Legal Medicine xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Legal Medicine journal homepage: www.elsevier.com/locate/legalmed
Case Report
An autopsy case of fatal repellent air freshener poisoning Masahito Hitosugi a,⇑, Chie Tsukada b, Shinobu Yamauchi b, Kazumi Matsushima c, Satoshi Furukawa a, Satomu Morita a, Toshiaki Nagai b a
Department of Legal Medicine, Shiga University of Medical Science, Japan Department of Legal Medicine, Dokkyo Medical University School of Medicine, Japan c Forensic Science Laboratory, Tochigi Prefectural Police Headquarters, Japan b
a r t i c l e
i n f o
Article history: Received 9 February 2015 Received in revised form 24 April 2015 Accepted 28 April 2015 Available online xxxx Keywords: Repellent air freshener Surfactant Poisoning Death Autopsy
a b s t r a c t We describe a first fatal case of repellent air freshener ingestion. A 79-year-old Japanese man with Alzheimer-type senile dementia orally ingested repellent air freshener containing three surfactants: polyoxyethylene 9-lauryl ether, polyoxyethylene (40) hydrogenated castor oil, and lauric acid amidopropyl amine oxide (weight ratio of 1.3%). About 1 h after the collapse, he was in cardiopulmonary arrest and subsequently died 10 h after his arrival. The forensic autopsy performed 5.5 h after death revealed the 380 ml of stomach contents with a strong mint perfume identical to that of the repellent air freshener and the findings of acute death. Toxicologically, 9.1 lg/ml and 558.2 lg/ml of polyoxyethylene 9-lauryl ether were detected from the serum and stomach contents taken at autopsy. Generally, ingestion of anionic or non-ionic surfactants have been considered as safe. However, because the patient suffered from cardiac insufficiency with a low dose of repellent air freshener ingestion, medical staff members must evaluate the elderly patient for cardiac and circulatory problems regardless of the ingested dose. Not only medical and nursing staff members, but also families who are obliged to care for elderly persons must be vigilant to prevent accidental ingestion of toxic substances generally used in the household. Ó 2015 Elsevier Ireland Ltd. All rights reserved.
1. Introduction
2. Case report
Surfactants, which contained in insecticide, herbicide, detergent and so on, decrease the surface tension of these chemicals and improve the ability of adhesions [1]. Surfactant poisonings are often seen in suicide attempts or accidents with the findings of gastrointestinal tract irritation, elevated leukocytosis, or hypotension [2]. In the fatal poisoning cases, cardiovascular collapse and respiratory failure were found [3–9]. Therefore, in forensic medicine, detection of the surfactant from the body fluid or tissues is required for the diagnosis of poisoning death. Repellents with specific perfumes are widely used in houses and offices. They are in the form of a liquid, of which surfactants are major components. Although fatal surfactant poisoning cases have been reported, there are no reports of repellent air freshener poisoning cases [3–9]. We herein describe a fatal case of repellent air freshener ingestion by an elderly person with senile dementia.
2.1. History
⇑ Corresponding author at: Department of Legal Medicine, Shiga University of Medical Science, Tsukinowa, Seta, Otsu-City, Shiga 520-2192, Japan. Tel./fax: +81 77 548 2200. E-mail address: [email protected] (M. Hitosugi).
A 79-year-old Japanese man had suffered from Alzheimer-type senile dementia for 5 years. He sometimes orally ingested anything on the table. One day after dinner, the family found that the man had collapsed in the dining room. Beside the man, a bottle of repellent air freshener (Mushiconaazu, Dainippon-jyocyugiku, Osaka, Japan) containing the remaining two-thirds of its liquid contents was found (Fig. 1). Some of the contents had spilled out of the bottle. The air freshener had a mint perfume. Because the man’s consciousness did not improve and the family noted a perfume on his face similar to that of the repellent air freshener, they suspected that he had ingested it and transferred him to the hospital. Upon arrival at the hospital, 1 h after the collapse, he was in cardiopulmonary arrest. At the time of intubation, the doctor confirmed a strong mint smell identical to that of the repellent air freshener. Results of the blood examination taken immediately after resumption of the heart beat were as follows: hemoglobin of 11.1 g/dl; total leukocyte count of 13,700/mm3; platelet count of 169,000/mm3. The examination for the serum revealed total protein of 5.6 g/dl; albumin of 2.7 g/dl; creatinine of 0.83 mg/dl, blood urea nitrogen
http://dx.doi.org/10.1016/j.legalmed.2015.04.004 1344-6223/Ó 2015 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Hitosugi M et al. An autopsy case of fatal repellent air freshener poisoning. Leg Med (2015), http://dx.doi.org/10.1016/ j.legalmed.2015.04.004
2
M. Hitosugi et al. / Legal Medicine xxx (2015) xxx–xxx
Fig. 1. Appearance of the repellent air freshener product.
