Status epilepticus after C-4 ingestion: using liquid chromatography to quantify toxicity

Abstract

Context: C-4, a commonly used explosive in military operations, is sometimes consumed by soldiers as a rite of passage. The primary component of C-4 is cyclotrimethylenetrinitramine, or Research Department Explosive (RDX), which causes euphoria along with nausea, vomiting, renal injury, encephalopathy and convulsions when consumed in toxic amounts. We present a case of status epilepticus caused by known ingestion of C-4, in which serum levels of the compound were measured with high-performance liquid chromatography (HPLC).Case details: A 22-year-old active-duty male with no prior medical history was brought to the ED with convulsions that only minimally improved traditional anti-epileptic treatment. EEG showed persistent epileptiform activity despite initial management. Continuous propofol infusion, lacosamide and levitiracetam eventually broke the seizures. The patient eventually reported consuming a piece of C-4 four hours prior to the start of his seizure activity.Results: HPLC showed a peak RDX concentration of 3.06 μg/ml. RDX concentration at cessation of seizure activity was 2.43 μg/ml.Conclusion: Per our review of the literature, this is the first case where the explosive's toxicity could directly be measured over time in a human patient. C-4 poisoning must be considered when assessing sudden onset epileptiform activity in soldiers with access to this substance.