Postmortem tricyclic antidepressant concentrations. Lethal versus nonlethal levels

Evidence has accumulated that postmortem release of tissue-bound tricyclic antidepressants (TCAs) may cause falsely elevated postmortem blood levels, thus rendering it more difficult to determine if the cause of death was an overdose. This study, a review of 24 TCA-related deaths, is aimed at defining the practical significance of such a problem and providing a workable approach to interpreting postmortem TCA levels. Deaths clearly due to TCA drugs were compared with deaths that were not caused by TCA drugs, but in which the decedent's postmortem blood tested positive for TCA medications. There is little evidence that postmortem elevations in blood TCA levels cause frequent problems in differentiating lethal from nonlethal levels (overdose from nonoverdose cases). The data suggest that using a heart blood level of 0.100 mg/dl as an indicator of lethality is practical at the present time and poses little likelihood of error. Isolated cases suggest that postmortem TCA increases can occur; further work is needed in this area to clarify more fully the significance and frequency of such cases. At present, it seems prudent to utilize peripheral blood samples for TCA testing on autopsy material, if a conservative estimate of TCA concentration is desired, possibly augmented by liver TCA levels and parent-metabolite ratios if money, facilities, and time permit.     

Post-mortem cases involving amphetamine-based drugs in The Netherlands. Comparison with driving under the influence cases

In this study we reviewed the post-mortem cases in the years 1999-2004 that were presented at the Netherlands Forensic Institute. The concentrations of amphetamine-based drugs in femoral blood from cases of suspected unnatural death were compared with concentrations in whole blood from non-fatal cases of driving under the influence (DUI cases) and with literature. Furthermore, the combinations with other drugs and/or alcohol were investigated. Amphetamine-based drugs were present in 70 post-mortem cases and 467 DUI cases. The most detected amphetamine-based drug was MDMA, followed by amphetamine. The presence of MDA could usually be explained by metabolism of MDMA. Methamphetamine and MDEA were rarely present. Frequently, the amphetamine-based drugs were taken in combination with alcohol and/or other non-amphetamine-based drugs such as cocaine or cannabinoids. The 70 post-mortem cases were divided into 38 amphetamine-based drug caused (i.e. the amphetamine-based drug directly caused or contributed to the death) and 32 amphetamine-based drug related deaths (i.e. death was not directly caused by the amphetamine-based drug). In the latter category, other (poly)drug intoxications and death by violence or drowning were the most frequent causes of death. In 30 cases, MDMA caused death directly. The range in blood concentrations of MDMA in these cases was substantial, i.e. 0.41-84 mg/L with a median concentration of 3.7 mg/L (n=30). MDMA blood concentrations in the MDMA related deaths (n=20) and in the DUI cases (n=360) varied up to 3.7 and 4.0 mg/L, respectively. Seven victims died from the direct effects of amphetamine; the blood concentration of amphetamine ranged from 0.24 to 11.3 mg/L, with a median concentration of 1.7 mg/L (n=7). The median concentrations of amphetamine in the amphetamine related deaths (n=13) and the DUI cases (n=208) were much lower, i.e. 0.28 and 0.22 mg/L, respectively. Amphetamine blood concentrations up to 6.0 and 2.3 mg/L were seen in the drug related deaths and DUI cases, respectively. The most frequently encountered amphetamine-based drugs in the investigated deaths were MDMA and amphetamine. The majority of MDMA- and amphetamine-caused deaths, i.e. 90% of these deaths, occurred with blood concentrations above 1.5 and 0.80 mg/L, respectively. MDMA and amphetamine blood concentrations in drug related deaths and DUI cases, however, overlap the range of fatal concentrations. Therefore, MDMA or amphetamine concentrations should never be used alone to establish the cause of death.     

Post-mortem cases involving amphetamine-based drugs in the Netherlands: Comparison with driving under the influence cases

