Accidental autoerotic death by volatile substance abuse or nonsexually motivated accidents?

In contrast to typical autoerotic fatalities, when death is due to asphyxia mostly by mechanical compression of the neck, atypical autoerotic accidental deaths (AADs) involve sexual self-stimulation by other means such as electrocution or inhalation of chemical agents. Especially in lethal cases of volatile substance abuse (VSA), a differentiation between suicide or sexually or nonsexually motivated accident is often complicated in practical casework. Considering the small number of AADs involving chemical substance abuse reported in the literature, the number of unreported cases seems to be very high. We report about 5 lethal cases of VSA; analysis was performed using headspace solid-phase microextraction (HS-SPME) and gas chromatography-mass spectrometry (GC/MS). When headspace sampling is not performed at autopsy, the analysis of volatile substances can be very complicated. In 2 cases, an AAD was diagnosed considering findings at the scene, reconstruction of the event, and discussion of the circumstances of the death. These findings demonstrate the importance of VSA in atypical autoerotic asphyxia. Therefore, in cases of suspected lethal inhalational intoxications, as a matter of principle, headspace asservation should be performed at autopsy and an autoerotic motivational background should be taken into consideration for differential diagnosis.     

Death during deliberate propane inhalation

Propane gas is used as a fuel and very rarely it is abused by young people in Greece. In this paper, we report a case of abuse of propane inhalation that resulted in accidental death. The determination of propane in autopsy samples was done by headspace gas chromatography and semiquantitation in liver, blood and the contents of the plastic bag through which the gas was diffused, which proved to be lethal.     

A case of suicidal suffocation simulating homicide

This case concerns an unusual suicidal plastic bag suffocation. An elderly white man was found dead and partially disrobed in his apartment lying supine on a sofa with a plastic bag closed by a rope over the head and the upper and lower extremities tightly tied with two other ropes, the end of both arranged into slipknots (self-rescue mechanism). Police investigations found no pornography in the apartment, and circumstantial data alleged no psychiatric disorders or suicidal intentions. The autopsy excluded signs of struggle and sexual intercourse as well as any type of injury or physical illness. Chemical analyses on the peripheral blood excluded acute drugs and/or alcohol intoxication. A differential diagnosis of the manner of death was performed, including scenarios of accidental autoerotic asphyxiation, homicide during either sexual activity or ritualistic, elderly suicide. The collected data most strongly supported the hypothesis of a suicidal asphyxiation simulating homicide to devolve a life insurance to the victim's sons because of economic difficulties.     

Fatality due to methyl acetylene-propadiene (MAPP) inhalation

A 33-year-old man died after intentionally inhaling a gaseous mix of methyl acetylene (propyne) and propadiene (allene) commonly known as MAPP, which is used for soldering and welding. He was found with a plastic bag securely placed over his head and a cylinder of MAPP alongside his head. The cylinder had been vented into the bag using a flexible hose. A comprehensive toxicological analysis revealed only a trace of diphenhydramine in the liver and 0.02 mg/L of morphine in the urine. Analysis of blood by headspace gas chromatography (HS-GC) detected two unknown peaks. These were determined to be the components of MAPP gas. MAPP was quantitated in femoral blood (59.6 mg/L) and brain (43.6 mg/kg) using a HS-GC method. The cause of death was attributed to acute MAPP intoxication, and the manner was determined to be suicide. A discussion on the analytical and interpretive considerations commonly encountered when analyzing volatile compounds is also presented.     

Panhypopituitarism in a young drug abuser

An intoxicated young man returned home from a drinking party and collapsed and died in his mother's presence. Three weeks earlier, he had been released from prison, having served a sentence for possession and sale of "street drugs". At the time of his release, he and his friends had gathered together for a celebration at which drugs were used. At the autopsy table, there was initial evidence of an intrasellar hemorrhage of recent onset with ablation of the adenohypophysis. At first the prosectors considered the case to be one of drug-induced pituitary "apoplexy". However, there was subsequent autopsy evidence of chronic panhypopituitarism. The intrasellar lesion proved to be a Rathke-cleft cyst of dysontogenetic origin, probably unrelated to drug abuse. This case is presented as an example of the increasing complexities encountered by the forensic pathologist in a world of increasing numbers of available toxic substances.     

