Postmortem PF4 antibodies confirm a rare case of thrombosis thrombocytopenia syndrome associated with ChAdOx1 nCoV-19 anti-COVID vaccination.

We report a case of cerebral venous sinus thrombosis, bilateral adrenal hemorrhage, and thrombocytopenia in a 70-year-old man found dead. He had previously received the ChAdOx1 nCoV-19 vaccine (Vaxzevria®, AstraZeneca) 18 days before, and had since developed unspecific and undiagnosed characteristics of what proved to be a rare case of vaccine-associated thrombocytopenia with thrombosis syndrome (TTS). He was found dead 1 week after the beginning of symptoms (day 25 post-vaccine). Autopsy yielded venous hemorrhagic infarction with the presence of thrombi within dural venous sinuses, and extensive hemorrhagic necrosis of the central part of the adrenal glands. Antibodies against platelet factor 4 (PF4) were strongly positive in postmortem fluids, as measured with an enzyme-linked immunosorbent assay (ELISA). This difficult diagnosis is usually made during the patient's lifetime. After eliminating differential diagnoses, we concluded on a fatal case of vaccine-induced immune TTS with positive anti-PF4 antibodies in cadaveric blood, 3 weeks after ChAdOx1 nCoV-19 vaccination. Specific search for anti-PF4 antibodies in cadaveric blood appears therefore paramount to assess postmortem cases of TTS associated with anti-COVID vaccines.

Using bone marrow matrix to analyze meprobamate for forensic toxicological purposes.

Bone marrow (BM) analysis is of forensic interest for postmortem toxicological investigations where blood samples are unavailable or unusable. Due to the lack of studies, it remains difficult to interpret concentrations of xenobiotics measured in this matrix. Based on a statistical approach published previously to interpret meprobamate concentrations in bile and vitreous humor, we propose here a diagnostic test for interpretation of BM meprobamate concentrations from analysis of 99 sets of autopsy data. The mean age was 48 years (range 18-80 years, one unknown) for males and 50 years (range 19-80 years, one unknown) for females, with a male/female ratio at 0.768. A BM concentration threshold of 11.3 µg/g was found to be statistically equivalent to that of a blood meprobamate concentration threshold of 50 µg/ml in distinguishing overdose from therapeutic use. The intrinsic qualities of this diagnostic test were good with sensitivity of 0.82 and specificity of 0.92. Compared to previous tests published with the same objective on vitreous humor and bile, this study shows that BM is a useful alternative matrix to reveal meprobamate overdose when blood, vitreous humor, and bile are not available or unusable.

Gas chromatography-tandem mass spectrometry assay for the quantification of four benzodiazepines and citalopram in eleven postmortem rabbit fluids and tissues, with application to animal and human samples.

Pharmacokinetic studies and postmortem toxicological investigations require a validated analytical technique to quantify drugs on a large number of matrices. Three-step liquid/liquid extraction with online derivatization (silylation) ahead of analysis by gas chromatography-tandem mass spectrometry was developed and validated on rabbit specimens in order to quantify citalopram and 4 benzodiazepines (diazepam, nordazepam, oxazepam and temazepam) in 11 biological matrices (blood, urine, bile, vitreous humor, liver, kidney, skeletal muscle, brain, adipose tissue, bone marrow (BM) and lung). Since the 11 biological matrices came from the same animal species, full validation was performed on 1 matrix, bone marrow (considered the most complex), while the other 10 underwent partial validation. Due to non-negligible matrix effects, calibration curves were performed on each matrix. Within-day and between-day precision (less than 12.0% and 12.6%, respectively) and accuracy (from 88.9% to 106.4%) were acceptable on BM at both low and high concentrations. Assessment on the other matrices confirmed accuracy and within-day precision (less than 12%, and generally between 85.1% and 114.5%, respectively). The lower limit of quantification of the method was 1ng/g for nordazepam, 5ng/g for citalopram and 10ng/g for oxazepam, diazepam and temazepam. The combination of 3-step extraction and MS/MS detection provided good selectivity in all matrices, including the most lipid-rich. Application to real-case samples showed that the method was sensitive enough to describe distribution patterns in an animal experiment, and specific enough to detect molecules in highly putrefied samples from human postmortem cases.

Macroscopic, histological and toxicological aspects of early Gammarus pulex scavenging.

Two cases of scavenging postmortem freshwater shrimps (Gammarus pulex) are presented. We report the two first illustrated observations of cutaneous postmortem injuries inflicted by a G. pulex population, a small freshwater crustacean, on two non putrefied drowning victims, and we describe their particular histological features and their potential in forensic investigations.

