The general toxicology unknown. I. The systematic approach

The general toxicology unknown often presents challenges and interests to toxicologists. A systematic analytical approach to search for drugs or poisons is presented here. The preliminary screening analyses were as follows: alcohol by gas chromatography (GC), ethchlorvynol colorimetric analysis, enzyme multiplied immunoassay technique (EMIT), basic drug screening by GC, and neutral and weakly acidic drug screening by GC. Other additional analyses were performed depending on the special circumstance of each individual case and the results of these preliminary analyses. Positive findings were confirmed by computerized gas chromatography/mass spectrometry when practical. Quantitation was performed by GC whenever possible.     

Bupropion and alcohol fatal intoxication: case report.

A fatality due to the ingestion of bupropion and ethanol is presented. Bupropion and its metabolites were extracted from several tissues and identified using gas chromatography with nitrogenphosphorus and mass spectrometry detection. The concentrations of bupropion, hydroxybupropion and the erythroamino and threoamino alcohol metabolites in heart blood were 4.2, 5.0, 0.6 and 4.6 mg/l, respectively. The heart blood ethanol concentration was 0.27 g/dl. In addition, bupropion was distributed as follows: subclavian blood, 6.2 mg/l; bile, 1.4 mg/l; kidney, 2.4 mg/l; liver, 1.0 mg/kg; stomach contents, 16 mg and urine, 37 mg/l.     

Lethal orphenadrine intoxication: report of a case.

A case of lethal orphenadrine intoxication is reported. Included are the anatomical and toxicological findings. Most conspicuous histologically was the centrilobular necrosis of the liver.     

Acute flurazepam intoxication: a case report

A fatality due to ingestion of flurazepam is reported. Flurazepam is a benzodiazepine, a widely prescribed hypnotic drug for use in sleep disorders. There are only few documented reports of the disposition of flurazepam in deaths due to overdose. A 68-year-old woman was found deceased at home with no evidence of trauma or asphyxia. Toxicologic analyses were performed and drug levels measured by means of gas chromatography coupled to mass spectrometry. The flurazepam concentration in each specimen was as follows: heart blood 2.8 microg/mL, bile 323 microg/mL, and urine 172 microg/mL. Presence of flurazepam into gastric content was observed too. Based on the autopsy findings, patient history, and toxicologic results, the cause of death was determined to be acute intoxication of flurazepam and the manner, suicide.     

Lithium intoxication. A case study

This study reports a fatal ingestion of lithium carbonate and its distribution in tissues and biological fluids.     

Pseudolaminar necrosis in cyanide intoxication: a neuropathology case report

We describe the gross and microscopic neuropathological changes in the brain of a 17-year-old male who died 4 days after being poisoned with cyanide. Previous reports indicate that following cyanide intoxication, the brain develops diffuse hypoxic/ischemic changes, predominantly of the basal ganglia. The case we describe here had similar features but in addition showed striking laminar necrosis of the cerebral cortex. This finding in cyanide poisoning has been previously demonstrated by neuroimaging, but not pathologically.     

Homicidal ethylene glycol intoxication: a report of a case

We report a case of a 75-year-old hypertensive, diabetic man who presented to the emergency room with symptoms and signs of nausea, acute intoxication, significant alteration in mental status with rapid neurologic deterioration, and blunt impact injuries sustained during a recent altercation with a 36-year-old female companion-caretaker. He denied a history of ethanol abuse or other recent toxic ingestion and had not been diagnosed with or treated for depression. Hospital laboratory tests revealed a metabolic acidosis and a negative urine toxicology screen. He was diagnosed with toxic encephalopathy with metabolic acidosis secondary to metformin. Despite treatments including hemodialysis, he expired after approximately 28 hours of hospitalization. A postmortem anatomic examination revealed recent blunt-impact injuries and cardiac and renal pathology. A subsequent histologic examination revealed the presence of calcium oxalate crystals in the kidneys and brain, in addition to cardiac and renal pathology. Comprehensive forensic toxicologic testing was performed on antemortem and postmortem samples and revealed lethal levels of ethylene glycol. The cause of death was as a result of acute intoxication by ethylene glycol with another condition of multiple blunt impacts to the head, trunk, and extremities. The manner of death was ruled as homicide. A trial by jury, involving the female companion-caretaker, resulted in her conviction, and she was sentenced to 23 years to life in prison. In this report, we present an unusual case of homicidal ethylene glycol intoxication in which legal proceedings have occurred.     

The poisoned pen. A case report

In a case of suicide by overdose of a sedative and hypnotic and a tranquilizer the author analyses the deterioration in writing ability in the time frame recorded by the victim.     

