Is it really possible to kill with insulin without leaving traces? From lifesaver to killer, the issues surrounding the analytical characterization of postmortem insulin illustrated by an exemplary case.

Evidence of an insulin overdose is very complicated in the medico-legal field. The analysis and subsequent interpretation of results is complex, especially when treating postmortem blood samples. The instability of insulin, the special pre-analytical conditions and the absence of specific analytical methods has led most laboratories not to analyze insulin in their routine with a consequent underestimation of cases. This paper aims to assess the difficulties associated with the analytical characterization of insulin by describing a case that typically represents most of the inconveniences encountered following a suspected insulin overdose. The case concerns a man found dead at home by his brother. After an external examination, which did not reveal a specific cause of death, toxicological analysis was requested which did not reveal any substance of toxicological interest. Only 9 months later, it was reported to the toxicologist that the subject was diabetic, on insulin lispro treatment and that three empty syringes were found next to his body. Following analysis by LC-high-resolution mass spectrometry, the presence of insulin lispro at a concentration of 1.1 ng/mL, a therapeutic concentration, was evidenced. Despite the low concentration found, overdose cannot be excluded and this paper will describe the criteria evaluated to reach this conclusion. This case highlights that the interpretation of a postmortem insulin concentration is very complex and requires the evaluation of various elements including the circumstances of death, the subject's medical history, the interval between death and sampling and the sample storage.

Testing for Kratom alkaloids in fingernail clippings - not only mitragynine.

Kratom (Mitragyna speciosa) is a species of large tree that grows in Southeast Asia and is part of the Rubiaceae family. Its fresh leaves are harvested for their medicinal properties and used for their psychoactive effects. Kratom contains many biologically active alkaloids, including mitragynine and 7-OH-mitragynine, which are considered the two most important psychoactive components and constitute approximately 66% and 2% of the total alkaloid content. Other alkaloids are present in the plant, such as speciogynine, speciociliatine and paynantheine, but have less psychoactive activity. Over the past decade, the sale of kratom powder has increased on the Internet. This led to a significant increase in forensic cases. Given the lack of data existing in the literature, and the total absence of data in nails, the authors report a study to determine the best target alkaloids for documenting kratom consumption in this matrix. Fingernail clippings from a supposed kratom powder user were analyzed after liquid-liquid extraction, chromatography separation using a HSS C18 column and performed on an ultra-high performance liquid chromatography coupled to a tandem mass spectrometer. In the specimen, mitragynine was quantified at 229 pg/mg, speciogynine and paynantheine were both quantified at 2 pg/mg, and speciociliatine was quantified at 19 pg/mg. 7-OH-mitragynine was not detected. The interpretation of these concentrations is complex, since there is currently no reference in the literature, as this is the first identification of mitragynine and other kratom alkaloids in nails. Nevertheless, in view of the high concentration of mitragynine, the subject seems to be a repetitive user of kratom. According to the measured concentrations, it seems that mitragynine remains the best target to document kratom consumption, but the identification of the other alkaloids would enhance the specificity of the test.

Testing for clomiphene in keratinous matrices using LC-MS/MS in doping purpose: Is a single intake of clomiphene detectable in hair and nail clippings?

Clomiphene is a selective estrogen receptor modulator. It is indicated for the treatment of female infertility issues but in sport, it can be misused to stimulate endogenous testosterone secretion in men. Therefore, it has been prohibited at all times by the World Anti-doping Agency. The aim of this study was to get data to be able to interpret concentrations in athletes. A healthy volunteer (male, 62 years-old) ingested a single therapeutic dose of clomiphene (Clomid™, 50 mg). Strands of hair (blond, 4 cm) were collected one month after the ingestion. Body hair (beard, axillary, pubic and chest hair), and finger and toenails were collected over 4-5 months. A previous method was modified to identify and quantify clomiphene in keratinous matrices. 30 mg of specimen were sonicated and incubated in 1 mL of methanol, in presence of 200 pg of clomiphene-D5 (internal standard). After centrifugation and evaporation of the organic phase, the samples were analyzed using LC-MS/MS. Linearity was verified in hair and nail clippings between 1 and 500 pg/mg. The limits of detection and quantification were determined at 0.3 and 1 pg/mg respectively. The study demonstrated that clomiphene tested positive in all the analyzed specimens at 9 pg/mg in head hair, from 28 to 486 pg/mg (body hair) and from 4 to 57 pg/mg (nails). Clomiphene was identified for the first time in multiple keratinous matrices. This study demonstrated that a single oral therapeutic dose is detectable in keratinous matrices over a long period of time.

