Introduction : Tryptamines and harmala alkaloids have been used individually and in combination for years for their abuse potential, as herbal remedies, and in religious ceremonies. Their abuse can be dangerous, and should be recognized by medical toxicologists. We present an ingestion of N,N dimethyltryptamine (DMT) and Peganum harmala (Syrian rue), with the DMT dose over 10 times the LD50.
Case report : A 24-year-old male presented with altered mental status and dizziness. His initial presentation was 4 h after ingesting 10 g of DMT and 4.5 g of Syrian rue. Physical exam included heart rate (HR) 120, blood pressure (BP) 145/84, normal skin, and reactive dilated pupils bilaterally. One hour after arrival his signs and symptoms worsened, with a HR in the 130s and significant confusion and hallucinations. The patient was admitted to a telemetry unit for monitoring and supportive care including IV fluids and benzodiazepines. Over the subsequent 8 h the patient’s hallucinations cleared, his mental status improved to near baseline, his HR declined to normal, and his BP stayed at roughly 140 systolic. He was discharged uneventfully at that time.
Discussion : This patient ingested a potentially fatal amount of DMT, which is a hallucinogenic tryptamine. Tryptamines can be found in many plants and animals. DMT in particular can be found in a number of different plants and is produced endogenously as well. Syrian rue belongs to a class of plants that produces harmala alkaloids. Harmala alkaloids produce monoamine oxidase (MAO) inhibition. DMT is orally active when used in conjunction with an MAOI. This combination also causes the effects of the DMT to last much longer than if smoked or injected on its own. The patient above took the DMT and Syrian rue to experience a long-lasting hallucinogenic high. He achieved this goal, and the course of the altered mental status lasted a total of 12 h, which is many times longer than the typical high would have lasted with DMT alone. The dose of the DMT this patient reported using is well above the estimated 8 mg/ kg LD50.
Conclusion : The presentation of this patient, with tachycardia and altered mental status, is consistent with the ingestion of DMT and Syrian rue that he reported. This combined ingestion should be recognized by the medical toxicologist.