Postmortem measurement of caffeine in bone marrow: influence of sample location and correlation with blood concentration.

Bone marrow (BM) analysis is of forensic interest in postmortem toxicological investigation in case of limited, unavailable or unusable blood samples. However, it remains difficult to determine whether a drug BM concentration is therapeutic or represents overdose, due to the lack of studies on this alternative matrix. Given the variations in BM composition in the body, sample location was suggested to be a relevant factor in assessing BM concentration. The aim of the present study was to compare postmortem caffeine concentrations in various BM sample locations and secondly to consider the correlation between BM and blood concentrations. Six BM samples (right and left side: proximal and medial femur and 5th rib) and a blood sample were collected from 21 forensic autopsies. Gas chromatography coupled to tandem mass spectrometry was performed. Blood caffeine concentrations ranged from 60 to 7591ng/mL. Femoral and rib BM concentrations ranged from 51 to 6171ng/g and 66 to 7280ng/g, respectively. Blood concentrations were always higher than BM concentrations. As a good correlation was demonstrated between blood and rib BM and between blood and the average of the four femoral BM concentrations, blood caffeine concentrations could be correctly extrapolated from BM concentrations. BM caffeine concentration was found to depend on sample location. Rib BM caffeine concentrations appeared to be systematically greater than averaged femur values and concentrations were much more variable between the 4 femur BM samples than between the 2 ribs. From a practical point of view, for caffeine analysis, rib BM appeared more relevant than femoral BM, which requires multisampling to overcome the concentration variability problem.

[Human main plant poisoning: revue of the literature]. / Intoxications humaines par les végétaux supérieurs: revue de la littérature.

The authors have reviewed the main toxic plants responsible for human deaths throughout the world. Forty plants (genera or species) were listed in order to establish an inventory of the botany of the plant, its use, the active molecules that could be identified, the already published analytical methods and the reported human fatal cases.

LC-EI-MS determination of veratridine and cevadine in two fatal cases of Veratrum album poisoning.

We report two fatal poisonings due to the ingestion of plant material. The two deceased were discovered in the water of a mountain lake about one month after the postmortem immersion of the corpses. Macroscopic examination of the stomachs revealed the presence of a very large number of small blackish granules, which were later identified as seeds of a Veratrum species. Veratridine and cevadine were identified and quantitated by high-performance liquid chromatography-electrospray ionization-mass spectrometry. Measured blood concentrations were 0.17 and 0.40 ng/mL for veratridine and 0.32 and 0.48 ng/mL for cevadine. The absence of other toxic substance led to the assumption that this massive ingestion was the cause of death, although the circumstances surrounding intake remained unknown.

[Urinary nandrolone metabolites in antidoping control]. / A propos des métabolites de la Nandrolone dans les contrôles urinaires antidopage.

The French National Laboratory of the International Olympic Committee (IOC) has detected norandrosterone (NA) and noretiocholanolone (NE) in urine samples from several sportsmen. These two substances are known to be urinary metabolites after nandrolone intake. In such cases, the NA level is always higher than the Ne level. However, in the urine samples of sportsmen tested positive, the NE concentrations were systematically higher than the NA levels. We therefore searched for other steroid precursors (commercially available capsules or tablets of dehydroepiandrosterone, 4-androstenediol, 5-androstenediol, 4-androstenedione, 19-norandrostenediol and 19-norandrostenedione, also illegally used in France) which could lead to an excretion of NA and NE and to an inverted ratio of these metabolites.

Analysis of corticosteroids in hair by liquid chromatography-electrospray ionization mass spectrometry.

The present study describes a confirmatory method for the quantitative determination in hair of the most common corticosteroids illegaly used as doping agents by athletes. Corticosteroids are extracted from 50 mg of powdered hairs by methanolic extraction follows by a solid-phase extraction on C18 cartridge. After extraction, the dried residue is reconstituted with 50 microl acetonitrile and injected in a liquid chromatograph. Liquid chromatography separation is performed on a reversed-phase C18 column with a binary gradient of formiate buffer pH 3-acetonitrile as mobile phase. Detection is performed with an electrospray ionization mass spectrometer in negative ion and selected-ion monitoring mode. The limits of sensitivity achieved is 0.1 ng/mg in hair. Application to hair sample collected during an antidoping control and comparison to results obtain on urines, collected on the same athletes at the same time, shows the interest and the complementarity of both matrices. Hair analysis could allow the detection of corticosteroids on a large period preceding the control, and the detection of natural corticosteroids administered as pro-drug, like hydrocortisone acetate.

Fatal aluminum phosphide poisoning.

