disorder that disrupts the normal degradation of 4-aminobutyric acid (GABA), and leads to an accumulation of GHB and GABA within the brain.

METHODS

Sleep interview, nighttime polysomnography, Multiple Sleep Latency Tests, and continuous 24-hour in-lab recordings in the patient; overnight polysomnography in her recessive mother and in a 13-year-old female control.

RESULTS

During quiet wakefulness, background electroencephalographic activity was slow and composed of 7-Hz activity. Sleep stage 3/4 was slightly increased (28.1% of total sleep period, norms 15%-28%), and the daytime mean sleep latency was short in the patient (3 minutes 42 seconds, norms > 8 minutes). Stage 2 spindles were infrequent in the child (0.18/minute, norms: 1.2-9.2/minute) and her mother (0.65/minute) but normal (4.6/minute) in the control. At the beginning of the second night, a tonic-clonic seizure occurred, followed by a dramatic increase in stage 3/4 sleep, that lasted 46.3 % of the total sleep period, double the normal value. The mother showed a reduced total sleep time and rapid eye movement sleep percentage.

DISCUSSION

This suggests that a chronic excess of GABA and GHB induces subtle sleep abnormalities, whereas increased slow-wave sleep evoked by a sudden event (here an epileptic seizure) may be caused by a supplementary increase in GABA and GHB.

Nonfatal instances of intoxication with gamma-hydroxybutyrate in the United Kingdom

There has been much publicity regarding the use and abuse of gamma-hydroxybutyrate (GHB, "liquid ecstasy," or "GBH"). GHB has been found to be an endogenous compound but has also been used for various therapeutic applications in addition to illicit use, particularly as a dietary supplement, sexual adjunct, and "party drug." Toxicological analysis was performed using urine and/or plasma specimens from 27 nonfatal instances of suspected GHB intoxication in the United Kingdom between May 1998 and May 2003. GHB was detected in the plasma and urine, invariably with the additional presence of ethanol and other drugs of abuse (eg, amphetamines, cocaine, and morphine). GBL was also detected in the majority of urine specimens analyzed but was not detected in the plasma samples (<10 mg/L). The mean plasma and urine concentrations measured as "total GBL" were found to be 245 mg/L (range 86-551 mg/L) and 1732 mg/L (range 5-5581 mg/L), respectively. This is believed to be the largest compilation of nonfatal cases from the United Kingdom.

[gamma-Hydroxybutyrate intoxication]

The drug gamma-Hydroxybutyrate (GHB), also known as liquid ecstasy, has now reached Europe. Estimating the dosage of liquid GHB is especially difficult leading to unintentional intoxication because the exact concentration is not known. We repeatedly had to treat young patients intoxicated by GHB in our intensive care unit. We describe the course and treatment of three patients with GHB intoxication. If alcohol or mixed intoxication with drugs detected in traditional hospital toxicological assays has been excluded as the cause of unconsciousness in young patients from disco's, an intoxication with GHB should be considered. The therapy is mainly symptomatic and supportive but monitoring in an intensive care unit with the option of short term respirator therapy is necessary. Serum and urine samples taken on arrival should be conserved for further investigation in a forensic institute.

A Reference Range for Endogenous Gamma-Hydroxybutyrate in Urine by Gas Chromatography-Mass Spectrometry

Gamma-hydroxybutyrate (GHB) has been implicated in drug-facilitated sexual assault (DFSA). The interpretation of GHB levels in biological samples collected for evidence is complicated by the natural presence of this compound in the body, and by its extremely rapid elimination after ingestion. There is a lack of agreement regarding a suitable cut-off concentration, which can reliably separate endogenous concentrations in urine from those reflecting ingestion. We have developed a method for the analysis of low levels of GHB in urine and have used it to establish a reference range for normal females. The method uses liquid-liquid extraction, silyl-derivatization, and gas chromatographic-mass spectrometric analysis. The limit of detection was 0.1 mg/L, and the method was linear from 0.1 to 5.0 mg/L. Our analysis of 50 urine samples donated by normal women indicates an upper limit of normal for urinary GHB of 1.46 mg/L or 323 microg GHB/mmol of creatinine. We propose that a 5 mg/L cut-off for urine GHB concentration, or 1000 microg GHB/mmol creatinine, will separate endogenous GHB concentrations from those reflecting GHB ingestion in antemortem samples with greater than 99% confidence, providing that a specific assay method comparable with that we describe is used. We demonstrate that urinary GHB concentrations fall with age and that this can be corrected for by measurement of the GHB/creatinine ratio.

