Forensic-medical diagnostic implication of morphine levels in the blood and urine

Toxicological characteristics are presented for 198 cases of acute parenteral poisoning with morphine and heroin. The range of their metabolites concentration in the blood and urine encountered in practice are analysed. Principal causes of death due to opiate poisoning in inpatients are shown. Opiates toxicity was assessed by the method of logit-regression and dose-effect curves for analysis of probability of death depending on opiate metabolite concentration in blood and urine. Relations between probability of death and detection of morphine in biological media of the victims are considered. Morphine concentrations in the blood and urine undoubtedly indicating morphine poisoning are determined.     

Forensic medicine and toxicologic aspects of 2-propanol poisoning

Two cases of poisoning with 2-propanol (isopropylalcohol) are reported. In one case, nail polish remover was drunk by a 2-year-old child. The concentration of 2-propanol and its metabolite acetone in the blood could be observed over a period of approximately 50 h. The highest concentration of 2-propanol determined was 4.22 g/l. Acetone reached a maximum value of 2.27 g/l 12 h after ingestion. The child survived without any observable after-effects. In the second case, a 35-year-old man drank ethanol in addition to 2-propanol. The poisoning was lethal. The possible time of intake before death is discussed in relation to the estimated levels of ethanol, 2-propanol and acetone found in the blood and urine. The histomorphological findings are often important as well with regard to time of intake.     

Death by potassium chloride intravenous injection: evaluation of analytical detectability

Potassium chloride intravenous injection is used in suicide attempts and lethal procedures for state-sanctioned punishment. Owing to its relatively high concentrations in hemolyzed blood (25-80 mM) compared to serum (about 4 mM), it is difficult to conclude potassium poisoning by postmortem analysis of biologic samples. A 41-year-man was found dead with an injection sign on his foot and a syringe close to the corpse. No particular signs were noted during the autopsy. Blood, bile, and urine were submitted to xenobiotic screening procedures used in the laboratory. Syringe content was found positive to potassium ions. Blood potassium concentration was determined by ion-selective electrode measurement (range 3.0-150 mM). Blood was found positive for diazepam at therapeutic level. Potassium concentration was 160.0 (cardiac) and 87.3 mM (femoral blood). Our results show that potassium concentration was significantly higher in heart blood in a suicide case. Hence, the general issue of considering potassium poisoning hardly demonstrable by toxicology needs to be questioned and thoroughly studied.     

Diagnostic implication of blood and urine morphine content in alcohol intoxication

A total of 198 cases of acute parenteral poisoning with opiates are characterized. The range of concentrations of opiates metabolites in the blood and urine, main causes of death due to opiate poisoning in alcohol intoxication are analysed. Opiates toxicity was assessed with the logit-regression method and dose-effect curves valid for analysis of relationships between probability of death and opiate metabolites concentration in blood and urine. Correlation between probability of death and detection of morphine and ethanol in biological media of the victims is considered. Concentrations of morphine in blood and urine definitely indicating opiates poisoning in alcohol intoxication as a cause of death are determined.     

Fatal doses and concentrations of drugs in biological objects

Information on the lethal doses and concentrations of drugs in biological objects is essential for the diagnosis of drug poisoning. Methods for measuring the concentrations of some drugs in the blood and urine have been developed and tables of lethal doses, concentrations, and metabolism coefficients for drugs most often occurring in forensic medical practice are offered. A method for estimating the drug dose which led to a lethal outcome is suggested.     

