Ethyl acetate from nail polish remover inhalation in a case of fatal voluntary intoxication

Abstract

To describe a case of fatal voluntary intoxication involving ethyl acetate (EA) inhalation. A 57-year-old woman was found dead on her bed with a plastic bag over her head filled with cotton balls soaked with nail polish remover. Several empty nail polish remover bottles corresponding to a total volume of approximatly one liter of EA, were found near the body. Among her medical history, gastric banding, an orphan disease that required numerous orthopedic surgeries, depression and suicide attempts were notified. Medications were found at home such as venlafaxine, lorazepam, acetaminophen and zopiclone. At the autopsy, no traumatic injuries were observed. A non-specific asphyxia syndrome with organ congestion was notified with macroscopic lesions in favor of an acute or subacute pathological condition with obstruction of the upper airways by gastric contents up to the main bronchi resulting in pulmonary edema. Anoxia was confirmed by the findings of the microscopic examination. The following samples were available for toxicological analysis: peripheral and cardiac blood, urine, stomach content and bile. A comprehensive forensic toxicological expertise was carried out including investigation of illegal drugs, prescribed drugs, alcohol, volatile substances and other poisons like carbon monoxide with several screenings (immunoassay, gas chromatography-mass spectrometry and liquid chromatography-mass tandem) of various postmortem samples. Each substance detected was quantified by a validated method. Lorazepam, zopiclone and venlafaxine and metabolite were quantified by high-performance liquid chromatography with photodiode-array detection. EA, ethanol and methanol were quantified by gas chromatography and static headspace gas chromatography with flame ionization detector. Peripheral blood concentrations of lorazepam, zopiclone and venlafaxine and O-desmethyl-Venlafaxine were respectively at 55, 49, 414 and < 20 μg/L. EA and ethanol concentrations were at 0.033 and 2.58 g/L in peripheral blood, at 0.034 and 2.76 g/L in cardiac blood, at 0.069 and 2.33 g/L in urine, at 0.155 and 2.27 g/L in stomach content and at 0.014 and 2.87 g/L in bile. EA is commonly used as component in nail polish remover. After exposure to EA vapor, absorption is mainly respiratory and percutaneous. Distribution involves all organs but predominates in fatty tissues. EA is rapidly metabolized by plasma esterases resulting in ethanol and acetic acid synthesis. EA may cause drowsiness, sleepiness, unconsciousness, narcosis, stupor and central nervous system depression. These symptoms are potentiated with ethanol. In this case, the low ratio of EA to ethanol concentrations in all postmortem samples confirmed this rapid biotransformation. This was already mentioned in a case of accidental workplace exposure (Coopman. Forensic Sci Int 2005;154:92–95). Blood concentrations of prescribed drugs were here within the therapeutic range. An EA blood concentration of 0.033 g/L can therefore be considered lethal associated with an ethanol concentration around 2.6 g/L. To our knowledge, this is the first fatal case of voluntary intoxication with EA inhalation. The measured concentrations in all usual autopsy samples can be added to toxicological databases.