Very unusual ethanol distribution in a fatality.

A 48-year-old man with an extensive history of alcoholism was found dead at home. He was lying face down on a carpet. There was evidence of gastric aspiration at autopsy and histologic examination. The distribution of ethanol was very unusual (concentrations in mg/100 mL or mg/100 g): femoral blood, 257 and 273 (two samples); heart blood, 643; vitreous humor, 763; urine, 84; bile, 616; liver, 250; and gastric, 4660 (2470 mg/53 g). In addition, this man ingested isopropanol, and, according to the history, may also have ingested acetone in the form of nail polish remover. The distribution of both isopropanol and acetone was as expected, which was approximately in proportion to the aqueous content of the respective tissues. It is proposed that agonal or postmortem aspiration of the ethanol-rich vomitus and postmortem fermentation could account for the apparently elevated concentrations of ethanol in heart blood and bile. The elevated vitreous ethanol could be explained if ethanol diffused across the eye in the agonal phase or postmortem from gastric aspirate in the carpet. The relatively low urinary ethanol concentration would be consistent with a recent binge-drinking episode, which allowed only a limited time period for excretion into an already partially full, but relatively ethanol-free, bladder.

An uncommon fatality due to moclobemide and paroxetine.

A young man was found shivering and incoherent at home. He was placed in bed and was observed having seizures some time later. About four hours after he was initially found, he suffered a full cardiac arrest. Paramedics found his jaw unusually stiff and were unable to open his mouth in order to intubate him. Resuscitation attempts were unsuccessful. The autopsy findings were unremarkable, but toxicology testing revealed the following: moclobemide (subclavian blood, 18.5 mg/L; liver, 28.5 mg/kg; gastric contents, 77 mg/69 g) and paroxetine (subclavian blood, 1.58 mg/L; liver, 15.3 mg/kg; gastric contents, 0.7 mg/69 g). The cause of death was attributed to the combined toxicity of moclobemide and paroxetine. Deaths attributed primarily to these drugs are extremely rare because both are considerably less toxic than older monoamine oxidase and tricyclic antidepressant drugs. Based on the history of the case and pharmacology of the drugs involved, the most likely mechanism of death was severe "serotonin syndrome" resulting from the overdose.