of 8.6 mg/dl; aspartate aminotransferase of 227 IU/l; alanine aminotransferase of 87 IU/l; alkaline phosphatase of 361 IU/l; cholinesterase of 165 IU/l; creatinine kinase of 92 IU/l; sodium of 152 mEq/l; potassium of 4.3 mEq/l; chloride of 102 mEq/l; C-reactive protein of 0.96 mg/dl. Despite treatment, the man was pronounced dead 10 h after his arrival. Because the police suspected that the man had not died of natural causes, a forensic autopsy was performed 5.5 h after death. 2.2. Autopsy findings The man was 156 cm in height and 50 kg in weight and had been in good general health. No injuries were noted on the body surface with the exception of a few injection marks. No corrosive changes were present on the mucosal surface of the tongue, pharynx, larynx, esophagus, or stomach. A total of 380 ml of material with a strong mint perfume identical to that of the repellent air freshener was found in the stomach. The heart weighed 380 g, and mild left ventricle hypertrophy was present. A stent was inserted into the left coronary artery. Moderate plaque formation with microfibrosis of the surrounding heart muscle was histologically observed. Other than the findings of acute death (fluid blood, visceral congestion, and petechial hemorrhage in the mucosa of the renal pelvis), the autopsy results were normal. 2.3. Toxicologic findings The repellent air freshener that the man had ingested comprised all 300 ml (full contents) of a bottle of blue liquid with a pH of 5–7. It contained three surfactants: polyoxyethylene 9-lauryl ether (weight ratio of 3.6%), polyoxyethylene (40) hydrogenated castor oil (weight ratio of 1.6%), and lauric acid amidopropyl amine oxide (weight ratio of 1.3%). The other major component was water, which accounted for a weight ratio of about 85%. Because surfactants were considered to be the major toxicologic substances of this repellent air freshener, we analyzed them from the samples taken from the man. Of the three surfactants, polyoxyethylene 9-lauryl ether was dominant, and a standard substance was available. Thus, we quantitatively evaluated the polyoxyethylene 9-lauryl ether in the serum and stomach contents.
Femoral vein blood was taken immediately after arrival at the emergency room, and inferior vena cava blood and stomach contents were sampled at autopsy. Polyoxyethylene 9-lauryl ether, C12H25-O-(CH2CH2O)9-H, was obtained from Wako Pure Chemical Industries, Product No. 148-07731 (Osaka, Japan). Calibrators were prepared from a standard solution in drug-free human serum at the following concentrations: 1 lg/ml, 2 lg/ml, 6 lg/ml, and 10 lg/ml. The sample was prepared by specimens that were diluted to fall within the range of the calibration curves. Fifty microliters of the sample was added to 0.75 ml of distilled water. The diluted solution was loaded onto an Extrelut NT1 column and retained for 15 min. The column was eluted with 6 ml of diethyl ether, and the elute was evaporated to dryness under nitrogen at 40 °C. The residue was dissolved in 200 ll of acetonitrile, and 3 ll of the extract was injected into a liquid chromatography column after filtration for the performance of liquid chromatography–mass spectrometry (LC–MS). LC–MS analysis was performed using an Agilent 1200 series LC/MSD SL (Agilent Technologies, Tokyo, Japan). The mobile phase involved 10 mM ammonium formate and acetonitrile. Their rates were 10:90 at 0 min; changed to 5:95 at 5 min and hold for 15 min; changed to 10:90 and hold for 10 min for a total run time of 30 min. An Eclipse XDB-C18 column (3.5 lm, 2.1 150 mm; Agilent Technologies) was used, and the column temperature was set at 40 °C. The flow rate was 0.2 ml/min. Ionization of analytes was performed using electrospray ionization in the positive mode. The MS parameters were follows: scan range of 100–2000, drying gas flow of 10 L, drying gas temperature of 350 °C, capillary voltage of 2500 V, and fragmentor voltage of 100 V. The calibration curve was linear in the range of 1–10 lg/ml. The regression equation was y = 9.5 105 1.6 105 and the correlation coefficient (R2) for calibration curves was 0.998. For quantitative analysis, the precursor ion m/z 600 was selected because it was the highest intensity of all detected ions. The serum concentration of polyoxyethylene 9-lauryl ether taken at the emergency room immediately after arriving was 30.1 lg/ml, and that measured at the time of the autopsy was 9.1 lg/ml. In addition, 558.2 lg/ml of polyoxyethylene 9-lauryl ether was detected from the stomach contents taken at autopsy (Fig. 2). Neither other drugs nor alcohol were detected by screening tests of the urine using Triage (Biosite Diagnostics, San Diego,