Determination of γ-hydroxybutyric acid in biological fluids by using capillary electrophoresis with indirect detection

gamma-Hydroxybutyric acid (GHB) is a central nervous system (CNS) depressant and hypnotic which, in recent times, has shown an increasing abuse either as recreational drug (due to its euphoric effects and ability to reduce inhibitions) or as doping agent (enhancer of muscle growth). Analogues of GHB, namely gamma-butyrolactone (GBL) and 1,4-butanediol (1,4-BD), share its biological activity and are rapidly converted in vivo into GHB. At present, GHB and analogues are placed in the Schedules of Controlled Substances. Numerous intoxications in GHB abusers have been reported with depressive effects, seizures, coma and possibly death. The purpose of the present work was the development of a rapid analytical method based on capillary zone electrophoresis for the direct determination of GHB in human urine and serum at potentially toxic concentrations. Analytical conditions were as follows. Capillary: length 40 cm (to detector), 75 microm i.d.; buffer: 5.0 mM Na(2)HPO(4), 15 mM sodium barbital adjusted to pH 12 with 1.0 M NaOH; voltage: 25 kV at 23 degrees C; indirect UV detection at 214 nm; injection by application of 0.5 psi for 5 s. alpha-Hydroxyisobutyric acid was used as internal standard (IS). Sample pretreatment was limited to 1:8 dilution. Under these conditions, the sensitivity was approximately 3.0 microg/ml (signal-to-noise ratio >3). Calibration curves prepared in water, urine and serum were linear over concentration ranges 25-500 microg/ml with R(2)>/=0.998. Analytical precision was fairly good with R.S.D.<0.60% (including intraday and day-to-day tests). Quantitative precision in both intraday and day-to-day experiments was also very satisfactory with R.S.D.</=4.0%. No interferences were found neither from the most common "drugs of abuse" nor from endogenous compounds. In conclusion, capillary electrophoresis can offer a rapid, precise and accurate method for GHB determination of biological fluids, which could be important for screening purposes in clinical and forensic toxicology.

Further Evidence for the Presence of GHB in Postmortem Biological Fluid: Implications for the Interpretation of Findings

Analysis and interpretation of the findings for the drug of abuse gamma hydroxybutyric acid (GHB) in fatalities has become very problematic. This is primarily because of variable data in postmortem biological fluids resulting from the endogenous nature of the compound, possible postmortem production, and varying methods of detection. Preliminary studies support the use of plasma standards in determining urinary GHB concentrations and indicate measurement of GHB in postmortem biological fluids may be dependent on the method of analysis. In order to assist interpretation of postmortem data based on gas chromatography-mass spectrometry (GC-MS) analysis using GHB-d6 internal standard, the results of GHB concentrations measured routinely in postmortem blood and urine specimens in 40 fatalities received during a three-month period are shown. In all cases, GHB was not implicated in the cause of death; there was no apparent correlation between manner of death and resultant GHB concentrations. Mean concentrations of GHB determined in postmortem blood were found to be 12.3 mg/L (range = 2-29 mg/L, n = 38) and 12.6 mg/L (range = 4-25 mg/L, n = 17) (unpreserved and sodium fluoride-preserved samples, respectively) and 5.5 mg/L in unpreserved urine (range 0-18 mg/L, n = 39) and 4.8 mg/L in sodium fluoride-preserved (range 0-10 mg/L, n = 15) urine samples. Vitreous humor was available in two of the cases analyzed (GHB = 1 and 3 mg/L). The data support the potential use of sodium fluoride-preserved samples for interpretation of GHB concentrations, particularly if there has been an extended postmortem interval. In addition, interpretative cut-offs can be proposed for both postmortem blood and urine, based on the specific GC-MS method used. At blood concentrations less than 30 mg/L and at urine concentrations less than 20 mg/L, it is possible that any GHB detected could represent only endogenous GHB production.