A 39-year-old man committed suicide by ingestion of aluminum phosphide, a potent mole pesticide, which was available at the victim's workplace. The judicial authority ordered an autopsy, which ruled out any other cause of death. The victim was discovered 10 days after the ingestion of the pesticide. When aluminum phosphide comes into contact with humidity, it releases large quantities of hydrogen phosphine (PH3), a very toxic gas. Macroscopic examination during the autopsy revealed a very important asphyxia syndrome with major visceral congestion. Blood, urine, liver, kidney, adrenal, and heart samples were analyzed. Phosphine gas was absent in the blood and urine but present in the brain (94 mL/g), the liver (24 mL/g), and the kidneys (41 mL/g). High levels of phosphorus were found in the blood (76.3 mg/L) and liver (8.22 mg/g). Aluminum concentrations were very high in the blood (1.54 mg/L), brain (36 microg/g), and liver (75 microg/g) compared to the usual published values. Microscopic examination revealed congestion of all the organs studied and obvious asphyxia lesions in the pulmonary parenchyma. All these results confirmed a diagnosis of poisoning by aluminum phosphide. This report points out that this type of poisoning is rare and that hydrogen phosphine is very toxic. The phosphorus and aluminum concentrations observed and their distribution in the different viscera are discussed in relation to data in the literature.

Compared interest between hair analysis and urinalysis in doping controls. Results for amphetamines, corticosteroids and anabolic steroids in racing cyclists.

In France during a famous bicycle race, the newspapers documented the degree in which doping seemed to be supervised in some teams by managers and doctors. Use of anabolic steroids and other substances was officially banned in the mid-seventies by sports authorities. This policy has been enforced through urine testing before competition. It is well known, however, that a latency period is all that is necessary to defeat these tests. Nevertheless, hair analysis could be a promising tool when testing for periods that are not accessible to urinalysis any more. We have developed different sensitive methods for testing hair for amphetamines, anabolic steroids and their esters and corticosteroids. For amphetamines, 50 mg of hair were digested with 1 M NaOH, extracted with ethyl acetate, derivatized with TFA and analyzed by gas chromatography positive chemical-ionization mass spectrometry. For corticosteroids, 50 mg of powdered hair were treated with methanol in an ultrasonic bath and subsequently purified using a C18 solid phase extraction column. Analysis was realized by high performance liquid chromatography coupled to electrospray-ionization tandem mass spectrometry. For anabolic steroids and their esters, 100 mg of powdered hair were treated with methanol in an ultrasonic bath for extraction of esters, then alkaline digested with 1 M NaOH for an optimum recovery of other drugs. The two liquid preparations were subsequently extracted with ethyl acetate, pooled, then finally highly purified using a twin solid phase extraction on aminopropyl and silica cartridges. Residue was derivatized with MSTFA prior to injection. Analysis was conducted by gas chromatography coupled to a triple quadrupole mass spectrometer. Thirty cyclists were sampled and tested both in hair and in urine. Amphetamine was detected 10 times in hair (out of 19 analyses) compared to 6 times in urine (out of 30 analyses). Corticosteroids were detected 5 times in hair (methylprednisolone 1 case, triamcinolone acetonide 3 cases and hydrocortisone acetate 1 case) in hair (out of 12 analyses) compared to 12 times (triamcinolone acetonide 10 cases and betamethasone 2 cases) in urine (out of 30 analyses). Anabolic steroids were detected twice (nandrolone 1 case, and testosterone undecanoate 1 case) in hair (out of 25 analyses) compared to none in urine (out of 30 analyses).

Poisoning by plant material: review of human cases and analytical determination of main toxins by high-performance liquid chromatography-(tandem) mass spectrometry.

The authors have reviewed the main toxic plants responsible for human deaths throughout the world. Forty plants (genera or species) were listed in order to establish an inventory of the active molecules that could be identified, the already published analytical methods and the reported human fatal cases. In a second step, the authors have developed a general method for the detection of various toxins in whole blood by high-performance liquid chromatography coupled to mass spectrometry or tandem mass spectrometry. Sample preparation was realized by liquid-liquid extraction at pH 9.5 for oleandrine, taxol and the alkaloids. These latter compounds were divided into two groups following their chemical properties and could be subsequently purified by acid/base clean up. Cyanogenic compounds and atractyloside were isolated by precipitation of the protein content with acetone and purified for atractyloside by washing with chloroform. Separation of the drugs occurred under reversed-phase conditions on a C18 analytical column 150x2 mm I.D. (5 microm particle size) using two different mobile phases. The first one, formiate buffer 2 mM acidified at pH 3.0, was used for the separation of atractyloside, oleandrine, taxol, the cyanogenic molecules and some alkaloids. The second mobile phase, formiate buffer 10 mM made basic at pH 8.2 was used for the majority of other alkaloids. A gradient elution mode was chosen using acetonitrile or acetonitrile-methanol (50:50, v/v) as the eluting solvent. Detection under positive ionization mode was the mode of choice for all compounds except for atractyloside (negative ions) and for taxol (mixed mode available). Application to real forensic cases has been demonstrated.