Please cite this article in press as: Hitosugi M et al. An autopsy case of fatal repellent air freshener poisoning. Leg Med (2015), http://dx.doi.org/10.1016/ j.legalmed.2015.04.004
3
M. Hitosugi et al. / Legal Medicine xxx (2015) xxx–xxx
a
b Relative abundance (%)
5.2min
A 5
a
10 Retention time (min)
1000
100 80 60 40 20 0 1000
500 m/z
b
5.2min
5
0
15
C
0
20 500
Relative abundance (%)
a
10 Retention time (min)
40
b
5.2min
5
60
m/z
B
0
80
15
Relative abundance (%)
0
100
10 Retention time (min)
15
100 80 60 40 20 0 1000
500 m/z
Fig. 2. Total ion chromatograms (a) and mass spectra (b) of polyoxyethylene 9-lauryl ether obtained from the blank serum spiked with standard solution (A), the serum taken at the hospital (B), and the stomach contents taken at the autopsy (C).
CA) and of the blood using GC/MS. The man was finally diagnosed with poisoning death due to ingestion of the surfactants in the repellent air freshener. 3. Discussion In this case, the major contents of the repellent air freshener were detected in the stomach contents and serum taken at the emergency room, indicating that the surfactant was absorbed into the blood from the alimentary tract within 1 h. Because gastric lavage was not performed at the hospital, we can estimate the ingested amount of surfactant from the concentrations in both the blood and stomach contents. Of course, some of the repellent air freshener went through the alimentary tract without being absorbed; thus, we can obtain the minimum amount of ingestion. Assuming that the blood volume of the man was 4 L, the amount of the surfactant found in the blood taken at the hospital was contained in 3.3 g of the repellent air freshener and that in the stomach at autopsy was contained in 5.8 g of the product. Because the relative density of the repellent air freshener was 0.99, the man was suspected to have ingested about 9.2 ml or more. Because two-thirds of the total amount of liquid remained in the bottle and some of contents had spilled out of the bottle, it could be deduced that the man had ingested less than 100 ml of the repellent air freshener. Many standard household detergents contain surfactants. Surfactants coexisting with hydrophilic and hydrophobic groups are grossly classified into cationic, anionic and non-ionic groups. Up to now, fatal detergent poisoning has been mainly associated to ingestion of cationic detergent. At the fatal poisoning by
benzalkonium chloride, a cationic surfactant, hypotension and other signs of circulatory shock were observed from a few minutes to 3 h after ingestion [5]. Because anionic and non-ionic surfactants are considered as low toxicity, it is generally accepted that ingestion of small amounts of surfactants does not cause any toxic symptoms [3,4,7]. However, there have been some reports that ingestion of anionic and non-ionic surfactants caused deaths [4,9–11]. For the anionic surfactants poisoning, corrosive changes of the digestive tract are often observed and it lead to the serious outcome, but even if lacking of corrosive changes, ingestion of anionic surfactant can cause acute death [1,8,12]. In this case, the main component of the surfactant contained in the repellant air fresher was polyethylene alkyl ether, which is one of the most frequently used non-ionic surfactants. As evidenced by cardiopulmonary arrest after ingestion, the patient suffered from cardiac insufficiency with a low dose of repellent air freshener ingestion within about an hour. The patient was elderly (79-year-old) and had suffered from left ventricle hypertrophy and plaque formation of peripheral coronary artery with micro fibrosis of the surrounding heart muscle. Although these findings may contribute to the death, as the lesions of the heart are not so severe and the patient fell in cardiopulmonary arrest after ingestion of the surfactant, the cause of death was decided as poisoning. To clarify the toxicity of the non-ionic surfactants for elderly or diseased patients, accumulation of the surfactant poisoning cases with evaluating their concentrations of the blood is needed. Anyway, when a person ingests surfactants, medical staff members must evaluate the patient for cardiac and circulatory problems regardless of the ingested dose. Some studies on acute surfactant poisoning (herbicide or insecticide) have revealed that more than 75% of cases occurred owing