Significant behavioral disturbances in succinic semialdehyde dehydrogenase (SSADH) deficiency (gamma-hydroxybutyric aciduria)

We report two adult patients with succinic semialdehyde dehydrogenase deficiency, manifesting as gamma-hydroxybutyric aciduria. For both, the clinical presentation included significant behavioral disturbances and psychosis (hallucinations, disabling anxiety, aggressive behavior, and sleep disorder), leading to multiple therapeutic attempts. Intervention with benzodiazepines appeared most efficacious, resulting in decreased aggression and agitation and improvement in anxiety. A review of 56 published and unpublished studies of SSADH-deficient patients revealed that 42% manifested behavioral disturbances, whereas 13% (predominantly adults) displayed psychotic symptomatology. To explore the potential biochemical basis of these behavioral abnormalities, we studied cerebrospinal fluid derived from 13 patients, which revealed significantly elevated GHB (65- to 230-fold), high free and total GABA (up to threefold), and low glutamine. Although within the control range, homovanillic and 5-hydroxyindoleacetic acids (end products of dopamine and serotonin metabolism, respectively) showed a significant linear correlation with increasing GHB concentration, suggesting enhanced dopamine and serotonin turnover. We conclude that elevated GABA combined with low glutamine suggest disruption of the glial-neuronal glutamine/GABA/glutamate shuttle necessary for replenishment of neuronal neurotransmitters, whereas altered dopamine and serotonin metabolism may be causally linked to the hyperkinetic movement disorders and behavioral disturbances seen in SSADH-deficient patients.

Ultra-rapid procedure to test for gamma-hydroxybutyric acid in blood and urine by gas chromatography-mass spectrometry

Gamma-hydroxybutyric acid (GHB) is a substance naturally present within mammal species. Properties of a neurotransmitter or neuromodulator are generally suggested for this substance. GHB is therapeutically used as an anaesthetic, but can be used for criminal offences (date-rape drug). It appears that the window of detection of GHB is very short in both blood and urine, and therefore its presence is very difficult to prove after a rape case. Twenty microl of blood or urine were pipetted into a glass tube, followed by 20 microl GHB-d(6) and 45 microl acetonitrile. After vortexing and efficient centrifugation, the supernatant was collected and evaporated to dryness. The residue was derivatized with BSTFA+1% TMCS for 20 min at 70 degrees C. After injection on a 30-m HP5 MS capillary column, GHB (m/z 233, 204 and 147) and GHB-d(6) (m/z 239) were identified by mass spectrometry. The procedure was linear from 1 to 200 mg/l for both blood and urine. Precisions were in the range 4 to 11%. The method appears simple, specific and rapid as an accurate result can be obtained within 1 h.

Gamma-hydroxybutyrate serum levels and clinical syndrome after severe overdose

STUDY OBJECTIVE

We discuss a prospective case series of patients who present with a severe gamma-hydroxybutyrate intoxication with confirmatory serum and urine gamma-hydroxybutyrate levels.

METHODS

Patients with a clinical suspicion of gamma-hydroxybutyrate-like drug overdoses and a Glasgow Coma Scale score of 8 or lower were identified from July 1998 through January 1999. Serial serum specimens and a single urine specimen were collected. The levels of gamma-hydroxybutyrate were performed by gas chromatography-mass spectrometry.

RESULTS

All 16 suspected severe gamma-hydroxybutyrate overdose patients had significant serum or urine levels of gamma-hydroxybutyrate. Serum levels ranged from 45 to 295 mg/L, with a median of 180 mg/L (interquartile range [IQR] 235 to 118 mg/L). Patients who developed a Glasgow Coma Scale score of 3 had serum levels that ranged from 72 to 300 mg/L, with a median of 193 mg/L (IQR 242 to 124 mg/L). The time of awakening ranged from 30 minutes to 190 minutes, with a median of 120 minutes (IQR 150 to 83 minutes). Quantitative serum gamma-hydroxybutyrate levels did not correlate with the degree of coma or the time to awakening. Urine levels ranged from 432 to 2,407 mg/L, with a median of 1,263 mg/L (IQR 1,550 to 796 mg/L). Mild transitory hypoventilation occurred in 5 of the 16 patients.

CONCLUSION

All of our patients with clinically suspected severe gamma-hydroxybutyrate overdose were confirmed to have significant serum and urine levels of exogenous gamma-hydroxybutyrate. They presented with severe coma that lasted 1 to 2 hours. Transient hypoventilation occurred in one third of these patients.

