Evaluation of the Role of Toxicological Data in Discriminating Between H2 S Femoral Blood Concentration Secondary to Lethal poisoning and Endogenous H2 S Putrefactive Production.

Hydrogen sulfide is a colorless gas and has a strong odor of rotten eggs. It is absorbed by the upper respiratory tract mucosa, and it causes histotoxic hypoxemia and respiratory depression by exerting an inhibitory effect on cytochrome oxidase. To evaluate the role of toxicological data in distinguishing between the H2 S blood concentration secondary to lethal poisoning and the endogenous H2 S produced during putrefaction, we compared the postmortem H2 S concentrations of six fatal H2 S poisoning cases (8.7-28.6 mg/L) with the postmortem concentrations of endogenous H2 S of 12 subjects who died from other causes (traffic-related deaths) (2.2-32.7 mg/L). These results will be of interest to the forensic community as it underlines the importance of considering circumstantial evidence along with the toxicological and pathological findings in the identification of H2 S lethal poisoning.

The therapeutic use of cannabinoids: Forensic aspects.

UNLABELLED: Since 2013 in the Italian market has been introduced the Nabiximols, a drug containing two of the main active cannabinoids: Δ(9)-tetrahydrocannabinol (Δ(9)-THC) and cannabidiol (CBD). This drug has been approved in Italy in the treatment of Multiple Sclerosis (MS). It is an oral spray formulation and each puff of 100µl contains 2.7mg of Δ(9)-THC and 2.5mg of CBD. In the present study we analyzed urine and blood samples collected from a group of 20 patients treated with Nabiximols in order to evaluate: blood Δ(9)-THC concentrations in relation to the dose administered and the duration of treatment and the potentiality of this medication to be used for drug habit. METHODS: The study was conducted on a sample group of patients affected by MS, of both sexes, age: 49-61 years, treated with Nabiximols for short (28 days) or long-term. The results of our study allow affirming that it is unlikely to use this medication for drug habit or to sale it in the black market because of the low blood concentrations available and of its high costs. These statements were confirmed by: (a) the low Δ(9)-THC concentrations in the pharmaceutical formulation; (b) the low blood concentrations produced by Nabiximols administration, more than 10 times smaller than the blood concentrations known to produce psychotropic effects; (c) the presence of CBD (Δ(9)-THC natural antagonist); (d) the route of administration (inhaled, not smoked).

Domino effect: An unusual case of six fatal hydrogen sulfide poisonings in quick succession.

Hydrogen sulfide (H2S) is one of the most serious toxic gases encountered in forensic practice. Aside from being a by-product of many industrial processes, this gas is naturally produced during the putrefaction of organic substances. We report six autopsy cases of fatal H2S poisonings from inhalation of H2S gas after an occupational accident. These six men died during the unblocking of a wastewater cistern. The first worker died shortly after clearing the obstruction, the other five died, one by one, as they attempted to help their colleagues. The macroscopic and histological findings are discussed here to provide useful information for future cases. Greenish discoloration of the skin and of internal organs (liver, trachea, esophagus, stomach) was observed, and one case showed signs typical of drowning. We present a very unusual incident, complete with rare photographs and toxicological analysis. In these cases, based on both macroscopic and microscopic findings, the cause of death was most likely an inhibitory effect on cellular cytochrome oxidase causing respiratory failure.

Levamisole-adulterated cocaine: Two fatal case reports and evaluation of possible cocaine toxicity potentiation.

Levamisole has been identified as a cocaine adulterant in the United States since 2002. Although there is a variation in the percentage of levamisole in cocaine samples between European countries, measurement of levamisole in human samples of cocaine users has become increasingly important. To our best knowledge, only five deaths are reported (one twice) as a result of complications secondary to levamisole-tainted cocaine and none of these cases reports the post-mortem levamisole concentration. In this article, we present the post-mortem levamisole concentrations in fluids and tissues in two young cocaine users, dead after levamisole-adulterated cocaine intake. With the dearth of levamisole reported concentrations in literature, this particular report is of interest to the forensic toxicological and pathological communities. This article aims to be a supplementary alert to aware the risk that may occur using levamisole-adulterated cocaine and an incentive to publication of toxicity reports and new researches involving the combination of levamisole and cocaine.

Takotsubo cardiomyopathy associated with rupture of the left ventricular apex: assessment of histopathological features of a fatal case and literature review.

Takotsubo cardiomyopathy, also known as "broken heart syndrome," is a cardiac entity characterized by transient left ventricular dysfunction without obstructive atherosclerotic coronary artery disease. An episode of emotional stress is believed to act as a trigger in the development of this syndrome, which typically occurs in female patients. We report a fatal case of a previously healthy 70-year-old woman who suffered an out-of-hospital cardiac arrest and cardiac rupture during emotional distress, due to Takotsubo cardiomyopathy. Ventricular rupture with Takotsubo cardiomyopathy is rare, but our case emphasizes the importance of dealing with this serious and potentially life-threatening disease. Takotsubo cardiomyopathy should be considered as a differential diagnosis in cases of early-developing heart failure, and clinicians should subsequently use adequate diagnostic and therapeutic options.