Suicide and Meningioma

A 73-year-old man committed suicide by placing a plastic bag over his head. At autopsy, a large meningioma of the frontal lobe of the brain was found. It is believed that the tumor contributed to death by its direct effect on the brain, causing depression. This article illustrates a relationship between disease, depression, and suicide and offers a brief review of the literature concerning this relationship.     

Cause of death and drug use pattern in deceased drug addicts in Sweden, 2002-2003

Compared with their contemporaries, individuals abusing illicit drugs suffer a higher risk of premature death. In Sweden, a simple protocol for registration of fatalities among abusers of alcohol, pharmaceuticals, illicit drugs, or other substances, has been used by the forensic pathologists since 2001. This routine was introduced to allow for an evaluation of the cause and manner of death, and patterns of abuse among different groups of abusers. We explored the data on drug abusers (i.e. abusers of illicit drugs) subjected to a forensic autopsy 2002-2003. The Swedish forensic pathologists examined 10,273 dead victims during the study period and 7% (743/10,273) of the cases were classified as drug abusers. Toxicological analyses were carried out in 99% (736/743) and illicit drugs were detected in 70% (514/736) of these. On average, 3.8 substances (legal or illegal) were found per case. The most common substances were ethanol and morphine, detected in 43 and 35% of the cases, respectively. When exploring the importance of the different substances for the cause of death, we found that the detection of some substances, such as fentanyl and morphine, strongly indicated a poisoning, whereas certain other substances, such as benzodiazepines more often were incidental findings. In total, 50% (372/743) died of poisoning, whereas only 22% (161/743) died of natural causes. Death was considered to be directly or indirectly due to drug abuse in 47% (346/743), whereas evidence of drug abuse was an incidental finding in 21% (153/743) or based on case history alone in 33% (244/743). We believe that this strategy to prospectively categorize deaths among drug addicts constitutes a simple means of standardizing the surveillance of the death toll among drug addicts that could allow for comparisons over time and between countries.     

Death due to baclofen and dipyrone ingestion.

A fatal suicidal intoxication with unusual drugs is reported. A 56-year-old man was found dead in his house; near by the corpse several empty drugs boxes were found. An autopsy was performed and the biological fluids were submitted to a full toxicological work-up.The analytical results supported the hypothesis of a death due to the acute baclofen (4-amino-3-(p-chlorophenyl)butyric acid) and dipyrone (sodium [N-(1,5-dimethyl-3-oxo-2-phenylpyrazolin-4-yl)-N-methylamino] methanesulfonate) intoxication.     

K2 Toxicity: Fatal Case of Psychiatric Complications Following AM2201 Exposure

Limited forensic and clinical experience and the lack of confirmatory testing strategies for synthetic cannabinoids (SC) prevent adequate characterization of SC toxicity and the potential impact on public health. A statewide surveillance system identified a fatality involving a 23‐year‐old man found with a large stab wound to the neck following use of a SC product suspected of containing AM2201. Analytical testing for common SCs, SC metabolites, routine drugs of abuse, and over‐the‐counter medications was performed on heart blood obtained at autopsy. Additionally, assays were performed on the SC raw material and drug paraphernalia found on the decedent. High concentrations of AM2201 were detected in all samples. AM2201 metabolites were detected in postmortem blood. Other than a trace amount of JWH‐073 found in smoke residue, no other substances were detected. Psychiatric complications including self‐induced, lethal trauma can occur after the use of SC products.     

Acute Poisoning Types and Prevalence in Shanghai,China, from January 2010 to August 2011

In recent years, the number of cases of acute poisoning has increased in China, yet; currently, there is no detailed report published that addresses acute poisoning in the mainland of China. We collected biological samples from 466 cases of suspected acute poisoning at the hospitals in Shanghai, China, and examined them using spectroscopy, chromatography and chromatography/mass spectrometry. Of the 466 cases, 230 cases (100 men and 130 women) were positively confirmed as acute poisonings. There were 80 types of compounds identified in this study. Medications were the most frequent substances identified, and the other substances included pesticides, multiple compounds, volatile compounds, natural toxins, and others. The results of this study indicate a need for strengthening the education about and management of the rational and safe use of drugs in Shanghai.     