A study of urinary endogenous gamma-hydroxybutyrate (GHB) levels

In recent years, the use of gamma-hydroxybutyrate (GHB), as a recreational drug has prompted forensic toxicology laboratories to incorporate the analysis for GHB into their routine screening procedures. GHB, being a natural occurring constituent of the human body, presents a challenge for forensic toxicologists in that endogenous levels and exogenous levels of GHB need to be differentiated in case samples. This study was designed to determine typical urinary endogenous levels of GHB in humans based on the analysis of urine samples voluntarily provided by 55 male and female subjects ranging in age from 6 to 59 years. All samples were initially screened for the presence of GHB utilizing a hydrolysis method designed to quantitatively convert the GHB in urine samples to gamma-butyrolactone (GBL) followed by the liquid-liquid extraction and analysis of any GBL present by gas chromatography-mass spectrometry (GC-MS). As a confirmation test, samples were then extracted by a solid-phase extraction technique, derivatized to GHB di-TMS, and analyzed by GC-MS. The median concentration determined for the 55 subjects was 1.3 mg/mL (mean = 1.65 microg/mL, range 0.9 microg/mL to 3.5 microg/mL, standard deviation 0.68 microg/mL). The results of this study confirm the previously suggested cutoff of 10 microg/mL for routine forensic analyses.

In vitro production of gamma-hydroxybutyrate in antemortem urine samples

The in vitro production of gamma-hydroxybutyrate (GHB) in antemortem urine samples was demonstrated over an eight-month period. Positive chemical ionization-gas chromatography-mass spectrometry (PCI-GC-MS) was used to detect trace amounts of GHB produced in vitro under certain storage conditions. Freshly prepared drug-free human urine was stored at 21, 4, and -20 degrees C in the presence of preservative. Although artifactual production of GHB occurred more rapidly at elevated temperatures, the presence of an antimicrobial agent (sodium azide) in the drug-free urine control did not impede GHB production. The preliminary data suggest that although in vitro production was demonstrated, the elevations in concentration were nominal and less than 5 mg/L for all conditions tested over the 244-day period. These preliminary data suggest that urine samples should be preserved and stored at -20 degrees C to minimize artifactual GHB production. Most importantly, conditions of storage and preservative should also be taken into consideration when interpreting GHB results that are close to the administrative cutoff. In order to establish the distribution of GHB concentrations in routine forensic case samples, a series of 100 antemortem urine samples, in which GHB was not suspected, was analyzed. Samples were preserved with sodium fluoride (1%) and had been stored for up to one year at room temperature. Although concentrations as high as 7 mg/L were measured in some samples, the mean and median concentrations were 1.8 mg/L and 1.6 mg/L, respectively. Even following storage at room temperature for an extended period, more than 95% of the urine samples contained less than 5 mg/L GHB and 100% contained less than 10 mg/L. An administrative cutoff of 10 mg/L in antemortem urine was used for routine antemortem casework.

Intra- and interindividual variations in urinary concentrations of endogenous gamma-hydroxybutyrate

This study was designed to determine the urinary concentrations of endogenous GHB over a one-week period, the variations that occur within those concentrations, and whether those variations are affected by normalization to urinary creatinine. Its purpose was to ascertain whether endogenous concentrations fluctuate to such an extent that they may be misinterpreted as due to GHB ingestion. Every urine void produced by eight GHB-free subjects (five males and three females) over a one-week period was individually collected and analyzed for the presence of endogenous GHB and creatinine. The results of the non-normalized and normalized concentrations were statistically analyzed. Non-normalized GHB concentrations ranged from 0.00 to 6.63 microg/mL over seven days. The coefficients of variation (CV) for the individual non-normalized data were 44.0% to 77.7%. When the data were normalized to creatinine, the concentrations ranged from 0.00 to 6.79 microg/mg. The CVs for the creatinine-normalized results were between 29.7% and 76.8%. Analysis of the differences in CVs by the paired t-test (alpha = 0.05) found these improvements to be statistically insignificant. Such normalization allows for correction of urinary dilution or concentration by the kidneys which may affect endogenous GHB concentrations. The data also suggest significant (p < 0.001) differences in median endogenous urinary concentrations of GHB between males and females using the Mann-Whitney test. Because of the small number of subjects in this study, further investigations are required to substantiate this observation. Some of the subjects in this study demonstrated a strong tendency to produce higher or lower GHB concentrations at consistent periods during the day. This was most evident when looking at the creatinine-normalized concentrations. The results of our study indicate that there are significant intra- and interindividual variations in the urinary concentrations of endogenous GHB. Furthermore, there are also wide variations between individuals in the total daily amount of GHB excreted in the urine. Nonetheless, no specimen's GHB concentration approached 10 microg/mL (non-normalized) or 10 microg/mg (normalized). This study of the variability in endogenous urinary GHB excretion supports the recommendation of 10 microg/mL as an appropriate cutoff to identify exogenous GHB exposure in the absence of rare genetic deficiencies such as GHB aciduria. Patients with such a deficiency should be readily identifiable through prominent symptoms, repeated urinalysis, or genetic testing.