Fatal intoxication due to tramadol alone: case report and review of the literature

Poisoning may also lead to both coma and multiple organ failure, also in youngsters without a known major medical history. As not all toxic agents are routinely screened when a poisoning is suspected, it is useful to consider less frequently encountered poisons in certain cases. We describe the occurrence of asystole and multiple organ failure which occurred in a young man after a suspected tramadol overdose. The tramadol concentration on admission in the ICU was indeed 8 microg/ml (mg/l), far above the therapeutic range. Subsequently, the patient developed severe acute liver failure, finally leading to death. Post-mortem toxicology did not reveal any other poison responsible for this unfavourable course as only very high serum and tissue tramadol and desmethyltramadol concentrations were found. Only a few fatal poisonings attributable to tramadol alone, as observed in our case, have been reported. An overview of these cases is presented.     

Fatal acute alcohol intoxication in an ALDH2 heterozygote: a case report

On an evening in November, a 25-year-old man was found dead in his bedroom. There were many empty snap-out sheets for flunitrazepam tablets in the trash at his bedside. He had been beaten by a gang of young people earlier in the morning of the same day. At the medico-legal autopsy, although there were many bruises and/or abrasions on the whole body, only slight subdural hemorrhage was observed, and none of them was thought to be the cause of death. Flunitrazepam and its metabolites were not detected in his body fluid by gas chromatography-mass spectrometry (GC-MS). Marked lung edema and a severe congestion of organs were observed. His blood alcohol concentration from the femoral vein was 2.00 mg/ml. Fatal cases of acute alcohol intoxication usually have shown higher alcohol concentration (2.25-6.23 mg/ml). Although the genotype of aldehyde dehydrogenase 2 (ALDH2) has not previously been mentioned as a contributing factor in determining the cause of death, in this case the genotype of ALDH2 was ALDH2*1/2 and thus is important. Those who possess the ALDH2*2 gene show high concentrations of acetaldehyde (AcH) at even comparatively lower alcohol levels. Consequently, the cause of death was considered to be acute alcohol intoxication including AcH poisoning.     

Characteristics and dose-effect relationship of clinical gamma-hydroxybutyrate intoxication: A case series

Gamma-Hydroxybutyrate (GHB) overdoses cause respiratory depression, coma, or even death. Symptoms and severity of poisoning depend on blood-concentrations and individual factors such as tolerance. A retrospective case study was conducted, evaluating GHB intoxication cases. GHB-concentrations in blood and urine were determined by gas chromatography-mass spectrometry (GC-MS) along with, in part, via enzymatic assay. GHB-concentrations, demographic data, and additional drug use, as well as specific clinical information, were evaluated. The correlation between GHB-levels in blood and associated symptoms were examined. In total, 75 cases originating from the Emergency Departments (EDs) of Hamburg and surrounding hospitals were included. Fifty-four of the patients (72%) were male. The mean GHB-concentration in blood was 248 mg/L (range 21.5–1418 mg/L). Out of the group with detailed clinical information (n = 18), the comatose group (n = 10/18) showed a mean of 244 mg/L (range 136–403 mg/L), which was higher than that of the somnolent and awake patients. Of the comatose collective, 70% (n = 7) showed co-use of one or more substances, with the additional use of cocaine being the most frequently detected (n = 5). In conclusion, a moderate dose-effect relationship was observed, although, there was some overlap in dosage concentration levels of GHB in awake and comatose patients. In GHB-intoxication cases, co-use was common as were clinical effects such as acidosis, hypotension, and impact on the heart rate. Timely analytical determination of the GHB-concentration in blood could support correct diagnosis of the cause of unconsciousness.     

Pathological intoxication and alcohol idiosyncratic intoxication--Part II: Legal aspects

The law does not generally allow alcohol intoxication as a defense in a criminal matter. Among the exceptions may be pathological intoxication, or PI, or its current psychiatric correlate, alcohol idiosyncratic intoxication (AII). Because of the lack of specificity in the medical concept and the varying approaches by different authors, careful analysis and adherence to current standards are necessary. Relevant laws, particularly that of the model penal code, are reviewed, as are three cases which demonstrate the issues involved. Actual testimony is presented to illustrate possible misuse or inappropriate use of the concept.     

A case of fatal intoxication with ammonium sulfate and a toxicological study using rabbits.