Increased risk of fatal intoxication and polypharmacy among psychiatric patients at death

Patients suffering from psychiatric disorders have an excess mortality and a shorter life span expectancy compared to the general population. Furthermore, they are treated with multiple drugs and are known to have an increased risk of drug abuse. In this study, we aimed at investigating the pharmaceutical drug and drug of abuse profiles of the deceased included in the Danish prospective autopsy‐based forensic study on psychiatric patients, SURVIVE. Using the postmortem systematic toxicological analysis results, we identified 129 different consumed compounds in our population (n = 443). Polypharmacy (≥5 compounds) was detected in 39.5% of the deceased. Deceased with a psychiatric diagnosis or who died from a fatal intoxication had significantly more compounds at the time of their death compared to having either no psychiatric diagnosis or another cause of death, respectively. Evidence of drug abuse was present, as 29.8% of our total population had consumed either methadone or illicit drugs of abuse, excluding tetrahydrocannabinol. Of those deceased with a psychiatric diagnosis, 33.6% had either consumed methadone or illicit drugs of abuse, a greater number than those without a psychiatric diagnosis. Fatal intoxication was the most frequent cause of death (40.6%) with methadone as the major intoxicant. Here, we found that those without a psychiatric diagnosis had fewer fatal pharmaceutical drug intoxications compared to the psychiatric diagnosis groups. Our findings add further context to understanding the excess mortality of psychiatric patents, since there is an increased occurrence of fatal intoxication, polypharmacy, and drug abuse in this population.     

Suffocation using plastic bags: a retrospective study of suicides in Ontario, Canada

One hundred and ten cases of suicidal suffocation using a plastic bag were identified in the files of the Office of the Chief Coroner of Ontario, Canada, between 1993 and 1997. The records were reviewed to determine the demographic characteristics of this group compared with all cases of suicide in Ontario, the scene information, autopsy findings and toxicology results. Most suicides occurred in people over 60 years of age, with older women making up a considerable proportion of cases as compared with other methods of suicide. In 40% of cases the deceased was suffering from a serious illness. Autopsy findings were usually minimal, with facial, conjunctival and visceral petechiae present in a minority of cases. One or more drugs were detected in the blood in 92.6% of cases where toxicologic testing was performed. Benzodiazepines, diphenhydramine and antidepressants were the most common drugs found, with diphenhydramine the most common drug present at an elevated concentration. Information at the scene from "right to die" societies was uncommon. One quarter of decedents took additional measures, besides the use of drugs or alcohol, to ensure the rapidity, certainty or comfort of their death. This study further elucidates the characteristics of this uncommon method of suicide. It emphasizes additional scene findings, such as the presence of dust masks, physical restraints and modification of the plastic bag that may be of use to death investigators in determining the correct manner of death.     

Death associated with volatile substance inhalation--histologic, scanning electron microscopic and energy dispersive X-ray spectral analyses of lung tissue

The investigation of deaths due to the inhalation of volatile substances may be complicated by a lack of scene and autopsy findings. Mechanisms of death may not be determinable at autopsy, and there may be very few markers of inhalant abuse. A 21-year-old man is reported who died from the combined effects of methadone toxicity and toluene inhalation. Histological examination of the lungs revealed congestion and edema, as well as particles of blue, pigmented material within the interstitium and in macrophages. Scanning electron microscopy was undertaken, revealing that the particles contained granules that measured 0.15-0.2microm in diameter, within the range of mean particle sizes for inorganic paint pigments. Energy dispersive X-ray spectral analysis of the granules demonstrated a significant percentage of titanium (12%) confirming their origin from paint. Ancillary investigations such as electron microscopy and X-ray spectral analysis in cases of possible lethal volatile inhalation may prove useful adjuncts in determining the type of substance inhaled and in providing evidence of previous non-lethal episodes.     