Determination of endogenous gamma-hydroxybutyric acid (GHB) levels in antemortem urine and blood

Gamma-hydroxybutyric acid's (GHB's) natural presence in the body has made the interpretation of its levels a challenging task for the forensic toxicologist. This study was designed to measure endogenous GHB levels in antemortem urine and blood samples. The range detected in urine was from 34 to 575 microg/dl and in blood from 17 to 151microg/dl. The results indicate that the concentration of endogenous GHB in urine and blood concur with the suggested cut-off levels at 1000 and 500 microg/dl, respectively.

Therapeutic intervention in mice deficient for succinate semialdehyde dehydrogenase (gamma-hydroxybutyric aciduria)

Therapeutic intervention for human succinic semialdehyde dehydrogenase (SSADH) deficiency (gamma-hydroxybutyric aciduria) has been limited to vigabatrin (VGB). Pharmacologically, VGB should be highly effective due to 4-aminobutyrate-transaminase (GABA-transaminase) inhibition, lowering succinic semialdehyde and, thereby, gamma-hydroxybutyric acid (GHB) levels. Unfortunately, clinical efficacy has been limited. Because GHB possesses a number of potential receptor interactions, we addressed the hypothesis that antagonism of these interactions in mice with SSADH deficiency could lead to the development of novel treatment strategies for human patients. SSADH-deficient mice have significantly elevated tissue GHB levels, are neurologically impaired, and die within 4 weeks postnatally. In the current report, we compared oral versus intraperitoneal administration of VGB, CGP 35348 [3-aminopropyl(diethoxymethyl)phosphinic acid, a GABA(B) receptor antagonist], and the nonprotein amino acid taurine in rescue of SSADH-deficient mice from early death. In addition, we assessed the efficacy of the specific GHB receptor antagonist NCS-382 (6,7,8,9-tetrahydro-5-[H]benzocycloheptene-5-ol-6-ylideneacetic acid) using i.p. administration. All interventions led to significant lifespan extension (22-61%), with NCS-382 being most effective (50-61% survival). To explore the limited human clinical efficacy of VGB, we measured brain GHB and gamma-aminobutyric acid (GABA) levels in SSADH-deficient mice receiving VGB. Whereas high-dose VGB led to the expected elevation of brain GABA, we found no parallel decrease in GHB levels. Our data indicate that, at a minimum, GHB and GABA(B) receptors are involved in the pathophysiology of SSADH deficiency. We conclude that taurine and NCS-382 may have therapeutic relevance in human SSADH deficiency and that the poor clinical efficacy of VGB in this disease may relate to an inability to decrease brain GHB concentrations.

Capillary gas chromatographic determination of 1,4-butanediol and gamma-hydroxybutyrate in human plasma and urine

This article describes two methods for the determination of 1,4-butanediol and gamma-hydroxybutyrate in human plasma and urine using capillary gas chromatography. For 1,4-butanediol, plasma or urine samples (500 microl) were extracted by protein precipitation whereas for gamma-hydroxybutyrate, plasma or urine samples (500 microl) were extracted and derivatised with BF3-butanol. The compounds were separated on a Supelcowax-10 column and detection was achieved using a flame ionization detector. The methods are linear over the specific ranges investigated, accurate (with a percentage of the nominal concentration <109.8%) and showed intra-day and inter-day precision within the ranges of 5.0-12.0 and 7.0-10.1%, respectively. No interferences were observed in plasma and urine from hospitalized patients.

GHB. Club drug or confusing artifact?