In this study we reviewed the post-mortem cases in the years 1999–2004 that were presented at the Netherlands Forensic Institute. The concentrations of amphetamine-based drugs in femoral blood from cases of suspected unnatural death were compared with concentrations in whole blood from non-fatal cases of driving under the influence (DUI cases) and with literature. Furthermore, the combinations with other drugs and/or alcohol were investigated. Amphetamine-based drugs were present in 70 post-mortem cases and 467 DUI cases. The most detected amphetamine-based drug was MDMA, followed by amphetamine. The presence of MDA could usually be explained by metabolism of MDMA. Methamphetamine and MDEA were rarely present. Frequently, the amphetamine-based drugs were taken in combination with alcohol and/or other non-amphetamine-based drugs such as cocaine or cannabinoids. The 70 post-mortem cases were divided into 38 amphetamine-based drug caused (i.e. the amphetamine-based drug directly caused or contributed to the death) and 32 amphetamine-based drug related deaths (i.e. death was not directly caused by the amphetamine-based drug). In the latter category, other (poly)drug intoxications and death by violence or drowning were the most frequent causes of death.In 30 cases, MDMA caused death directly. The range in blood concentrations of MDMA in these cases was substantial, i.e. 0.41–84 mg/L with a median concentration of 3.7 mg/L (n = 30). MDMA blood concentrations in the MDMA related deaths (n = 20) and in the DUI cases (n = 360) varied up to 3.7 and 4.0 mg/L, respectively. Seven victims died from the direct effects of amphetamine; the blood concentration of amphetamine ranged from 0.24 to 11.3 mg/L, with a median concentration of 1.7 mg/L (n = 7). The median concentrations of amphetamine in the amphetamine related deaths (n = 13) and the DUI cases (n = 208) were much lower, i.e. 0.28 and 0.22 mg/L, respectively. Amphetamine blood concentrations up to 6.0 and 2.3 mg/L were seen in the drug related deaths and DUI cases, respectively. The most frequently encountered amphetamine-based drugs in the investigated deaths were MDMA and amphetamine. The majority of MDMA- and amphetamine-caused deaths, i.e. 90% of these deaths, occurred with blood concentrations above 1.5 and 0.80 mg/L, respectively. MDMA and amphetamine blood concentrations in drug related deaths and DUI cases, however, overlap the range of fatal concentrations. Therefore, MDMA or amphetamine concentrations should never be used alone to establish the cause of death.     

Is urine a suitable material for the preliminary screening of drugs in autopsy cases?

This paper reports a survey of drug screening in the urine specimens of 45 autopsy cases whose livers contained medicinal substances. The extractions were carried out by a solid phase/liquid technique and the analyses by thin-layer chromatography. Nine compounds out of 43 actually present in the liver were not detectable in the urine; eight cases with high drug concentrations in the liver and also in the blood would have evaded the intoxication suspicion had the urine been used as the only material for the chemical survey. On the basis of these data we advocate that the preliminary drug screening of medical-examiner cases not be carried out on urine alone.     

HIV-infection in forensic autopsy cases

Sudden and unexpected death and violent death of persons with a high risk of acquiring HIV-infections, especially homosexual males and intravenous drug abusers, have to be investigated by forensic autopsies. Therefore every forensic pathologist has to be aware of this infection and should try to make the proper diagnosis. Three typical cases are described: (1) suicide by hanging, (2) homicide by cutting the throat and (3) intravenous heroin overdose. Merely retrospectively it could be cleared up that the deceased were homosexual but did not manifestly suffer from AIDS. The morphological findings in the lymph nodes and the postmortem serological findings are described in detail.     

Investigating demodex in forensic autopsy cases

Demodex is an ectoparasite living in the skin as a nonpathogen or a pathogen. It is also known that demodex acts as a vector of pathogenic microorganisms. In this study, we have investigated the rate of occurrence and vitality of demodex in forensic autopsies that have a high risk of contamination by infected organisms. The study, which was cross-sectional, conducted on 100 autopsy cases: 77 of the bodies were male and 23 female. The average age was 41. The samples were taken from the forehead, nose, cheeks, eyelashes and the temporal areas using the standardized skin surface biopsy and hair epilation techniques that were modified for this study. The data obtained were assessed statistically. Demodex was determined in 10% of all the cases. The cases revealed that demodex increased in old age and was more frequently seen in people with fair complexion. It was most frequently found in the forehead and the cheek. The longest postmortem interval in the positive cases was 55 h. The relationship between the postmortem interval and the presence of demodex was not statistically significant. Considering the fact that demodex, which is transmitted from human to human through skin contact, acts as a vector of pathogenic organisms and can stay alive in dead bodies for a long time, we think that the personnel performing autopsies without taking the necessary precautions are under risk.     

Detection of antidepressant and antipsychotic drugs in human hair

The presence of therapeutic drugs and their metabolites in the hair of psychiatric patients was investigated using gas chromatography (GC)-mass spectroscopy (MS)-electron ionization (EI) and GC-MS-chemical ionization (CI). In hair samples tested from 35 subjects, carbamazepine, amitriptyline, doxepin, trihexyphenidyl, chlorpromazine, chlorprothixene, trifluoperazine, clozapine and haloperidol were detected, with maximal concentrations of 22.5, 57.7, 183.3, 15.6, 68.2, 30.0, 36.8, 59.2 and 20.1 ng/mg of hair sample, respectively. Chlorpromazine and clozapine concentrations in the hair were found to be dependent on the dosage used and their correlation coefficients were 0.8047 (P<0.001, n=16) and 0.7097 (P<0.001, n=16), respectively. Segmental analysis demonstrated that there was a correlation between the history of subject's drug exposure and the distribution of drug along the hair shaft. Our results also show that drug analysis in hair may provide useful information about drug treatment and the history of usage, and that drugs can be detected in normally kept hair for at least 16 months after intake.     