Agricultural fertilizers such as ammonium sulfate are widely used in house gardens as well as in agriculture, but few case reports or toxicological studies of ingested fertilizers have been reported. This paper investigates a fatal case of ammonium sulfate poisoning and demonstrates its clinical and biochemical findings in rabbits. An 85-year-old woman was found dead lying on the ground outside her house in the middle of March, but the autopsy could not determine the cause of her death. Examination at the police laboratory of the solution in the beer can found next to her showed that it was very likely ammonium sulfate. Our measurement showed a significant increase of ammonium and sulfate ions in serum and gastric contents. The cause of her death was determined as poisoning by ammonium sulfate. The total dose of 1500 mg/kg of ammonium sulfate was administered to three rabbits, all of which showed similar symptoms such as mydriasis, irregular respiratory rhythms, local and general convulsions, until they fell into respiratory failure with cardiac arrest. EEG showed slow, suppressive waves and high-amplitude slowing wave pattern, which is generally observed clinically in hyperammonemia in man and animal. There was a remarkable increase in the concentration of ammonium ion and inorganic sulfate ion in serum, and blood gas analysis showed severe metabolic acidosis. These results, mainly findings by EEG, have shown that a rapid increase in ammonium ions in blood can cause damaging the central nervous system without microscopic change. When the cause of death can not be determined, measurement of ammonium ion, inorganic ion and electrolytes in blood as well as in stomach contents at forensic autopsy is necessary.     

Means for identifying unknown cadavers. A report of experiences from forensic practice]

98 cases of unidentified corpses found in the region of Frankfurt/M. during the period 1981-1986 were investigated. The different methods used in the investigation processes were compared. The most important results: 1. The condition of the body had very little influence on the time required for identification. 2. The estimated ages tended for ages up to 50 years to be too low and for ages of 50 years and over too high. 3. Visual recognition of the deceased and comparison of finger prints proved to be the most successful methods and provided the best results. 4. In more than half of the cases distinguishing bodily features, clothing and jewelry were helpful in the identification procedure; in 9% of the cases they alone formed the basis of identification. 5. Abductions were carried out in only 30% of the cases, 43% of which led to conclusive results.     

Scald burns complicated by isopropyl alcohol intoxication. A case of fatal child abuse

Scald burns are the most common type of thermal injury in child abuse. Death associated with nonaccidental burns, however, is uncommon. We recently investigated the case of a 4-year-old child who died from extensive body burns due to scalding. A contributory cause of death was isopropyl alcohol intoxication resulting from application of this chemical to the burns.     

A death due to ethchlorvynol abuse. A case report

A fatal case of ethchlorvynol abuse is reported with blood and tissue determinations.     

A diflunisal related fatality: a case report

A case is reported where the death of an individual resulted from the ingestion of diflunisal. Diflunisal was identified by a combination of liquid chromatography, UV spectrophotometry and colorimetry. Diflunisal was quantified in blood (260 mg/l), bile (71 mg/l), kidney (350 mg/kg), liver (400 mg/kg), stomach contents (34 mg) and urine (78 mg/l). No previous literature references discussing diflunisal related fatalities were available.     

The unknown depths of political theory: The case for a multidimensional concept of corruption

Defining corruption has proven to be such a difficult challenge that many contemporary analysts pass over the question as quickly as possible. But while definitions are too important to be dismissed as an analytical concern, a single one-dimensional definition that will satisfy all observers will never be found. Rather than proposing yet another definition, this article explores five dimensions of the concept: corruption as social decline, as deviant behavior, as a logic of exchange, as a system of measurable perceptions, and corruption as shadow politic. All help us view corruption within actual social settings; all lend further detail to the sorts of contrasts among concepts and usages that Arnold Heidenheimer explored in his work. In the end one of the most important aspects of the issue is that of trust, which not only helps us understand how corruption functions in actual cases but also underscores the reasons why we must continue to fight it.     

Bullet embolism with radiologic documentation. A case report

A case of bullet embolism is reported wherein a handgun missile, fired during a "shoot-out," perforated (among other structures) the anterior and posterior walls of the thoracic aorta, rebounded into the aortic lumen, and was transported to the left femoral artery where it came to rest. Roentgenographic study was instrumental in promptly locating the errant bullet whose recovery established the identity of the responsible firearm. The implications of bullet embolism of the arterial, venous, and paradoxical types for the forensic pathologist and the clinician are discussed briefly.     

Chronic extradural haemorrhage. A case report and brief literature review

A case of chronic extradural haemorrhage with a presumed time interval of 5-6 weeks between injury and diagnosis at postmortem examination is presented. The literature relating to this entity has been reviewed, and relevant features commented upon, including time intervals, age, sex, location, clinical features, pathological findings, associated skull fractures, mechanisms involved, and the source of the bleeding.