GHB can be produced either as a pre- or postmortem artifact. The authors describe two cases in which GHB was detected and discuss the problem of determining the role of GHB in each case. In both cases, NaF-preserved blood and urine were analyzed using gas chromatography. The first decedent, a known methamphetamine abuser, had GHB concentrations similar to those observed with subanesthetic doses (femoral blood, 159 microg/ml; urine, 1100 microg/ml). Myocardial fibrosis, in the pattern associated with stimulant abuse, was also evident. The second decedent had a normal heart but higher concentrations of GHB (femoral blood, 1.4 mg/ml; right heart, 1.1 mg/ml; urine, 6.0 mg/ml). Blood cocaine and MDMA levels were 420 and 730 ng/ml, respectively. Both decedents had been drinking and were in a postabsorptive state, with blood to vitreous ratios of less than 0.90. If NaF is not used as a preservative, GHB is produced as an artifact. Therefore, the mere demonstration of GHB does not prove causality or even necessarily that GHB was ingested. Blood and urine GHB concentrations in case 1 can be produced by a therapeutic dose of 100 mg, and myocardial fibrosis may have had more to do with the cause of death than GHB. The history in case 2 is consistent with the substantial GHB ingestion, but other drugs, including ethanol, were also detected. Ethanol interferes with GHB metabolism, preventing GHB breakdown, raising blood concentrations, and making respiratory arrest more likely. Combined investigational, autopsy, and toxicology data suggest that GHB was the cause of death in case 2 but not case 1. Given the recent discovery that postmortem GHB production occurs even in stored antemortem blood samples (provided they were preserved with citrate) and the earlier observations that de novo GHB production in urine does not occur, it is unwise to draw any inferences about causality unless (1) blood and urine are both analyzed and found to be elevated; (2) blood is collected in NaF-containing tubes; and (3) a detailed case history is obtained.

Effect of storage temperature on endogenous GHB levels in urine

Because gamma-hydroxybutyrate (GHB) is an endogenous substance present in the body and is rapidly eliminated after ingestion, toxicologists investigating drug-facilitated sexual assault cases are often asked to differentiate between endogenous and exogenous levels of GHB in urine samples. This study was designed to determine the effects of storage temperature on endogenous GHB levels in urine. Specifically, it was designed to ascertain whether endogenous levels can be elevated to a range considered indicative of GHB ingestion. Urine specimens from two subjects that had not been administered exogenous GHB were collected during a 24h period and individually pooled. The pooled specimens were separated into standard sample cups and divided into three storage groups: room temperature ( approximately 25 degrees C), refrigerated (5 degrees C), and frozen (-10 degrees C). Additionally, some specimens were put through numerous freeze/thaw cycles to mimic situations that may occur if multiple laboratories analyze the same specimen. Periodic analysis of the samples revealed increases in the levels of endogenous GHB over a 6-month period. The greatest increase (up to 404%) was observed in the samples maintained at room temperature. The refrigerated specimens showed increases of 140-208%, while the frozen specimens showed smaller changes (88-116%). The specimens subjected to multiple freeze/thaw cycles mirrored specimens that had been thawed only once. None of the stored urine specimens demonstrated increases in GHB concentrations that would be consistent with exogenous GHB ingestion.

Determination of gamma-hydroxybutyrate in water and human urine by solid phase microextraction-gas chromatography/quadrupole ion trap spectrometry

A simple method of detection was developed for gamma-hydroxybutyrate (GHB). The method involves the derivatization of GHB using a hexyl-chloroformate procedure in aqueous media (such as water or urine), extraction of the derivatization product directly from the sample using solid-phase microextraction, and subsequent separation and detection with gas chromatography quadrupole ion trap mass spectrometry. The deuterated form of GHB (GHB-D6) is used as an internal standard for quantitation. The method was linear for GHB-spiked pure water samples from 2 to 150 microg/mL GHB with a detection limit of 0.2 microg/mL. Spiked urine samples showed linearity from 5 to 500 microg/mL GHB with a detection limit of 2 microg/mL. The SPME-GC/MS method is applied to actual case samples, and the results are compared to those values obtained using a conventional GC/MS method. Sensitivity and linearity are comparable to those seen using traditional methods of separation, yet the SPME method is superior due to the simplicity, speed of analysis, reduction in solvent waste, and ability to differentiate between GHB and gamma-butyrolactone (GBL).

The urinary excretion of gamma-hydroxybutyric acid in man

gamma-Hydroxybutyric acid (GHB) has been widely associated with drug-facilitated sexual assault (DFSA). However, its excretion profile in man has not been well characterized. To assess the detectability of GHB for forensic cases and to correlate urinary levels with dose, we have examined the excretion profiles of 1- and 2-g doses of GHB (sodium salt) in a healthy male volunteer. The urinary levels were measured by a novel, simple and highly reproducible method. The drug was found to be excreted in small amounts in the free form (0.86 and 1.16% for 1- and 2-g doses, respectively) rapidly in urine (< or = 10 h). The urinary levels were found to be in the low mg L(-1) range (up to 29.1 mg L(-1)). The work presented demonstrates that it is of the utmost importance to collect the samples as soon as possible following the alleged assault.