Please cite this article in press as: Hitosugi M et al. An autopsy case of fatal repellent air freshener poisoning. Leg Med (2015), http://dx.doi.org/10.1016/ j.legalmed.2015.04.004
4
M. Hitosugi et al. / Legal Medicine xxx (2015) xxx–xxx
to attempted suicide [13]. However, accidental ingestion of surfactants by psychiatric patients have often been reported [5,8,14]. In this case, the man accidentally ingested repellent air freshener because he had senile dementia. In developed countries, including Japan, the increase in the elderly population has become a large nationwide issue. As we previously reported in a case of fatal accidental ingestion of benzalkonium chloride in a nursing home for the aged, persons with senile dementia are at high risk for ingestion of such toxic materials [5]. To the best of our knowledge, this is the first autopsy case of repellent air freshener poisoning. We suggest that not only medical and nursing staff members, but also families who are obliged to care for elderly persons must be vigilant to prevent accidental ingestion of toxic substances generally used in the household. References [1] Ago M, Ago K, Orihara Y, Ogata M. A case of death associated with ingestion of liquid windshield-washer detergent. Leg Med (Tokyo) 2003;5:S135–7. [2] Sawada Y, Nagai T, Ueyama M, Yamamoto I. Probable toxicity of surfactantactive agent in commercial herbicide containing glyphosate. Lancet 1988;I(8580):299. [3] Okumura T, Suzuki K, Yamane K, Kumada K, Kobayashi R, Fukuda A, et al. Intravenous detergent poisoning. Clin Toxicol 2000;28:347–50. [4] Prabhakar KS, Pall AA, Woo KT. Rhabdomyolysis and acute renal failure complicating detergent ingestion. Singapore Med J 2000;41:182–3.
[5] Hitosugi M, Maruyama K, Takatsu A. A case of fatal benzalkonium poisoning. Int J Legal Med 1998;111:265–6. [6] Sribanditmongkol P, Jutavijittum P, Pongraveevongsa P, Wunnapuk K, Durongkadech P. Pathological and toxicological findings in glyphosatesurfactant homicide fatality, a case report. Am J Forensic Med Pathol 2012;33:234–7. [7] Usui K, hayashizaki Y, Okubo Y, Hashiyada M, Funayama M. A case of death after ingestion of an agrochemical spreading agent. Forensic Sci Int 2011;210:117–21. [8] Kawamoto O, Ishikawa T, Oritani S, Kuramoto Y, Michiue T, Maeda H. Death following the ingestion of detergent: an autopsy case with special regard to the histochemical findings. Forensic Sci Med Pathol 2013;9:208–13. [9] Furukawa S, Morita S, Nishi K, Hitosugi M. A case and review of death associated with ingestion of detergent. Forensic Med Anat Res 2014;2:89–94. [10] Katsura S, Niitsu H, Kumagai R, Nakayashiki T, Nakajima M. A judgement case of suspected death by oral giving of a large amount of surfactants. Res Pract Forensic Med 1987;30:105–11 [in Japanese with English abstract]. [11] Gunji H, Matsumoto Y, Fujii M. Two cases of surfactant poisoning. Jpn J Toxicol 1990;3:245–8 [in Japanese with English abstract]. [12] Gawarammana IB, Ariyanada PA, Palangasinshe C, de Silva NGL, Femando K, Vidanapathirana M, et al. Emerging epidemic of fatal human self-poisoning with a washing powder in Southern Sri Lanka: a prospective observational study. Clin Toxicol (Phila) 2009;47:407–11. [13] Chen YJ, Wu ML, Deng JF, Yang CC. The epidemiology of glyphosate-surfactant herbicide poisoning in Taiwan, 1986–2007: a poison center study. Clin Toxicol 2009;47:670–7. [14] Kamijo Y, Soma K, Inoue A, Nagai T, Kurihara K. Acute respiratory distress syndrome following asthma-like symptoms from massive ingestion of a monoethanolamine-containing detergent. Vet Hum Toxicol 2004;46:79–80.
