Case 407 -- A 49-year-old white woman found dead in her bed

Contributed by DN Ionescu, MD, JK Janssen, MS, BI Omalu, MD, MPH
Published on line in November, 2004


PATIENT HISTORY:

A family member had gone to pick up this 49 year old, white female, from her apartment for a family dinner and found her unresponsive in bed, wearing her blue pajamas. Scene investigation revealed multiple, randomly situated medication bottles around the apartment, some with the lids off. Some of the bottles were empty and others contained the following prescribed pills: Desipramine, Imipramine and Fluoxetine. The prescriptions had been filled two days prior and a significant number of pills were unaccounted for. There was no scene evidence of any struggle or any signs of violence. There was a strong family and personal history of long standing depression. She was under psychiatric treatment and attended several support groups for the depressed. She had mentioned an intention to commit suicide four years prior, but there was no recent mention or suggestion of suicide. She seemed stable and responded well to therapy. There was no history of any previous suicide attempt (para-suicide). No suicide note was found at the apartment.

AUTOPSY FINDINGS:

A complete autopsy revealed the body of a well-developed, well-nourished white female with evidence of early decomposition and without any evidence of trauma. There was no significant anatomic pathologic finding that may have explained her sudden and unexpected demise. Representative samples of the heart blood, femoral blood, urine, bile and vitreous fluid were taken and submitted for forensic toxicologic analyses.

LABORATORY FINDINGS:

A preliminary screening protocol was performed on the submitted samples:

  1. Volatiles (Alcohols and Acetone) using Head Space Gas Chromatography-Flame Ionization Detector (GC-FID)
  2. Carbon monoxide and Cyanide using Conway Diffusion Chamber Color Test
  3. Benzodiazepines using Gas Chromatography-Electron Capture Detector (GC-ECD)
  4. Basic drug screens using:
    1. Gas Chromatography-Nitrogen Phosphorus Detector (GC-NPD)
    2. Gas Chromatography-Mass Spectrometer (GC-MS)
  5. Opiates and Tricyclic using Florescence Polarization Immunoassay.
  6. Salicylates and Phenothiazines using branded color test kits

Following preliminary qualitative screening and detection of drugs present, the following confirmatory and quantitative analyses were performed:

      

  1. Fluorescence Polarization Immunoassay for Acetaminophen
  2. High pressure Liquid Chromatography-Ultraviolet Detector for Imipramine and Desipramine ( Figure 1)
  3. Gas Chromatography-Nitrogen Phosphorus Detector (GC-NPD) for Oxycodone and Diphenhydramine

The following drugs were identified on the basic drug screen (Figure 2) and confirmed by quantitative analyses: Imipramine (Figure 3), Desipramine, Oxycodone, Acetaminophen (Figure 4) and Diphenhydramine (table 1). The screen was negative for Cocaine, Opiates, Cyanide, Carbon Monoxide and Benzodiazepines.

      

Table 1: Positive blood and urine screen

 

Blood

Femoral Blood

Urine GLC/GCMS

Imipramine

0.468 mg%

0.039 mg%

+, +

Desipramine

0.442 mg%

0.036 mg%

+, +

Oxycodone

0.197mg%

Insuficient

+, +

Acetaminophen

194.2 ug/ml

N/A

-, +

Ethanol was also detected in the body fluids, with the following levels:

Table 2: Ethanol levels in body fluids

 

Blood

Urine

Bile

Eye Fluid

Ethanol

0. 125%

0.089%

0.079%

0.076%

WHAT IS YOUR DIAGNOSIS?


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