Gamma-hydroxybutyrate (GHB): a newer drug of abuse

Gamma-hydroxybutyrate (GHB) is an illicitly marketed substance that has recently gained popularity among body builders and party attendees as a drug of abuse. GHB is a depressant that acts on the central nervous system. It is purported as a strength enhancer, euphoriant and aphrodisiac and is one of several agents reported as being used as a "date rape" drug. Because of its central nervous system depressant effects, GHB can be lethal when combined with alcohol or other depressants. Currently, there is no accepted medical use for GHB, and the U.S. Food and Drug Administration has prohibited its manufacture and sale. Clinicians should be familiar with the typical clinical presentation of GHB and its adverse effects. In addition, patients should be warned of its potential toxicity and be cautioned to avoid the use of GHB.

Involvement of drugs in sexual assault

OBJECTIVE

To obtain information about the relationship of alcohol and drug usage in victims of sexual assault, including the newly identified "date rape" drugs gamma hydroxybutyrate and flunitrazepam.

STUDY DESIGN

Analysis of urine samples with gas chromatography combined with mass spectrometry can identify alcohol and numerous other drugs with a high degree of specificity. This service was offered to rape treatment centers throughout the United States in May 1996; urine samples obtained from sexual assault victims suspected of drug use by history or physical examination were sent for testing at the discretion of the examiner.

RESULTS

As of March 1999, a total of 2,003 specimens were analyzed. Nearly two-thirds of the samples contained alcohol and/or drugs; the predominant substances found were alcohol, present in 63%, and marijuana, present in 30%. A substantial subset of the specimens was found to contain other illicit substances, frequently in combination. GHB and flunitrazepam were found in < 3% of the positive samples. Additionally, over the two-year study period, the use of these two drugs appeared to be declining.

CONCLUSION

These findings support prior data indicating that alcohol, marijuana and/or other drugs are important risk factors in sexual assault. Continued monitoring of drug use by victims of sex crimes is important, and programs that serve victims should modify protocols to reflect this.

Determination of gamma-hydroxybutyrate (GHB) in biological specimens by gas chromatography--mass spectrometry

A simple liquid-liquid extraction procedure for the analysis of gamma-hydroxybutyrate (GHB) in biological fluids without conversion to its lactone, gamma-butyrolactone, is described. Following derivatization to its di-TMS derivative, GHB was detected using gas chromatography-electron impact mass spectrometry. Diethylene glycol was used as the internal standard. The limit of quantitation in 1 mL of blood was 1 mg/L, and a linear response was observed over the concentration range 1 to 100 mg/L. Coefficients of variation for both intra-assay precision and interassay reproducibility ranged between 3.9 and 12.0%. GHB was detected in the blood of a sexual assault victim (3.2 mg/L), in the blood of two driving (DUI) cases (33 and 34 mg/L), and in the blood and urine of two nonfatal GHB-overdose cases (blood 130 and 221 mg/L; urine 1.6 and 2.2 g/L). The observed clinical symptoms ranged from confusion, disorientation, vomiting, and nystagmus to ataxia, sinus bradycardia, unconsciousness, and apnea.

Analysis of gamma-hydroxybutyrate (GHB) in urine by gas chromatography-mass spectrometry

A simple method for the direct analysis of gamma-hydroxybutyrate (GHB) from human urine is described. The method uses solid-phase extraction, liquid-liquid extraction, and silyl-derivatization, then gas chromatographic-mass spectrometric analysis using GHB-d6 as the internal standard. The method was linear from 5 to 500 mg/L, and coefficients of variation were less than 10%. Twenty-six urine specimens previously analyzed by an existing method were analyzed and yielded GHB concentrations ranging from 0 to 6100 mg/L; the results correlated between the two methods. Compared with existing methods, the method described here is superior because it is specific to GHB and can discriminate between GHB and gamma-butyrolactone.

The clinical phenotype of succinic semialdehyde dehydrogenase deficiency (4-hydroxybutyric aciduria): case reports of 23 new patients

OBJECTIVES

To further define the clinical spectrum of the disease for pediatric and metabolic specialists, and to suggest that the general pediatrician and pediatric neurologist consider succinic semialdehyde dehydrogenase (SSADH) deficiency in the differential diagnosis of patients with (idiopathic) mental retardation and emphasize the need for accurate, quantitative organic acid analysis in such patients.