Screening analysis for medicinal drugs and drugs of abuse in whole blood using ultra-performance liquid chromatography time-of-flight mass spectrometry (UPLC-TOF-MS)-Toxicological findings in cases of alleged sexual assault

An ultra-performance liquid chromatography time-of-flight mass spectrometry (UPLC-TOF-MS) method for simultaneous screening of 46 medicinal drugs and drugs of abuse in whole blood was developed and validated. The method includes most of the commonly used and abused drugs such as amphetamines, cocaine, benzodiazepines, and opioids. Chromatographic separation of the targeted drugs was achieved using a Waters ACQUITY UPLC coupled to a Waters Micromass LCT Premier XE time-of-flight mass spectrometer. The total chromatographic run time was 13.5min injection to injection. The estimated method LOQ is in the range of 0.06-27ng/g, which is below the therapeutic levels for each of the drugs analyzed but LSD. The extraction recovery ranged from 6% to 197% with median value 95% and mean value 82%. Matrix effect ranged from 81% suppression to 29% enhancement of the signals compared to signals obtained in the absence of biological matrix. The method was tested on 55 authentic forensic toxicology samples confirming the same positive results as found using the routine analytical procedures as well as some additional compounds. Recently there has been considerable attention paid to drug-facilitated sexual assault and the toxicological findings in these cases. As part of a pilot study to investigate the prevalence of medicinal drugs, drugs of abuse, and alcohol in victims of alleged sexual assault, biological specimens were obtained from 167 victims being examined at the Sexual Assault Center in Aarhus, Denmark. The obtained blood samples were analyzed using the novel screening method supported by additional analyses for e.g. THC and alcohol. 124 victims reported they have been drinking alcohol prior to the assault (74%). Alcohol analyses revealed 59 positive findings (48%). 35 of the cases were found positive for one or more drugs excluding alcohol (21%). 20 of the victims reported they have been subject to a drug-facilitated sexual assault (12%). For the victims suspecting drug-facilitated sexual assault, the toxicological analyses revealed four positive for alcohol and nine victims were positive for one or more drugs, with six of the victims found positive for benzodiazepines or other drugs with sedative effects. It was notable that victims tested positive for medicinal drugs and drugs of abuse as well as victims of alleged drug-facilitated sexual assault in average underwent medical examination later than the whole study population.     

Toxicological analysis after asphyxial suicide with helium and a plastic bag

A 23-year-old man was found on a raised hide in lying position, the head wrapped in a plastic bag connected with a helium gas cylinder by a polypropylene tube. The autopsy did not show any specific findings nor did the routine toxicological analysis reveal significant information regarding the cause of death (BAC 0.9 mg/g, diphenhydramine 0.81 μg/ml in heart serum). For the detection of helium in the lungs, gas samples from both lungs were collected by a method ensuring minimal dilution. Gas analyses were performed using a GC–MS with a split–splitless injector and a headspace syringe. As carrier gas the commonly used helium was replaced by nitrogen. Helium was found in clearly elevated concentrations in gas samples from both lungs. Therefore, suffocation by breathing helium enriched, and thus oxygen deficient atmosphere, can strongly be assumed as the cause of death.     

Trends and pattern of drug abuse deaths in Maryland teenagers

The Office of the Chief Medical Examiner of Maryland recorded a total of 149 drug abuse deaths of teenagers aged 13-19 years between 1991 and 2006. Of these deaths, 96 (64.4%) were caused by the use of narcotic drugs only, 29 (19.5%) by both narcotics and cocaine, four (2.7%) by both narcotics and methylenedioxymethamphetamine, six (4.0%) by cocaine only, and 14 (9.4%) by volatile substances (e.g., butane, Freon, nitrous oxide, and propane). The annual death rate from drug abuse for teenagers increased from 1.4 deaths per 100,000 population in 1991 to 2.7 deaths per 100,000 population in 2006 (chi-square test for time trend, p<0.01). The increase in teenager drug abuse deaths occurred in 1999 and since has remained at a higher rate. Further analysis revealed that the increase in drug abuse deaths was attributable to a large degree to narcotic drugs, particularly heroin/morphine and methadone, and was confined to teenagers residing in the suburban and rural areas.     