Testing hair for pharmaceuticals.

More than hundred pharmaceuticals, drugs of abuse or doping agents have been reported to be detectable in human hair. This article reviews the analysis of 90 drugs and drug metabolites by chromatographic procedures, including the pretreatment steps, the extraction methods, the reported limits of detection and the measured concentrations in real human hair samples. Some progress is observed in the detection of low dose drugs, like fentanyl or flunitrazepam. The general tendency in the last years, to highly sophisticated techniques (GC-MS-NCI, HPLC-MS, GC-MS-MS) illustrates well this constant fight for sensitivity. Some new findings, based on the recent experience of the authors, are also added.

Gas chromatographic-tandem mass spectrometric determination of anabolic steroids and their esters in hair. Application in doping control and meat quality control.

We have developed a powerful and simple sensitive method for testing hair for anabolic steroids and their esters. A 100-mg amount of powdered hair was treated with methanol in an ultrasonic bath for extraction of esters, then alkaline digested with 1 M NaOH for an optimum recovery of other drugs. The two liquid preparations were subsequently extracted with ethyl acetate, pooled, then finally highly purified using a twin solid-phase extraction on amino and silica cartridges. The residue was derivatized with N-methyl-N(trimethylsilyl)-trifluoracetamide (MSTFA) prior to injection. Analysis was conducted by gas chromatography coupled to a triple quadrupole mass spectrometer. The generally chosen parent ion was the molecular ion while two daughter ions were selected for each compound with collision energies ranging from -16 to -21 eV. Internal standards were nandrolone d3 for non-esterified drugs and testosterone phenyl propionate for esters. The limits of detection calculated from an analysis of the blanks (n=30) were 0.08 pg/mg for nandrolone, 6.20 pg/mg for boldenone, 0.07 pg/mg for methyl testosterone, 0.15 pg/mg for ethinyl estradiol, 2.10 pg/mg for metandienone, 0.86 pg/mg for testosterone propionate, 0.95 pg/mg for testosterone cypionate, 1.90 pg/mg for nandrolone decanoate, 3.10 pg/mg for testosterone decanoate and 4.80 pg/mg for testosterone undecanoate. Application to doping control has been demonstrated. In a series of 18 sportsmen, two tested positive for anabolic steroids in hair whereas urinalysis was negative for both of them. The first positive case was nandrolone and the second case concerned the identification of testosterone undecanoate. Measured in 10 white males aged between 22 and 31 years, the testosterone concentration was in the range 1.7-9.2 pg/mg (mean=5.0 pg/mg). The method was also applied in meat quality control. Of the 187 analyses realized based upon hair and urine sampling in slaughter houses, 23 were positive for anabolic steroids in hair: one case for boldenone, one case for metandienone, two cases for testosterone propionate, three cases for nandrolone, five cases for testosterone decanoate and 11 cases for methyl testosterone. In the meantime, urinalysis was always negative for these drugs or their metabolites.

Gas chromatographic-mass spectrometric quantitation of dextropropoxyphene and norpropoxyphene in hair and whole blood after automated on-line solid-phase extraction. Application in twelve fatalities.

After conversion of norpropoxyphene (NP) to its corresponding amide, dextropropoxyphene (DP) and NP are extracted from 1 ml of blood or 50 mg of powdered hair, on C18 cartridges and eluted using methanol containing 0.5% acetic acid. Automated extraction is conducted on-line with automated device, starting from buffered and centrifuged sample. After extraction, the dried residue is reconstituted with 40 microl of methanol, and then injected in a gas chromatograph at 250 degrees C. Quantitation is carried out by gas chromatography-mass spectrometry in the selected-ion monitoring mode, lidocaine being the internal standard. The method gave relative standard deviations lower than 6.2% in whole blood, and 6.0% in hair for the entire range of calibration from 0.5 to 10 microg/ml in blood and from 1 to 20 ng/mg in hair of both compounds. Limits of detection in blood and hair for DP are, respectively, 0.07 microg/ml and 0.05 ng/mg, whereas the respective limits of detection in whole blood and hair for NP are 0.09 microg/ml and 0.04 ng/mg. The present method was used for one year in our laboratory. Postmortem concentrations of DP in blood ranged from 1.6 to 44.0 microg/ml (mean=9.8microg/ml, n = 12) and are comparable to those found in the literature. Out of 30 hair samples from people who died from heroin overdose, 13 were positive both for DP and NP with concentrations ranging from 0.2 to 27.4 ng/mg (mean 8.7 ng/mg) for DP and 0.3 to 68.9 ng/mg (mean 24.1 ng/mg) for NP.