Using DNA-barcoding to make the necrobiont beetle family Cholevidae accessible for forensic entomology

Although many cases of fatal hydrogen sulfide poisoning have been reported, in most of these cases, it resulted from the accidental inhalation of hydrogen sulfide gas. In recent years, we experienced 17 autopsy cases of fatal hydrogen sulfide poisoning due to the inhalation of intentionally generated hydrogen sulfide gas. In this study, the concentrations of sulfide and thiosulfate in blood, urine, cerebrospinal fluid and pleural effusion were examined using GC/MS. The sulfide concentrations were blood: 0.11-31.84, urine: 0.01-1.28, cerebrospinal fluid: 0.02-1.59 and pleural effusion: 2.00-8.59 (μg/ml), while the thiosulfate concentrations were blood: 0-0.648, urine: 0-2.669, cerebrospinal fluid: 0.004-0.314 and pleural effusion: 0.019-0.140 (μmol/ml). In previous reports, the blood concentration of thiosulfate was said to be higher than that of sulfide in hydrogen sulfide poisoning cases, although the latter was higher than the former in 8 of the 14 cases examined in this study. These results are believed to be strongly influenced by the atmospheric concentration of hydrogen sulfide the victims were exposed to and the time interval between exposure and death.     

A case of suicide by ingestion of sodium nitroprusside.

The study reports a case of suicide by ingestion of sodium nitroprusside which resulted in acute cyanide poisoning. Analyses carried out on body fluid yielded the quantitation of total (5.00 mg/L) and free (3.30 mg/L) cyanide in blood and of methemoglobin (blood = 10.5%). At the scene, some solid reddish-brown material was found in a glass, which on toxicological analysis was found to contain sodium nitroprusside; about 9 g of the same substance was identified in stomach contents. The detection and quantification of cyanide and methemoglobin in biological samples from the case indicated that the lethal effect was due to both metabolic products (cyanide and methemoglobin).     

溴敌隆及其代谢物-苄叉丙酮在犬体内的死后分布

目的研究溴敌隆及其代谢物-苄叉丙酮在中毒致死犬体内死后分布规律,为溴敌隆中毒检材的采取提供实验依据。方法分别经口给予犬2倍和4倍LD_(50)溴敌隆,待其死亡后迅速解剖取材,气相色谱-质谱联用法测定心血、外周血、尿、胆汁、心、肝、脾、肺、肾、脑、左下肢肌、膀胱、胃、胃内容、胰等脏器和体液中溴敌隆和代谢物-苄叉丙酮的含量。结果犬经2倍和4倍LD_(50)溴敌隆灌胃染毒后3d开始出现出血症状,(178.40±20.94)h后死亡。溴敌隆和代谢物-苄叉丙酮在各组织脏器及体液中的死后分布为:溴敌隆2LD_(50)组溴敌隆:胆汁尿、肝、心、肾心血、外周血、脾、肺等;苄叉丙酮:胆汁、尿、心血、外周血、肺、胃内容中含量高于其他脏器。溴敌隆4LD_(50)组溴敌隆:胆汁、尿肝、外周血心血、胃内容物等脏器。苄叉丙酮:胆汁、尿、肺浓度高于其他脏器。结论溴敌隆及其代谢物-苄叉丙酮在中毒致死犬体内死后分布不均匀,溴敌隆在胆汁、尿、肝脏、心血和外周血含量较高,代谢物-苄叉丙酮在胆汁、尿、肺较高。胆汁、尿、肝脏、心血、外周血可作为疑似溴敌隆中毒毒物分析的检材。     

Bupropion Overdose Resulted in a Pharmacobezoar in a Fatal Bupropion (Wellbutrin®) Sustained‐release Overdose: Postmortem Distribution of Bupropion and its Major Metabolites

Bupropion (BUP) overdose commonly causes generalized seizures and central nervous system depression. The case of a 28‐year‐old woman who died from a massive lethal overdose with sustained‐release bupropion (Wellbutrin^® 300 mg) is herein presented. The autopsy revealed the presence of a pharmacobezoar consisting of at least 40 tablets in the stomach. Determination of bupropion and its active metabolites (hydroxybupropion, threobupropion, erythrobupropion) was achieved by a liquid chromatographic mass spectrometry (LC‐MS/MS) method. Postmortem concentrations for bupropion, hydroxybupropion, threobupropion, and erythrobupropion were obtained in intracranial blood, urine, bile, liver, kidney, and vitreous humor. In this case, intracranial blood level of the parent drug was 1.9 mg/L. Threobupropion was the most abundant metabolite in both blood and urine, 59.3 and 890.6 mg/L. Tissue distribution showed the highest concentration in the liver, 12.3 mg/kg. The 0.8 bupropion concentration ratio vitreous/blood suggested that vitreous could be a valuable specimen for toxicological analysis should postmortem blood be unavailable.     