Two tricyclic antidepressant poisonings: levels of amitriptyline, nortriptyline and desipramine in post-mortem biological samples

Two deaths due to amitriptyline and desipramine overdoses are reported. The first case deals with a 20-year-old Caucasian male who was found dead at his residence. Toxicological analysis of the blood, urine, liver and kidney revealed the presence of amitriptyline (1.7 mg/l, 0.13 mg/l, 36.0 mg/kg and 98.0 mg/kg) and nortriptyline (0.66 mg/l, 0.74 mg/l, 12.0 mg/kg and 37.0 mg/kg). The gastric content contained only 220 mg of amitriptyline. The urine also contained norverapamil, which was consistent with previous verapamil therapy. The second case involved a 19-year-old Caucasian male who attempted suicide earlier and was on desipramine medication. The blood, urine, liver and gastric content disclosed the presence of desipramine in the concentrations of 14.2 mg/l, 33.7 mg/l, 112.5 mg/kg and 180 mg, respectively. The levels of these tricyclics analyzed by high pressure liquid chromatography were in agreement with the levels reported in the literature. Though with the amitriptyline poisoning no significant anatomic changes were noted, the desipramine-caused death was further supported by the multisystem vascular congestion and ischemic changes consistent with cardiopulmonary failure.     

An autopsy case of combined drug intoxication involving verapamil,metoprolol and digoxin

We present here a fatal poisoning case involving verapamil, metoprolol and digoxin. A 39-year-old male was found dead in his room, and a lot of empty packets of prescribed drugs were found near the corpse. The blood concentrations of verapamil, metoprolol and digoxin were 9.2 microg/ml, 3.6 microg/ml and 3.2 ng/ml, respectively. The cause of death was given as cardiac failure, hypotension and bradycardia due to a mixed drug overdose of verapamil, metoprolol and digoxin, based on the results of the autopsy and toxicological examination. We speculate that the toxicity of verapamil is potentiated by drug interaction with metoprolol and digoxin.     

607例不同年份中毒尸检资料对比分析

目的研究不同年份中毒案例的毒物种类、中毒途径、中毒方式等相关问题,为此类案例的法医学鉴定提供参考。方法对华中科技大学同济医学院法医学系（湖北同济法医学司法鉴定中心）1957—2008年鉴定的607例中毒案例尸检资料进行对比分析。结果 1999—2008年218例中毒案例中死者男性居多,30～49岁占50%,中毒以口服方式为主,意外中毒居首位,毒物种类以杀鼠剂、有毒气体、农药类位居前三位。与1983—1998年及1957—1982年的中毒尸检资料对比,不同年份间毒物种类明显变化,近年农药、氰化物中毒减少,杀鼠药、有毒气体及醇类中毒增加,毒品滥用激增。结论农药中毒是长期威胁公众健康的一类毒物,须对此提高防范意识;对联合中毒日益增多的趋势应引起关注。     

100例重度颅脑损伤尸检分析

本文总结分析１００例重度颅脑损伤的尸检资料。年龄最小４个月，最长者７１岁，男性７０例，女性３０例。颅脑损伤成因以钝器伤、高坠伤、跌伤及交通事故为多。头皮损伤占８３％，头皮无明显损伤但有颅脑损伤者占１７％。颅骨骨折占７１％，以线状骨折为多（４５％），粉碎骨折次之（２２．５３％），颅骨骨折常合并颅内出血。两者并存者６９例，占颅内出血７０．４１％，有颅内出血无颅骨骨折２９例，占２９．５９％，略高于文献报告。硬膜外出血（ＥＤＨ）占３５％，冲击部占８８．５７％，对冲部占２０％。硬膜下出血（ＳＤＨ）占４０％，冲击部占８５％，对冲部占２５％。蛛网膜下腔出血占８７％。髓内出血８６％，合并ＥＤＨ占３３．７２％，合并ＳＤＨ占３６．０５％，ＥＤＨ、ＳＤＨ和髓内出血者同时发生占８．２６％。脑室出血占１２％。脑挫伤裂伤占６４％，有冲击伤和对冲伤占４６．８８％，有冲击伤无对冲伤占２８．１２％，无冲击伤有对冲伤占２５％。脑疝：小脑扁桃体疝占６７％，海马钩回疝占６０％，略高于文献报告，结合本文资料，对病理特点及法医鉴定中应注意问题略加讨论。     

头孢类药物致过敏性休克死亡20例分析

目的 探讨头孢类药物所致过敏性休克死亡案件的病理学特点,为法医学鉴定提供依据.方法 对中国医科大学法医司法鉴定中心2005年4月-2009年8月受理的20头孢类药物致过敏性休克死亡鉴定案件进行回顾性分析.结果 死者年龄主要集中在40～60岁,90%的案例发生在基层医疗机构.用药后至休克症状出现在30s～150min,休...     