A fatal accidental subarachnoid injection of lidocaine and levobupivacaine during a lumbar paravertebral block.

Paravertebral block (PVB) is the technique of injecting a local anesthetic solution alongside the vertebral column, close to where the spinal nerves emerge, resulting in unilateral somatic and sympathetic nerve blockade. Here is reported a fatal case involving a 60-year-old woman with spondylitis arthropathy, who developed cardiac and respiratory arrest 40min after receiving an accidental subarachnoid injection (L5-S1 bilaterally) of depomedrol lidocaine and levobupivacaine. A complete autopsy including histological and toxicological analyses was performed in order to establish the cause of death. Liquid/liquid extraction (LLE) and GC-MS analysis were performed according to a previously published method. Lidocaine and bupivacaine were detected both in blood, at concentrations of 14.8mg/L and 13.3mg/L respectively, and in cerebrospinal fluid (CSF) at concentrations of 287.1mg/L and 464.2mg/L respectively. Both lidocaine and bupivacaine were also detected in the urine. The toxicological findings along with the autopsy allowed us to establish that the accidental subarachnoid injection of lidocaine and levobupivacaine had led to a progressive hypotension and normovolaemic shock caused by a severe ganglionic block, determining the patient's death.

A singular case of survival after acute methanol poisoning: toxicological and neuroimaging findings.

Acute methanol poisoning is a relatively uncommon and dangerous form of intoxication. It generally occurs after suicidal or accidental events and can be potentially fatal if not diagnosed and treated promptly. Here reported is the case of a 52-year-old Romanian man who survived acute methanol intoxication. Therefore, it was possible to monitor the clinical evolution, the arterial blood gas assay and toxicological research of methanol in blood and urine, as well as the brain damage by computed tomography and magnetic resonance imaging during a period of 20 days after the intake.

Fatal accidental ingestion of 35 % hydrogen peroxide by a 2-year-old female: case report and literature review.

Deaths after ingestion of hydrogen peroxide (HP) are very rare, but poisoning due to consumption of HP is not uncommon. Most HP exposure involves common household-strength (3 %) HP and is usually benign. Even if it is not generally considered to be a poison, it can cause accidental death. HP results in morbidity through two main mechanisms: direct cytotoxic injury to tissues and formation of oxygen gas. We describe a rare case of a 2-year-old female who died after accidentally ingesting two sips of 35 % HP. For the first time, we provide histopathological images of the damage caused by HP in organic tissues.

A fatal iatrogenic right vertebral injury after transoral odontoidectomy and posterior cervical stabilization for a type II odontoid fracture.

The authors present a singular case of an iatrogenic right vertebral artery injury, involving a 67 year-old man, who reported a type II odontoid fracture (Anderson and D'Alonzo Classification) and posterior atlantoaxial dislocation following a road traffic accident. A small injury involving the right vertebral artery occurred as a consequence of transoral odontoidectomy and posterior cervical stabilization. It was caused by bone spicules of spinal origin and their presence was confirmed by the histological section of the right vertebral artery at the level of C1-C2. The case confirms how iatrogenic vertebral artery injuries during cervical spine surgery may be potentially lethal, especially where complications arise some days after surgery.

A suicidal poisoning due to tramadol. A metabolic approach to death investigation.

Tramadol is a synthetic opioid, widely used for post-surgical and chronic pain. Lethal overdose due only to tramadol is not common; more often the poisoning is due to tramadol in combination with other substances. Reported is a suicidal case of lethal tramadol poisoning in a 48-year-old woman. Tramadol and its metabolites O-desmethyltramadol (M1), N-desmethyltramadol (M2), N,N-didesmethyltramadol (M3), N,O-didesmethyltramadol (M5) were detected by GC/MS in biological fluids (femoral blood, bile, urine, gastric content) and viscera (brain, lung, liver and kidney). The tramadol concentration in femoral blood was 61.83 mcg/ml which is approximately 30 times higher than that believed to be lethal. According with other Authors, a preferential formation of M1 over M2 (M1/M2 ratio >1) is indicative of acute death, while M1/M2 ratio <1 suggests that death occurred after a longer time lapse from ingestion.

The pathogenetic role of adulterants in 5 cases of drug addicts with a fatal outcome.

The purpose of the present study is to determine the role of lidocaine, caffeine and dextromethorphan, used as adulterant substances, in five cases of drug overdose which have come to our attention. Taking into account the pharmacological mechanism, blood concentration and route of administration (intravenous) we evaluated the hypothesis that these substances could act with a synergistic effect - or at least additive - with the illicit drugs on the central nervous system and cardiovascular system.