Evaluating suspected co-proxamol overdose.

In three instances of suicidal poisoning by co-proxamol (paracetamol and dextropropoxyphene) blood samples were obtained from 11 sites together with eight tissue samples, bile, urine, gastric contents and duodenal contents. Site-dependent differences in blood propoxyphene concentration varied between the three cases but concentrations were consistently lowest in peripheral blood and highest in central sites: 3.9-5.5 (pulmonary vein) mg/l; 4.6-25 (pulmonary vein) mg/l; 3.2-40 (aorta) mg/l. There was a less than twofold variation in corresponding blood paracetamol concentrations. Reference data on fatal propoxyphene blood concentrations do not specify the blood sampling site and can be misleading. The intra-individual variability of propoxyphene concentrations in blood in these three cases underscores this problem. Tissue concentrations of propoxyphene showed considerable inter-individual variability in degree and pattern. Tissue concentrations of paracetamol showed a less than twofold intra-individual variation. Body drug loads were calculated by two methods: from organ weights and tissue concentrations; from published volume of distribution data (Vd). For paracetamol the body drug load is underestimated by the organ weight calculation but the Vd calculation approximates the suspected dose based on anamnestic information. For propoxyphene the body drug load is seriously underestimated by the organ weight calculation and overestimated up to 2.5 times by the Vd calculation. Since the two drugs have a fixed ratio in co-proxamol then the dose of propoxyphene (the effective lethal agent) can be inferred from the paracetamol dose calculated by Vd. This approach may be applicable to cases of overdose with other compounded drug preparations.     

离子色谱法检测全血中的亚硝酸盐及其代谢产物

目的建立全血中亚硝酸盐的离子色谱分析方法。方法将0.5mL全血和1mL水混合,用乙腈沉淀血液中的蛋白质后依次过C18柱、Ag柱和Na柱,用于去除其中的有机物和氯离子后进行离子色谱检测,并对蛋白沉淀溶剂、前处理柱等最佳实验条件进行考察。结果采用本文方法对空白添加全血进行检测,在色谱图上亚硝酸根离子及其氧化产物硝酸根离子的保留时间分别为10.02min、19.21min。选择乙腈作为蛋白沉淀剂,C18柱去除有机物,Ag柱去除氯离子,Na柱去除银离子。全血中亚硝酸根离子的检出限为0.05μg/mL,亚硝酸根和硝酸根的总回收率为95.9%~117.3%。结论本文方法简便,回收率好,灵敏度高,适用于中毒者血液中亚硝酸盐的检测。     

阿普唑仑在家兔体内的分布研究

建立生物检材内阿普唑仑的薄层扫描定性定量检测方法，研究阿普唑仑在染毒家兔体内的分布情况。家兔按21mg/Kg剂量灌胃染毒后4h，其体内肝、脾、肾、肺、心、脑、血、胆汁和尿内阿普唑仑的浓度分别为19．6±6．1、3．3±0．5、3．5±0．3、0．4±0．1、0．4±0．1、1．6±1．8、4．0±1．3、20．4±8．5和8.6±2．4（ug／g或ug／ml）。阿普唑仑在染毒家兔体内的分布不均匀，血、胆汁和尿是阿普唑仑中毒死者毒物分析较好的检材。     

Forensic medical expert evaluation of lethal poisoning with narcotics

Morphological manifestations of lethal narcotic poisoning are analyzed on the basis of results presented in "Acts of Medical Examination of Corpse" and "Expert Conclusions" on 352 cases with lethal narcotic poisoning, suspected (with good grounds) poisoning, and combined poisoning with narcotics and other agents. Causes of failure to detect narcotics in forensic chemical analysis of biological material from the corpse are enumerated.     