Fatal pyomyositis: a report of 8 autopsy cases

Pyomyositis is an acute bacterial infection manifesting as pyemic abscess formation in the skeletal muscles. We examined 8 autopsy cases (seven males, one female; age range 21-75 years) of fatal nontropical pyomyositis to better describe individual case characteristics and pathologic features of this rare disease. The pathogen most frequently involved was Staphylococcus aureus. In most cases, there were several abscesses and multiple sites involved. The trunk, shoulder girdle, and thigh muscles were most frequently affected and involvement of multiple sites was a common finding. In 6 cases, a recent trauma had occurred to the anatomic location where the pyemic abscesses were found. Three deceased were known as intravenous drug abusers. Except for the presence of pyomyositis, liver diseases such as cirrhosis in 3 cases, and a fatty liver in 2 cases were the most frequent autopsy findings. Death was due to sepsis in all cases. Because pyomyositis may develop in association with intravenous catheterization in the clinical setting, the question whether pyomyositis was caused by an infected or improperly placed indwelling intravenous catheter may be of forensic importance in the light of alleged medical malpractice. According to our observations, severe underlying illnesses seem not always necessary for fatal outcome of pyomyositis. Because a detailed dissection of superficial as well as deep skeletal muscles during autopsy is a prerequisite for the diagnosis, the disease may be overlooked when this essential step is not performed.     

Argemone mexicana poisoning: autopsy findings of two cases

Epidemic dropsy, a disease due to Argemone mexicana poisoning, is characterized by pathological accumulation of diluted lymph in body tissues and cavities. Recently, the largest epidemic of the disease in India affected Delhi and its neighboring states during the months of August-September 1998. Over 3000 persons fell ill, and more than 65 died in the state of Delhi alone. Two cases belonging to the same family died, out of the large number of cases admitted in this tertiary care teaching hospital situated in eastern part of Delhi. Autopsy findings of these two cases are presented and discussed here along with the review of toxicity due to this poisoning.     

200例颅脑损伤尸体剖验分析

通过对200例颅脑损伤致死亡案件的损伤情况进行对比分析,总结不同致伤物体以不同打击方向、着力点、先后顺序等造成的颅脑损伤形态特点,对推断致伤工具及判断案件性质有一定意义。     

A study of 44 forensic autopsy cases of adrenal hemorrhage

44 cases of adrenal hemorrhage (AH) were analyzed. The forensic autopsy showed that AH occurred mainly in male aged from 20 to 40 years old. The traumatic AH was more often seen in young men and the pathologic AH was mostly seen in elderly persons. AH were more likely found in bilateral adrenal corticomedullary junction. The pathological grade of AH was not related to the interval time of survival. The pathologic mechanism of AH was discussed as well.     

新疆地区66例多类型栓塞死亡法医学尸检分析

总结分析不同类型的栓子(血栓、脂肪、空气、羊水)栓塞致死的一般特点,探讨其法医病理学鉴定要点及注意事项.对2015～2021年在新疆医科大学司法鉴定所鉴定的66例栓塞致死案例进行回顾分析.经过研究分析,导致患者出现栓塞的因素较多,栓塞致死以肺动脉血栓栓塞多见,另外空气栓塞、羊水栓塞和脂肪栓塞也不容忽视,其均能导致呼吸、...     

论网络色情案件侦查难点

网络色情犯罪主要是指利用互联网络以牟利为目的,制作、复制、贩卖、传播色情信息,或者虽不以牟利为直接目的,传播淫秽信息情节严重的行为,或者引诱、介绍卖淫等犯罪行为。目前我国网上扫黄行动方兴未艾,严重打击了网络犯罪行为,净化了网络环境。色情网站不会随着一次专项斗争而消失,在未来还将长期存在,如何高效地打击网络色情犯罪,快速地发现并破获网络色情犯罪是一件非常重要的课题。本文就网络色情案件的特点与规律进行分析,并针对网络色情犯罪侦查难点进行了深入的探讨。