PATIENTS

The clinical features of 23 patients (20 families) with SSADH deficiency (4-hydroxybutyric acid-uria) are presented. The age at diagnosis ranged from 3 months to 25 years in the 11 male and 12 female patients; consanguinity was noted in 39% of families.

OUTCOME MEASUREMENTS

The following abnormalities were observed (frequency in 23 patients): motor delay, including fine-motor skills, 78%; language delay, 78%; hypotonia, 74%; mental delay, 74%; seizures, 48%; decreased or absent reflexes, 39%; ataxia, 30%; behavioral problems, 30%; hyperkinesis, 30%; neonatal problems, 26%; and electroencephalographic abnormalities, 26%. Associated findings included psychoses, cranial magnetic resonance or computed tomographic abnormalities, and ocular problems in 22% or less of patients. Therapy with vigabatrin proved beneficial to varying degrees in 35% of the patients. Normal early development was noted in 30% of patients.

CONCLUSIONS

Our data imply that two groups of patients with SSADH deficiency exist, differentiated by the course of early development. Our recommendation would be that accurate, quantitative organic acid analysis in an appropriate specialist laboratory be requested for any patients presenting with two or more features of mental, motor, or language delay and hypotonia of unknown cause. Such analyses are the only definitive way to diagnose SSADH deficiency; the diagnosis can be confirmed by determination of enzyme activity in white cells from whole blood. We think that increased use of organic acid determination will lead to increased diagnosis of SSADH deficiency and a more accurate representation of disease frequency. As additional patients are identified, we should have a better understanding of both the metabolic and clinical profiles of SSADH deficiency.

Driving under the influence of GHB?

A driver was found asleep behind the steering wheel of his car, and the vehicle was at rest in a traffic lane with the engine running. His manifestations included horizontal and vertical gaze nystagmus, muscle flaccidity, and severe ataxia. He admitted ingesting a white powder, which he identified as an amino acid, about 1 hour prior to discovery by police. A urine specimen collected approximately 1 hour after the traffic stop contained 1975 mg/L of gamma-hydroxybutyrate (GHB). We tentatively conclude that GHB may cause impairment of the psychomotor skills required for safe operation of a motor vehicle.

Quality assessment of urinary organic acid analysis

The number of known inherited metabolic disorders resulting in an organic aciduria has increased steadily over the past two decades. Prompt and reliable detection is both clinically and technically demanding but is essential if appropriate treatment is to be undertaken. This is the first study of laboratory performance in the detection of these disorders to be undertaken in the UK. Some conditions were accurately identified by most laboratories: for example for maple syrup urine disease, 12 of 14 laboratories provided an appropriate response and medium chain acyl-CoA dehydrogenase deficiency was correctly identified by 15 of 17 laboratories. However, accuracy of detection was poorer for other conditions: for example, only eight of 17 laboratories detected tyrosinaemia type 1 and nine of 18 laboratories detected 4-hydroxybutyric aciduria. The strongest correlation with good performance was obtained by comparison with the extent of peak identification: r = 0.62, P = 0.002. The need for regular attendance at scientific symposia was also supported by a weaker positive correlation with the average score achieved, P = 0.08. Evidence also suggested that some of the laboratories with a low workload performed less well. No significant difference in performance could be demonstrated between the 17 laboratories who used gas chromatography-mass spectrometry and the six participants who used gas chromatography alone.

Therapeutic gamma-hydroxybutyric acid monitoring in plasma and urine by gas chromatography-mass spectrometry

A gas chromatographic-mass spectrometric (GC-MS) method for the determination of therapeutic levels of gamma-hydroxybutyric acid (GHB) in plasma and urine samples is described. GHB is converted to its lactonic form gamma-butyrolactone (GBL) which is extracted from biological fluids after the addition of the internal standard delta-valerolactone. Final GC-MS analysis is obtained under electron impact selected ion monitoring (SIM) conditions. Mean relative recoveries of GHB from plasma and urine are 75.5% (RSD% = 2.2) and 76.4% (RSD% = 2.4), respectively. The assay is linear over a plasma GHB range of 2-200 micrograms ml-1 (r = 0.999) and a urine GHB range of 2-150 micrograms ml-1 (r = 0.998). Intra- and inter-assay relative standard deviations (n = 5) determined at 10 and 100 micrograms ml-1 are below 5%. The method is simple, specific and accurate, and may be applied for analytical purposes related to pharmacokinetic studies and therapeutic drug monitoring.