Evidence of polydrug use using hair analysis: a fatal case involving heroin, cocaine, cannabis, chloroform, thiopental and ketamine.

A case is presented involving a young woman on several illicit drugs (heroin, cocaine and cannabis) as well as two medications and a solvent used for their anesthetic and narcotic properties: thiopental, ketamine and chloroform. This complex drug use was supported by hair analysis over a 10.5 cm segment of the hair taken at autopsy. The average measured concentrations in hair were: thiopental = 5.3 ng/mg, pentobarbital = 10.0 ng/mg, ketamine = 11.3 ng/mg norketamine = 1.0 ng/mg, diazepam = 1.2 ng/mg, nordiazepam = 0.1 ng/mg, 6-acetylmorphine = 4.4 ng/mg, morphine = 3.4 ng/mg, codeine = 1.2 ng/mg, cocaine = 5.5 ng/mg, benzoylecgonine = 1.5 ng/mg and methylecgonine ester = 1.0 ng/mg. While the ketamine/norketamine ratio is consistent with that already reported on drug detection in hair, the thiopental/pentobarbital ratio seems to be inverted.

Case report of an unusual use of lidocaine during episodes of self mutilation.

We are reporting on a case of polyintoxication by cocaine, lidocaine, methadone, and dextromoramide. This conclusion is supported by the analysis of a strand of hair. We note for the first time the detection of dextromoramide as well as lidocaine and desethyl-lidocaine in hair. Concentrations in hair were: cocaine = 2.4 ng/mg, benzoylecgonine = 0.3 ng/mg, methadone = 10.2 ng/mg, EDDP = 1.5 ng/mg, dextromoramide = 1.6 ng/mg, lidocaine = 115.9 ng/mg and desethyl-lidocaine = 1.6 ng/mg. The victim who was seeking an anesthesia effect without the loss of consciousness ingested cocktails during episodes of self mutilation. The wounds were of two different types and with different morphological locations: long and deep without ablation of tissue, clean lacerations found on the neck, the pectoral region, and the left upper extremity; either round or discoid with deep excavation found on the head (ears, forehead, chin, and lips) and also, on the neck and on the left upper extremity. Near the most recent wounds, needle marks were noticed indicating probable local infiltration of lidocaine.

Moclobemide fatalities: report of two cases and analytical determinations by GC-MS and HPLC-PDA after solid-phase extraction.

We have described a rapid and simple solid-phase extraction on C18 cartridges of moclobemide suitable for the analysis of post-mortem whole blood and urine. The methods used for identification were GC-MS and HPLC-PDA. Quantification was performed by the HPLC-PDA technique with detection at 238 nm. The limit of detection was 0.012 microgram/ml in blood. A between-day precision study gave relative standard deviations which were always less than 4.7% over the entire range of calibration (0.2 to 20.0 micrograms/ml). The method was applied in a case of moclobemide overdose due to a deliberate ingestion of 4.5 g of the drug. A second case concerned a polyintoxication including moclobemide as one of the main toxins. The post-mortem whole blood concentrations were 15.5 and 13.8 micrograms/ml respectively. Determination of the drug in other biological specimens is also reported.

Meprobamate overdosage: a continuing problem. Sensitive GC-MS quantitation after solid phase extraction in 19 fatal cases.

We describe a simple method for the urinary identification and blood quantitation of meprobamate suitable for any toxicological laboratory. After urinary screening using GC-MS technology, quantitation is performed by GC-MS in the selected-ion monitoring mode. Isolation of the drug is achieved by solid phase extraction on a C-18 cartridge. A specific elution is obtained by three volumes of acetone:triethylamine (99:1 v/v). Lidocaine is used as internal standard. RSDs (%) of the within-day and between-day precision studies are always less than 7.2 on the entire range of calibration. Linearity is inspected using an analysis of variance ANOVA. Homogeneity of the variances is tested using Hartley's test. Weighted linear regression is then computed. Limits of detection and quantification are given by an analysis of the blanks. The present method was applied in our laboratory over a period of 1 year. Meprobamate appeared as a drug which still has a significant frequency (5.5%) and is the most frequently involved in fatal pharmaceutical overdoses (15.3%). Post mortem concentrations ranged from 41 to 397 mg/l (mean = 182) and are compared to those of the literature.