Testing for clomiphene in keratinous matrices (hair and nail).

Clomiphene or clomifene is a selective estrogen receptor modulator used to treat female fertility in case of ovulatory dysfunction. In sport, clomiphene is prohibited at all times for use by athletes and is listed in the section S4.2 (hormone and metabolic modulators) by the World Anti-Doping Agency. Indeed, clomiphene can indirectly increase testosterone levels in the body and can mitigate some side effects of synthetic steroid abuse. Despite its prescription to millions of subjects, its detection in human hair or nail clippings has never been reported. The aim of this study was to develop a specific method to identify clomiphene in hair and nail clippings by liquid chromatography-quadrupole tandem mass spectrometry. The procedure was then applied in a case of challenged doping results. The method involves sonication/incubation for 1 h of 30 mg of pulverized material in 1 mL of methanol in the presence of 2 ng diazepam-d5 used as internal standard. The chromatographic separation was performed using a HSS C18 column with a 15 min gradient elution. After spiking blank hair and nail with the corresponding amounts of clomiphene, linearity was verified from 1 to 500 pg/mg (r2 = 0.9994 and 0.9995 for hair and nail, respectively). The limit of detection was estimated at 0.3 pg/mg for both matrices. No interference was noted from endogenous compounds, particularly steroids. Clomiphene was identified at 85 and 20 pg/mg in the pubic hair and the fingernail clippings, respectively, of a male athlete challenging an adverse analytical finding.

First identification of dapagliflozin in human hair: Development of a new liquid chromatography with tandem mass spectrometry method.

Sodium-glucose cotransporter 1 inhibitors are a new class of drugs used for the treatment of type II diabetes. Due to their diuretic capabilities and the glycosuria they induce, these molecules cause effective weight loss that could attract the interest of a wider public than diabetics with all the health consequences knowing the adverse effects of these substances. In order to reveal a past exposure to these substances, hair analysis can be very useful especially in the medicolegal context. There are no data in the literature about gliflozin testing in hair. In this study, a method was developed for the analysis of three molecules belonging to the gliflozin family (dapagliflozin, empagliflozin and canagliflozin) using a liquid chromatography system coupled to tandem mass spectrometry. After decontamination with dichloromethane, gliflozins were extracted from hair following incubation in methanol in the presence of dapagliflozin-d5. Validation showed acceptable linearity for all compounds between 10 and 10,000 pg/mg, with limit of detection and limit of quantification at 5 and 10 pg/mg, respectively. Repeatability and reproducibility were below 20% at three concentrations for all analytes. The method was subsequently applied to the hair of two diabetic subjects under dapagliflozin treatment. In one of the two cases, the result was negative, while in the second case, the concentration was 12 pg/mg. Due to the absence of data, it is difficult to explain the absence of dapagliflozin in the hair of the first case. Physico-chemical characteristics of dapagliflozin could explain its bad incorporation in hair, making detection difficult even after daily treatment.

The Power of Keratinous Matrices (Head Hair, Body Hair and Nail Clippings) Analysis in a Case of Death Involving Anabolic Agents.

A 29-year-old man with no previous medical history was found dead at home. Anabolic products (tablets and oily solutions) and syringes were found at the scene. The man was known to train regularly at a fitness club and to use anabolic drugs. Following an unremarkable autopsy with normal histology, toxicological analyses were requested by the local prosecutor to provide further information. Blood, head hair (5 cm, black), body hair (axillary and leg) and toe and finger nail clippings were submitted to liquid and gas chromatography coupled to tandem mass spectrometry (LC and GC-MS-MS) methods to test for anabolic steroids. Blood tested positive for testosterone (4 ng/mL), boldenone (26 ng/mL), stanozolol (3 ng/mL) and trenbolone (<1 ng/mL). Segmental head hair tests (2 × 2.5 cm) revealed a repeated consumption of testosterone (65-72 pg/mg), testosterone propionate (930-691 pg/mg), testosterone isocaproate (79 pg/mg to <5 pg/mg), nandrolone decanoate (202-64 pg/mg), boldenone (16 pg/mg), stanozolol (575-670 pg/mg), trenbolone (4 pg/mg-not detected), drostanolone (112-30 pg/mg), drostanolone enanthate (26-5 pg/mg) and drostanolone propionate (15-4 pg/mg). In addition to the substances identified in head hair, testosterone decanoate, testosterone cypionate and nandrolone were identified in both body hair and nails. The experts concluded that the manner of death can be listed as toxic due to massive repetitive use of anabolic steroids during the previous months. For anabolic agents, blood does not seem to be the best matrix to document a fatal intoxication. Indeed, these products are toxics when abused long term and are known to cause cardiac, hepatic and renal diseases. When compared to blood, hair and nails have a much larger window of detection. Therefore, keratinous matrices seem to be the best approach to test for anabolic steroids when a sudden death is observed in the context of possible abuse of steroids.