Please cite this article in press as: Hitosugi M et al. An autopsy case of fatal repellent air freshener poisoning. Leg Med (2015), http://dx.doi.org/10.1016/ j.legalmed.2015.04.004
Contents lists available at ScienceDirect
Legal Medicine journal homepage: www.elsevier.com/locate/legalmed
Case Report
An autopsy case of fatal repellent air freshener poisoning Masahito Hitosugi a,⇑, Chie Tsukada b, Shinobu Yamauchi b, Kazumi Matsushima c, Satoshi Furukawa a, Satomu Morita a, Toshiaki Nagai b a
Department of Legal Medicine, Shiga University of Medical Science, Japan Department of Legal Medicine, Dokkyo Medical University School of Medicine, Japan c Forensic Science Laboratory, Tochigi Prefectural Police Headquarters, Japan b
a r t i c l e
i n f o
Article history: Received 9 February 2015 Received in revised form 24 April 2015 Accepted 28 April 2015 Available online xxxx Keywords: Repellent air freshener Surfactant Poisoning Death Autopsy
a b s t r a c t We describe a first fatal case of repellent air freshener ingestion. A 79-year-old Japanese man with Alzheimer-type senile dementia orally ingested repellent air freshener containing three surfactants: polyoxyethylene 9-lauryl ether, polyoxyethylene (40) hydrogenated castor oil, and lauric acid amidopropyl amine oxide (weight ratio of 1.3%). About 1 h after the collapse, he was in cardiopulmonary arrest and subsequently died 10 h after his arrival. The forensic autopsy performed 5.5 h after death revealed the 380 ml of stomach contents with a strong mint perfume identical to that of the repellent air freshener and the findings of acute death. Toxicologically, 9.1 lg/ml and 558.2 lg/ml of polyoxyethylene 9-lauryl ether were detected from the serum and stomach contents taken at autopsy. Generally, ingestion of anionic or non-ionic surfactants have been considered as safe. However, because the patient suffered from cardiac insufficiency with a low dose of repellent air freshener ingestion, medical staff members must evaluate the elderly patient for cardiac and circulatory problems regardless of the ingested dose. Not only medical and nursing staff members, but also families who are obliged to care for elderly persons must be vigilant to prevent accidental ingestion of toxic substances generally used in the household. Ó 2015 Elsevier Ireland Ltd. All rights reserved.
1. Introduction
2. Case report
Surfactants, which contained in insecticide, herbicide, detergent and so on, decrease the surface tension of these chemicals and improve the ability of adhesions [1]. Surfactant poisonings are often seen in suicide attempts or accidents with the findings of gastrointestinal tract irritation, elevated leukocytosis, or hypotension [2]. In the fatal poisoning cases, cardiovascular collapse and respiratory failure were found [3–9]. Therefore, in forensic medicine, detection of the surfactant from the body fluid or tissues is required for the diagnosis of poisoning death. Repellents with specific perfumes are widely used in houses and offices. They are in the form of a liquid, of which surfactants are major components. Although fatal surfactant poisoning cases have been reported, there are no reports of repellent air freshener poisoning cases [3–9]. We herein describe a fatal case of repellent air freshener ingestion by an elderly person with senile dementia.
2.1. History
⇑ Corresponding author at: Department of Legal Medicine, Shiga University of Medical Science, Tsukinowa, Seta, Otsu-City, Shiga 520-2192, Japan. Tel./fax: +81 77 548 2200. E-mail address: [email protected] (M. Hitosugi).
A 79-year-old Japanese man had suffered from Alzheimer-type senile dementia for 5 years. He sometimes orally ingested anything on the table. One day after dinner, the family found that the man had collapsed in the dining room. Beside the man, a bottle of repellent air freshener (Mushiconaazu, Dainippon-jyocyugiku, Osaka, Japan) containing the remaining two-thirds of its liquid contents was found (Fig. 1). Some of the contents had spilled out of the bottle. The air freshener had a mint perfume. Because the man’s consciousness did not improve and the family noted a perfume on his face similar to that of the repellent air freshener, they suspected that he had ingested it and transferred him to the hospital. Upon arrival at the hospital, 1 h after the collapse, he was in cardiopulmonary arrest. At the time of intubation, the doctor confirmed a strong mint smell identical to that of the repellent air freshener. Results of the blood examination taken immediately after resumption of the heart beat were as follows: hemoglobin of 11.1 g/dl; total leukocyte count of 13,700/mm3; platelet count of 169,000/mm3. The examination for the serum revealed total protein of 5.6 g/dl; albumin of 2.7 g/dl; creatinine of 0.83 mg/dl, blood urea nitrogen
http://dx.doi.org/10.1016/j.legalmed.2015.04.004 1344-6223/Ó 2015 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Hitosugi M et al. An autopsy case of fatal repellent air freshener poisoning. Leg Med (2015), http://dx.doi.org/10.1016/ j.legalmed.2015.04.004
2
M. Hitosugi et al. / Legal Medicine xxx (2015) xxx–xxx
Fig. 1. Appearance of the repellent air freshener product.