阿维菌素在急性中毒死家兔体内的再分布研究

目的考察阿维菌素在急性中毒死家兔体内的再分布。方法按最小致死量一次性灌胃250mg/kg阿维菌素,HPLC法检测家兔死后0h、24h、48h和72h中阿维菌素的含量。结果给家兔一次性灌胃250mg/kg阿维菌素的临床死亡时间为120.6±9.2min(±s,n=10);测定了阿维菌素的致死血浓度和致死组织浓度;家兔死后0h~72h心血和各主要脏器组织中阿维菌素含量存在体内再分布现象;确定肝、肾、肺为最佳组织检材。结论阿维菌素在急性中毒死家兔体内的再分布数据,对法医办理此类案件具有重要参考价值。     

Disopyramide and Mianserin Intoxication: A Unique Fatal Case – Review of the Literature

Lethal occurrence is exceptional after disopyramide or mianserin poisoning. A case of intentional lethal intoxication with these drugs was reported, as well as a review of the literature. Pre‐ and postmortem blood concentrations of disopyramide or mianserin were assessed in a woman who died from acute cardiac failure after ingestion. The premortem blood concentration of disopyramide alone was considered lethal, and a toxic premortem concentration of mianserin was observed that may have increased cardiovascular failure induced by disopyramide because the metabolism of both drugs is mediated via cytochrome P450. Moreover, it was shown that the postmortem redistribution of disopyramide was limited, as pre‐ and postmortem concentrations were 48 and 65 mg/L, respectively. As regards mianserin, redistribution was observed after death with pre‐ and portmortem concentrations at 0.23 and 0.79 mg/L, respectively. This case illustrates that if postmortem blood concentration of disopyramide is known, the premortem concentration can be deduced.     

Liquid chromatography/photodiode array detection for determination of strychnine in blood: a fatal case report

An original liquid chromatography method with photodiode-array detection (DAD) is presented for the determination of strychnine in blood. This sensitive method allows the use of only 0.1 ml of sample. The strychnine was isolated from blood using a liquid-liquid extraction procedure and chloroquine as an internal standard. The limits of detection (LOD) and quantification were 0.06 and 0.5 mg/l, respectively. The recovery was 94% and the coefficients of variation (CV) ranged from 5.9 to 10.8%. A fatal case of strychnine poisoning is presented, with a lethal blood concentration of 25 mg/l.     

A fatal poisoning involving Bromo-Dragonfly

This paper reports a fatal overdose case involving the potent hallucinogenic drug Bromo-Dragonfly (1-(8-bromobenzo[1,2-b; 4,5-b′]difuran-4-yl)-2-aminopropane). In the present case, an 18-year-old woman was found dead after ingestion of a hallucinogenic liquid. A medico-legal autopsy was performed on the deceased, during which liver, blood, urine and vitreous humour were submitted for toxicological examination. Bromo-Dragonfly was identified in the liver blood using UPLC–TOFMS, and was subsequently quantified in femoral blood (0.0047 mg/kg), urine (0.033 mg/kg) and vitreous humour (0.0005 mg/kg) using LC–MS/MS. Calibration standards were prepared from Bromo-Dragonfly isolated from a bottle found next to the deceased. The structure and purity of the isolated compound were unambiguously determined from analysis of UPLC–TOFMS, GC–MS, HPLC–DAD, ¹H and ¹³C NMR data and by comparison to literature data.The autopsy findings were non-specific for acute poisoning. However, based on the toxicological findings, the cause of death was determined to be a fatal overdose of Bromo-Dragonfly, as no ethanol and no therapeutics or other drugs of abuse besides Bromo-Dragonfly were detected in the liver, blood or urine samples from the deceased. To our knowledge, this is the first report of quantification of Bromo-Dragonfly in a biological specimen from a deceased person. This case caused the drug to be classified as an illegal drug in Denmark on 5th December 2007.     