Inhalant deaths in South Australia: a 20-year retrospective autopsy study

A 20-year retrospective study of inhalant deaths in South Australia, autopsied at Forensic Science SA, was undertaken from January 1983 to December 2002. Thirty-nine cases were identified from an autopsy pool of 18,880 cases, with a male to female ratio of 12:1. Sixty-four percent of the victims (N = 25) died during voluntary inhalation of volatile substances and 28% (N = 11) committed suicide utilizing a volatile substance or gas. The remaining 3 cases involved a workplace accident (N = 1) and 2 cases of autoerotic death where inhalants were being used to augment solitary sexual activity. The mean age of the 28 victims of accidental inhalant death of 21 years (range, 13-45 years) was considerably less than that of the 11 suicide victims of 31.5 years (range, 17-48 years). No homicides were found. Approximately one quarter of the victims were Aboriginal (N = 11), 10 of whom had died as a result of gasoline inhalation ("petrol sniffing"). Other common substances of abuse were aliphatic hydrocarbons such as butane. The study has shown that those most at risk for accidental or suicidal inhalant deaths were young males, with 92% of victims overall being male, and with 77% of victims being under 31 years of age. Gasoline inhalation remains a significant problem in Aboriginal communities in South Australia.     

An Unusual Suicide Inside a Grave with Two Gunshot Wounds to the Head—The Psychological Approach

Abstract: In this report, the authors present a case of suicide committed by a 66-year-old man, inside a grave at the local cemetery, with two gunshot wounds to the head. A multiple-paged, handwritten suicide note was found in an army type bag inside the victim’s car, while a second one was found in his house. Medicolegal examination of the body revealed two typical contact gunshot entrance wounds and one exit wound to the head. Toxicological analysis of the femoral blood was negative for alcohol and drugs. The history, scene and autopsy findings, along with further police investigation, indicated an obvious case of suicide. The literature is reviewed and discussed. We report this case as the place of suicide is extremely uncommon and as there is no mention of a gunshot suicide inside a grave in the current literature.     

Fatality of 33‐Year‐Old Man Involving Kratom Toxicity

Kratom is an herbal product commonly used for its effects which are similar to opioids and stimulants. Few studies demonstrate the dangers and lethality of Kratom, and most fatalities from Kratom involve other abused substances. In the current case report, a 33‐year‐old white man with a known history of opioid abuse and mental illnesses was found unresponsive in his basement with no obvious signs of trauma. After resuscitative efforts, he was pronounced dead and taken for autopsy evaluation. Blood from the inferior vena cava was analyzed for common abused substances. The laboratory toxicology work‐up revealed positive findings of caffeine, cotinine, and naloxone with low levels of Δ‐9 tetrahydrocannabinol. However, a marked level of mitragynine at 1.9 mg/L was observed, the highest reported to date. Given the facts and evidence, the medical examiner certified the cause of death as “mitragynine toxicity” and the manner of death was classified as an “accident.”     

Violent crime and substance abuse: a medico-legal comparison between deceased users of anabolic androgenic steroids and abusers of illicit drugs

Several case reports and survey studies have indicated that abuse of anabolic androgenic steroids (AAS) often leads to increased aggressiveness and feelings of hostility that may occasionally trigger violent behaviour. Other observations indicate that many users of AAS also abuse alcohol and/or various illegal substances. Since substance abuse is a well-known risk factor for violent behaviour, it could be that violence committed by AAS users might, at least in many cases, actually be caused by abuse of other drugs. In order to examine this possibility further here, the criminal histories (in terms of incidences of convictions) of deceased users of AAS with (AASpos-subst.pos) and without (AASpos-subst.neg) signs of abuse of other illegal substances were compared to the corresponding histories of deceased users of illicit substances testing negatively for AAS (subst.pos-AASneg) at the time of autopsy. The risk of being convicted for a crime against property was significantly higher in the subst.pos-AASneg group than in either the AASpos-subst.neg or AASpos-subst.pos groups (RR=0.048 versus 0.408). At the same time, the risk of being convicted for a crime of violence was at least as high for the two AAS-positive groups as for the AAS-negative group. Furthermore, when compared with the first 3 years after the first criminal conviction, a pronounced increase in the proportion of incidence of violent crimes and a marked reduction in the proportion of incidence of crime against property was observed during the 3-year period immediately preceding death only among the AASpos-subst.neg subjects. In conclusion, the incidence of violent crime among users of AAS without signs of other drug abuse was comparable to the corresponding incidences for drug addicts without AAS use. This observation suggests that the violent criminality observed among AAS users is not confounded in any systematic fashion by abuse of other drugs. The findings also indicate that use of AAS in certain predisposed individuals might cause a high rate of violent crimes, especially if the use of AAS is combined with the use of other illegal substances.