of 8.6 mg/dl; aspartate aminotransferase of 227 IU/l; alanine aminotransferase of 87 IU/l; alkaline phosphatase of 361 IU/l; cholinesterase of 165 IU/l; creatinine kinase of 92 IU/l; sodium of 152 mEq/l; potassium of 4.3 mEq/l; chloride of 102 mEq/l; C-reactive protein of 0.96 mg/dl. Despite treatment, the man was pronounced dead 10 h after his arrival. Because the police suspected that the man had not died of natural causes, a forensic autopsy was performed 5.5 h after death. 2.2. Autopsy findings The man was 156 cm in height and 50 kg in weight and had been in good general health. No injuries were noted on the body surface with the exception of a few injection marks. No corrosive changes were present on the mucosal surface of the tongue, pharynx, larynx, esophagus, or stomach. A total of 380 ml of material with a strong mint perfume identical to that of the repellent air freshener was found in the stomach. The heart weighed 380 g, and mild left ventricle hypertrophy was present. A stent was inserted into the left coronary artery. Moderate plaque formation with microfibrosis of the surrounding heart muscle was histologically observed. Other than the findings of acute death (fluid blood, visceral congestion, and petechial hemorrhage in the mucosa of the renal pelvis), the autopsy results were normal. 2.3. Toxicologic findings The repellent air freshener that the man had ingested comprised all 300 ml (full contents) of a bottle of blue liquid with a pH of 5–7. It contained three surfactants: polyoxyethylene 9-lauryl ether (weight ratio of 3.6%), polyoxyethylene (40) hydrogenated castor oil (weight ratio of 1.6%), and lauric acid amidopropyl amine oxide (weight ratio of 1.3%). The other major component was water, which accounted for a weight ratio of about 85%. Because surfactants were considered to be the major toxicologic substances of this repellent air freshener, we analyzed them from the samples taken from the man. Of the three surfactants, polyoxyethylene 9-lauryl ether was dominant, and a standard substance was available. Thus, we quantitatively evaluated the polyoxyethylene 9-lauryl ether in the serum and stomach contents.
Femoral vein blood was taken immediately after arrival at the emergency room, and inferior vena cava blood and stomach contents were sampled at autopsy. Polyoxyethylene 9-lauryl ether, C12H25-O-(CH2CH2O)9-H, was obtained from Wako Pure Chemical Industries, Product No. 148-07731 (Osaka, Japan). Calibrators were prepared from a standard solution in drug-free human serum at the following concentrations: 1 lg/ml, 2 lg/ml, 6 lg/ml, and 10 lg/ml. The sample was prepared by specimens that were diluted to fall within the range of the calibration curves. Fifty microliters of the sample was added to 0.75 ml of distilled water. The diluted solution was loaded onto an Extrelut NT1 column and retained for 15 min. The column was eluted with 6 ml of diethyl ether, and the elute was evaporated to dryness under nitrogen at 40 °C. The residue was dissolved in 200 ll of acetonitrile, and 3 ll of the extract was injected into a liquid chromatography column after filtration for the performance of liquid chromatography–mass spectrometry (LC–MS). LC–MS analysis was performed using an Agilent 1200 series LC/MSD SL (Agilent Technologies, Tokyo, Japan). The mobile phase involved 10 mM ammonium formate and acetonitrile. Their rates were 10:90 at 0 min; changed to 5:95 at 5 min and hold for 15 min; changed to 10:90 and hold for 10 min for a total run time of 30 min. An Eclipse XDB-C18 column (3.5 lm, 2.1 150 mm; Agilent Technologies) was used, and the column temperature was set at 40 °C. The flow rate was 0.2 ml/min. Ionization of analytes was performed using electrospray ionization in the positive mode. The MS parameters were follows: scan range of 100–2000, drying gas flow of 10 L, drying gas temperature of 350 °C, capillary voltage of 2500 V, and fragmentor voltage of 100 V. The calibration curve was linear in the range of 1–10 lg/ml. The regression equation was y = 9.5 105 1.6 105 and the correlation coefficient (R2) for calibration curves was 0.998. For quantitative analysis, the precursor ion m/z 600 was selected because it was the highest intensity of all detected ions. The serum concentration of polyoxyethylene 9-lauryl ether taken at the emergency room immediately after arriving was 30.1 lg/ml, and that measured at the time of the autopsy was 9.1 lg/ml. In addition, 558.2 lg/ml of polyoxyethylene 9-lauryl ether was detected from the stomach contents taken at autopsy (Fig. 2). Neither other drugs nor alcohol were detected by screening tests of the urine using Triage (Biosite Diagnostics, San Diego,
