Case report of sudden death in a twin infant given melatonin supplementation: A challenging interpretation of postmortem toxicology.

Melatonin (MEL) is a neurohormone in humans produced in a number of locations. Starting with the amino acid tryptophan, MEL is produced through a number of enzymatic steps that includes serotonin as an intermediate compound. The primary production of MEL is in the pineal gland located in the brain. It is directly associated with the the suprachiasmatic nucleus (SCN) located in the hypothalamus. In young and adult humans, the blood levels of MEL are typically in the picogram levels and produced in a cyclic schedule highly regulated by light detected in the retina by intrinsically photosensitive retinal ganglion cells (ipRGCs), resulting in production primarily during periods of darkness. During periods of light, MEL levels are typically very low or undetectable. Basal levels of MEL in infants have been observed to be either undetectable or also in the picogram levels, although some medical treatment has involved administration of exogenous MEL resulting in peak levels in the nanogram range. MEL is considered to be well tolerated and there have been limited reports of toxicity. In this case, an infant was found unresponsive and cause of death was ruled as Undetermined. Melatonin was detected in the peripheral blood at a concentration of 1,400ng/mL.

Detection of 25C-NBOMe in Three Related Cases.

An accidental death associated with the use of the designer drug, 2-(4-chloro-2,5-dimethoxyphenyl)-N-(2-methoxybenzyl)ethanamine (25C-NBOMe), is reported. A 23-year-old Caucasian male experienced severe respiratory distress and died after being subdued by military law enforcement. At autopsy, remarkable findings upon internal examination included mild to moderate coronary atherosclerosis, biventricular dilation, mild right ventricular hypertrophy and bilateral pulmonary edema and congestion. The decedent's blood contained no drugs, ethanol or other volatile compounds. Pseudoephedrine, nicotine and cotinine were detected in his urine. A LC-QTOF designer drug screen, employing a basic solid-phase extraction, was used to isolate 25C-NBOMe, 25C-NBOH and 2C-C from both blood and urine specimens. Quantitative analysis was performed by LC-MS-MS operating in multiple reaction monitoring mode. 25C-NBOMe and 2C-C were present in the blood (2.07 and 0.12 ng/mL) and in the urine (27.43 ng/mL and 0.38 ng/mL), respectively. 25C-NBOMe concentrations were determined by standard addition in the brain (19.10 ng/g), spleen (27.13 ng/g), lung (25.21 ng/g), liver (15.20 ng/g), kidney (25.06 ng/g) and gastric contents (30.24 µg total in 100 mL submitted). On the basis of decedent case history, autopsy and toxicological findings, the medical examiner ruled the cause of death as 25C-NBOMe toxicity temporally associated with excited delirium and forcible restraint. The manner of death was ruled accidental.