Ethyl sulphate and ethyl glucuronide in vitreous humor as postmortem evidence marker for ethanol consumption prior to death

To clarify the circumstances of death, the degree of inebriation is of importance in many cases, but for several reasons the determination of the ethanol concentration in post-mortem samples can be challenging and the synopsis of ethanol and the direct consumption markers ethyl glucuronide (EtG) and ethyl sulphate (EtS) has proved to be useful. The use of a rather stable matrix like vitreous humor offers further advantages. The aim of this study was to determine the concentrations of ethanol and the biomarkers in the robust matrix of vitreous humor and to compare them with the respective levels in peripheral venous blood and urine. Samples of urine, blood from the femoral vein and vitreous humor were taken from 26 deceased with suspected ethanol consumption prior to death and analyzed for ethanol, EtS and EtG. In the urine samples creatinine was also determined. The personal data, the circumstances of death, the post-mortem interval and the information about ethanol consumption prior to death were recorded. EtG and EtS analysis in urine was performed by LC-ESI-MS/MS, creatinine concentration was determined using the Jaffé reaction and ethanol was detected by HS-GC-FID and by an ADH-based method. In general, the highest concentrations of the analytes were found in urine and showed statistical significance. The mean concentrations of EtG were 62.8mg/L (EtG100 206.5mg/L) in urine, 4.3mg/L in blood and 2.1mg/L in vitreous humor. EtS was found in the following mean concentrations: 54.6mg/L in urine (EtS100 123.1mg/L), 1.8mg/L in blood and 0.9mg/L in vitreous humor. Ethanol was detected in more vitreous humor samples (mean concentration 2.0g/kg) than in blood and urine (mean concentration 1.6g/kg and 2.1g/kg respectively). There was no correlation between the ethanol and the marker concentrations and no statistical conclusions could be drawn between the markers and matrices.     

Distribution of 3,4-methylenedioxymethamphetamine (MDMA) and 3,4-methylenedioxyamphetamine (MDA) stereoisomers in a fatal poisoning

This communication presents the quantitation and differential distribution of the enantiomers of 3,4-methylenedioxymethamphetamine (MDMA) and its physiologically active metabolite 3,4-methylenedioxyamphetamine (MDA) in a fatal poisoning following insufflation of MDMA, cocaine and heroin. Animal studies have demonstrated the stereoselective pharmacokinetics and neurotoxicity of these compounds; however, enantiomeric distributions have not been reported in humans. Quantitation of MDMA and MDA enantiomer was by gas chromatography/mass spectrometry (GC/MS) following chiral derivatization with N-trifluoroacetyl-l-triproyl chloride (LTPC). The decedents' blood concentration of S(+)-MDMA was slightly less than that of R(−)-MDMA (1.3 vs. 1.6 mg/l, respectively), while the S(+)- and R(−)-MDA blood concentrations were identical (0.8 mg/l). Both primary routes of excretion, bile and urine, had greater concentrations of R(−)-MDMA than the S(+) isomer. These fluids also contained twice the concentration of S(+)-MDA than the R(−)-isomer. These data indicate that S(+)-MDMA is metabolized and eliminated faster than R(−)-MDMA. The results appear to support the findings in animals regarding stereoselective metabolism of MDMA.     

舒乐安定在急性中毒家兔体内的分布

从生物检材中提取分离舒乐安定，采用薄层邑谱扫描法能准确定性、定量，适合于做微量毒物分析。对急性中毒家兔体内舒乐安定测定结果表明，血药浓度达峰值时，肾中含量显著高于其它脏器。因此，在疑为该药中毒时，采集尿进行分析是重要的。