Please cite this article in press as: Hitosugi M et al. An autopsy case of fatal repellent air freshener poisoning. Leg Med (2015), http://dx.doi.org/10.1016/ j.legalmed.2015.04.004
3
M. Hitosugi et al. / Legal Medicine xxx (2015) xxx–xxx
a
b Relative abundance (%)
5.2min
A 5
a
10 Retention time (min)
1000
100 80 60 40 20 0 1000
500 m/z
b
5.2min
5
0
15
C
0
20 500
Relative abundance (%)
a
10 Retention time (min)
40
b
5.2min
5
60
m/z
B
0
80
15
Relative abundance (%)
0
100
10 Retention time (min)
15
100 80 60 40 20 0 1000
500 m/z
Fig. 2. Total ion chromatograms (a) and mass spectra (b) of polyoxyethylene 9-lauryl ether obtained from the blank serum spiked with standard solution (A), the serum taken at the hospital (B), and the stomach contents taken at the autopsy (C).
CA) and of the blood using GC/MS. The man was finally diagnosed with poisoning death due to ingestion of the surfactants in the repellent air freshener. 3. Discussion In this case, the major contents of the repellent air freshener were detected in the stomach contents and serum taken at the emergency room, indicating that the surfactant was absorbed into the blood from the alimentary tract within 1 h. Because gastric lavage was not performed at the hospital, we can estimate the ingested amount of surfactant from the concentrations in both the blood and stomach contents. Of course, some of the repellent air freshener went through the alimentary tract without being absorbed; thus, we can obtain the minimum amount of ingestion. Assuming that the blood volume of the man was 4 L, the amount of the surfactant found in the blood taken at the hospital was contained in 3.3 g of the repellent air freshener and that in the stomach at autopsy was contained in 5.8 g of the product. Because the relative density of the repellent air freshener was 0.99, the man was suspected to have ingested about 9.2 ml or more. Because two-thirds of the total amount of liquid remained in the bottle and some of contents had spilled out of the bottle, it could be deduced that the man had ingested less than 100 ml of the repellent air freshener. Many standard household detergents contain surfactants. Surfactants coexisting with hydrophilic and hydrophobic groups are grossly classified into cationic, anionic and non-ionic groups. Up to now, fatal detergent poisoning has been mainly associated to ingestion of cationic detergent. At the fatal poisoning by
benzalkonium chloride, a cationic surfactant, hypotension and other signs of circulatory shock were observed from a few minutes to 3 h after ingestion [5]. Because anionic and non-ionic surfactants are considered as low toxicity, it is generally accepted that ingestion of small amounts of surfactants does not cause any toxic symptoms [3,4,7]. However, there have been some reports that ingestion of anionic and non-ionic surfactants caused deaths [4,9–11]. For the anionic surfactants poisoning, corrosive changes of the digestive tract are often observed and it lead to the serious outcome, but even if lacking of corrosive changes, ingestion of anionic surfactant can cause acute death [1,8,12]. In this case, the main component of the surfactant contained in the repellant air fresher was polyethylene alkyl ether, which is one of the most frequently used non-ionic surfactants. As evidenced by cardiopulmonary arrest after ingestion, the patient suffered from cardiac insufficiency with a low dose of repellent air freshener ingestion within about an hour. The patient was elderly (79-year-old) and had suffered from left ventricle hypertrophy and plaque formation of peripheral coronary artery with micro fibrosis of the surrounding heart muscle. Although these findings may contribute to the death, as the lesions of the heart are not so severe and the patient fell in cardiopulmonary arrest after ingestion of the surfactant, the cause of death was decided as poisoning. To clarify the toxicity of the non-ionic surfactants for elderly or diseased patients, accumulation of the surfactant poisoning cases with evaluating their concentrations of the blood is needed. Anyway, when a person ingests surfactants, medical staff members must evaluate the patient for cardiac and circulatory problems regardless of the ingested dose. Some studies on acute surfactant poisoning (herbicide or insecticide) have revealed that more than 75% of cases occurred owing
