Suicide of a young woman using a kit containing sodium nitrite ordered on the internet

Abstract

We report the case of a 13-year-old girl, found dead by her father, with a glass containing 15 g of white powder and a bottle containing 5 g of white powder with a moistened appearance. The autopsy was performed four days after the death. The anatomopathological study of the specimens was included in formaldehyde and prepared according to the Saffron Eosin Hematein technique. First of all, a post-mortem toxicological screening was performed on cardiac blood, peripheral blood, urine and gastric contents by high performance liquid chromatography coupled to high resolution mass spectrometry (HPLC-HRMS). Ethanol testing was performed by gas chromatography coupled to a flame ionization detector (GC-FID), and drug testing by liquid chromatography coupled to a mass spectrometer (LC-MS/MS, opiates, cocaine, amphetamine) or gas chromatography coupled to a mass spectrometer (GC-MS, cannabis). A rapid analysis of powders found near the body was carried out by RAMAN spectrometry, and confirmed by ion chromatography coupled with mass spectrometry and X-ray diffractometry. In order to establish the concentration of the substance found by those analyses in peripheral blood and gastric contents, we later used the saltzman reaction after addition of potassium ferrocyanide and zinc sulfate. External examination and autopsy revealed a non-specific asphyxia syndrome. This was confirmed by the anatomopathological study which showed signs of non-specific acute heart failure: diffuse visceral congestion (heart, lungs, spleen, liver, pancreas, kidneys, thyroid, stomach) and pulmonary haemorrhage. First of all, toxicological analyses revealed the presence of metoclopramide, in cardiac blood (0.37 mg/L), urines (0.20 mg/L), gastric contents (0.24 mg/L) and in peripheral blood at a concentration of 0.40 mg/L. However, no ethanol and presence of drugs of abuse (cannabinoids, opiates, cocaine, and amphetamines) were detected. Secondly, powders found close to the body were analysed by three different techniques, and revealed the presence of sodium nitrite in pure form. Finally, the analysis of gastric contents confirmed the presence of nitrites at a concentration of 30.9 mg/L. This analysis could not be performed on the blood samples due to colour interference. This young girl died of anoxia secondary to the ingestion of a suicide kit containing sodium nitrite. Diverted from their original use as euphoriants (poppers), nitrites are now used for suicidal purposes. Specific kits have emerged on the internet. They contain sodium nitrite, metoclopramide and antacid. NaN02 is presented in the form of a powder, similar to salt, which dissolves easily in a liquid to reconstitute a toxic drink (Durão C, J Forensic Leg Med, 2020;73:101989). The lethal dose of nitrites is estimated for an adult at 2.6 g (Hwang C, Forensic Sci Med Pathol, 2021;17(3):475–80). This dose seems variable since a fatal case is described in the literature for an ingestion of 1 g (Gowans WJ, Br J Gen Pract J R Coll Gen Pract, 1990;40(340):470–1) and one non-fatal case following ingestion of 6 g (Chui JSW, Anaesthesia, 2005;60(5):496–500). In our victim's case, metoclopramide was also detected, at a concentration of 0.40 mg/L in the peripheral blood. The metoclopramide's concentration is therapeutic between 0.05 and 0.15 mg/L and toxic from 0.2 mg/L (Schulz M, Crit Care,2012;16(4):R136). Such a concentration of metoclopramide is therefore potentially toxic and can cause extrapyramidal symptoms (tremors), drowsiness, impaired consciousness, confusion, hallucinations, even cardiorespiratory arrest (Vidal) and may have contributed to death. The alarming increase in the number of cases and the access facility to these suicide kits on the internet shows that it is essential to implement measures to regulate this substance to prevent its diversion and use.