Pregnancy denial and unplanned home delivery: Considerations about fetal death causes and maternal drug use imputability.

Determining fetal death causes is a complex problem for the forensic pathologist. Beyond the medico-legal context, the expert must be able to evaluate the viability of the fetus at the time of death, to eliminate in-utero fetal death and to determine if the death is related to a fetal, a maternal, a placental cause, or simply related to obstetrical complications. The authors present the case of a 21-year-old woman who unexpectedly gave birth to a fetus during a party. As pregnancy was not acknowledged by the mother (regular menstrual cycles and use of hormonal contraception), no obstetrical check-up had been performed. She would have presented violent abdominal pain and expelled a mass in the toilet. The fetus body, enclosed in the amniotic pouch, and the placenta were found in the toilet. A forensic autopsy was performed jointly by a forensic pathologist and a specialist in fetal pathology. Histological, toxicological and genetic samples were collected. Body morphometry and bone maturation indicated a gestational age of 31-32 weeks of amenorrhea. A significant asphyxia syndrome and non-specific multi-visceral congestion were noted at autopsy. Histological analysis of the fetal tissues revealed a lung and skeletal muscle maturation in accordance with the estimated term. At the brain level, there were signs of anoxia and abnormal cortical development with periventricular nodular heterotopia areas. The placenta microscopic analysis revealed acute chorioamniotitis, the probable cause of the premature fetal expulsion. Toxicological analyses revealed the presence of ecstasy (48 ng/mL) and its metabolite MDA (2 ng/mL) in fetal blood. Although negative in blood, THC-COOH tested positive in urine (9 ng/mL). The fetus was repetitively exposed to cannabis, as Δ9-THC tested positive in hair (51 pg/mg). Maternal hair analysis on 4 × 3 cm evidenced a long-term use of cannabis, while results support single massive exposure to ecstasy. In this article, the authors try to explain the reflexive pathway carried out to establish death causes and the maternal toxic consumption imputability on the cerebral malformations and fetal death. This case illustrates both the interest of toxicological analyses in cases of fetal death and the importance of a collaborative work between forensic and fetal pathologists and toxicologists, which appeared critical to answer in the best conditions to the magistrates questions, as well as to the bereaved families.

In a Case of Death Involving Steroids, Hair Testing is More Informative than Blood or Urine Testing.

A 59-year-old male was found dead at home, with two empty vials of an oily preparation obtained from a manufacturer from East Europe. There was no label on the vial. The subject was a former weightlifter, also known as an anabolic steroids abuser. The local prosecutor ordered a body examination, which was unremarkable, and allowed collecting femoral blood, urine and scalp hair (6 cm, brown). He was treated for cardiac insufficiency with quinidine. Biological specimens were submitted not only to standard toxicological analyses including a screening with liquid chromatography (LC)-quadrupole time of flight, but also to a specific LC-tandem mass spectrometry method for anabolic steroids testing. Ethanol was not found in both blood and urine. Quinidine blood concentration (791 ng/mL) was therapeutic. No drug of abuse was identified. In blood, testosterone was less that 1 ng/mL and no other steroid was identified. In urine, testosterone/epitestosterone was 1.56 and boldenone was present at a concentration of 9 ng/mL. The hair test results, performed on the whole length, demonstrated repetitive steroids abuse, including not only testosterone (140 pg/mg), testosterone propionate (605 pg/mg) and testosterone decanoate (249 pg/mg), but also boldenone (160 pg/mg), trenbolone (143 pg/mg) and metandienone (60 pg/mg). Since forensic laboratories have limited access to steroid urinary metabolite reference material due to specific regulations (to avoid testing athletes before anti-doping verifications), hair analyses seem to be the best approach to document anabolic agents abuse. Indeed, in hair, the target drug is the parent compound; in addition, when compared to blood or urine, this matrix has a much larger window of detection. The pathologist concluded cardiac insufficiency in a context involving repetitive abuse of anabolic drugs. This case indicates that more attention should be paid to anabolic steroids, in a context of sudden cardiac death.