Please cite this article in press as: Hitosugi M et al. An autopsy case of fatal repellent air freshener poisoning. Leg Med (2015), http://dx.doi.org/10.1016/ j.legalmed.2015.04.004
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to attempted suicide [13]. However, accidental ingestion of surfactants by psychiatric patients have often been reported [5,8,14]. In this case, the man accidentally ingested repellent air freshener because he had senile dementia. In developed countries, including Japan, the increase in the elderly population has become a large nationwide issue. As we previously reported in a case of fatal accidental ingestion of benzalkonium chloride in a nursing home for the aged, persons with senile dementia are at high risk for ingestion of such toxic materials [5]. To the best of our knowledge, this is the first autopsy case of repellent air freshener poisoning. We suggest that not only medical and nursing staff members, but also families who are obliged to care for elderly persons must be vigilant to prevent accidental ingestion of toxic substances generally used in the household. References [1] Ago M, Ago K, Orihara Y, Ogata M. A case of death associated with ingestion of liquid windshield-washer detergent. Leg Med (Tokyo) 2003;5:S135–7. [2] Sawada Y, Nagai T, Ueyama M, Yamamoto I. Probable toxicity of surfactantactive agent in commercial herbicide containing glyphosate. Lancet 1988;I(8580):299. [3] Okumura T, Suzuki K, Yamane K, Kumada K, Kobayashi R, Fukuda A, et al. Intravenous detergent poisoning. Clin Toxicol 2000;28:347–50. [4] Prabhakar KS, Pall AA, Woo KT. Rhabdomyolysis and acute renal failure complicating detergent ingestion. Singapore Med J 2000;41:182–3.
[5] Hitosugi M, Maruyama K, Takatsu A. A case of fatal benzalkonium poisoning. Int J Legal Med 1998;111:265–6. [6] Sribanditmongkol P, Jutavijittum P, Pongraveevongsa P, Wunnapuk K, Durongkadech P. Pathological and toxicological findings in glyphosatesurfactant homicide fatality, a case report. Am J Forensic Med Pathol 2012;33:234–7. [7] Usui K, hayashizaki Y, Okubo Y, Hashiyada M, Funayama M. A case of death after ingestion of an agrochemical spreading agent. Forensic Sci Int 2011;210:117–21. [8] Kawamoto O, Ishikawa T, Oritani S, Kuramoto Y, Michiue T, Maeda H. Death following the ingestion of detergent: an autopsy case with special regard to the histochemical findings. Forensic Sci Med Pathol 2013;9:208–13. [9] Furukawa S, Morita S, Nishi K, Hitosugi M. A case and review of death associated with ingestion of detergent. Forensic Med Anat Res 2014;2:89–94. [10] Katsura S, Niitsu H, Kumagai R, Nakayashiki T, Nakajima M. A judgement case of suspected death by oral giving of a large amount of surfactants. Res Pract Forensic Med 1987;30:105–11 [in Japanese with English abstract]. [11] Gunji H, Matsumoto Y, Fujii M. Two cases of surfactant poisoning. Jpn J Toxicol 1990;3:245–8 [in Japanese with English abstract]. [12] Gawarammana IB, Ariyanada PA, Palangasinshe C, de Silva NGL, Femando K, Vidanapathirana M, et al. Emerging epidemic of fatal human self-poisoning with a washing powder in Southern Sri Lanka: a prospective observational study. Clin Toxicol (Phila) 2009;47:407–11. [13] Chen YJ, Wu ML, Deng JF, Yang CC. The epidemiology of glyphosate-surfactant herbicide poisoning in Taiwan, 1986–2007: a poison center study. Clin Toxicol 2009;47:670–7. [14] Kamijo Y, Soma K, Inoue A, Nagai T, Kurihara K. Acute respiratory distress syndrome following asthma-like symptoms from massive ingestion of a monoethanolamine-containing detergent. Vet Hum Toxicol 2004;46:79–80.
Please cite this article in press as: Hitosugi M et al. An autopsy case of fatal repellent air freshener poisoning. Leg Med (2015), http://dx.doi.org/10.1016/ j.legalmed.2015.04.004
