Veratrum Alkaloid Determination in Four Cases of Veratrum Aqua Poisonings

Veratrum poisonings are known to the toxicology literature as multiple Veratrum species grow in different parts of the Northern Hemisphere and are occasionally ingested by mistake. Veratrum toxicity is attributed to the steroidal alkaloids contained in all parts of the plant. In Russia Veratrum poisonings are more common since there is an over-the-counter Veratrum Lobelianum-based tincture, Veratrum Aqua (VA), that is topically used for treatment of lice infestation. Despite its toxicity, VA is misused in traditional medicine as a remedy for alcohol use disorder. We describe four cases of VA poisoning that occurred in Moscow, Russia. Three main Veratrum Lobelianum alkaloids (jervine, protoveratrine A and protoveratrine B), were determined in patient plasma and urine samples using liquid chromatography tandem mass-spectrometry (LC-MS/MS). Here we describe a novel validated LC-MS/MS method for jervine and protoveratrine A quantification. Simple and rapid liquid-liquid extraction with methyl tert-butyl ether was utilized for analyte extraction. Chromatographic separation was achieved using Poroshell 120 EC-C18 column, and the total run time was 14 min. The lower limit of quantification was 0.1 ng/mL for jervine and proA in both plasma and urine. Biological samples were obtained upon hospital admission and during treatment, thus enabling to get a better understanding of the alkaloid elimination profile. Upon admission plasma concentrations of jervine (concentration range: 0.10-5.01 ng/mL) prevailed over protoveratrine A (concentration range: 0-0.67 ng/mL). At this time, protoveratrine A already reached maximum concentrations in urine (concentration range: 0.15-37.70 ng/mL). Maximum concentrations of jervine in urine were observed 24 hours after admission (concentration range: 0.10-9.55 ng/mL). In all cases plasma concentrations of Veratrum alkaloids correlated with condition severity. Since none of the patients confirmed VA intake, instrumental analysis was the basis for the definitive diagnosis of VA poisoning.