County of San Diego Medical Examiners Office

San Diego, CA, United States

County of San Diego Medical Examiners Office

San Diego, CA, United States

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Cantrell F.L.,California Poison Control System | Cantrell F.L.,University of California at San Francisco | Ogera P.,County of San Diego Medical Examiners Office | Mallett P.,County of San Diego Medical Examiners Office | Mcintyre I.M.,County of San Diego Medical Examiners Office
Journal of Forensic Sciences | Year: 2014

Methylphenidate (MPD) is a widely prescribed stimulant used primarily for the treatment for attention-deficit/hyperactivity disorder (ADHD). Suicide attempts involving MPD ingestion have been well described; however, deaths attributed solely to MPD ingestion have not been reported. A 62-year-old woman was found dead on her floor. The only discrepancy in among her medication quantities was that >three hundred 10 mg MPD tablets were missing. Analysis utilizing gas chromatography-mass spectrometry revealed elevated postmortem MPD peripheral and central blood, liver and vitreous humor concentrations. Considering both the central blood to peripheral blood ratio (0.89) and the liver to peripheral blood ratio (3.3), MPD does not appear subject to significant postmortem redistribution. With no other identifiable cause of death, we report what appears to be the first isolated MPD ingestion associated with a fatality. © 2014 American Academy of Forensic Sciences.


Cantrell F.L.,California Poison Control System | Cantrell F.L.,University of California at San Francisco | Mena O.,County of San Diego Medical Examiner's Office | Gary R.D.,County of San Diego Medical Examiner's Office | McIntyre I.M.,County of San Diego Medical Examiner's Office
International Journal of Legal Medicine | Year: 2015

Gabapentin (GBP) (Neurontin®, Horizant®, Gralise®) is a widely prescribed medication used primarily for the treatment of epilepsy and neuropathic pain. GBP has a favorable adverse effect profile in therapeutic dosing with the most common reported effects being dizziness, fatigue, drowsiness, weight gain, and peripheral edema. Even with intentional GBP self-poisonings, serious effects are rare. A 47-year-old female was found dead at work with her daughter’s bottle of GBP 600 mg. There were 26 tablets missing and the decedent’s only known medication was hydrocodone/acetaminophen. Following initial detection by an alkaline drug screen (GC-MS), analysis utilizing specific liquid chromatography–mass spectrometry revealed an elevated postmortem GBP peripheral blood concentration of 37 mg/L, central blood 32 mg/L, liver 26 mg/kg, vitreous 32 mg/L, and gastric contents 6 mg. Screening for volatiles, drugs of abuse, alkaline compounds, and acid/neutral compounds was negative with the exception of ibuprofen (<2 mg/L) detected in peripheral blood. This report presents a fatality that appears to be associated with an isolated and acute GBP ingestion. © 2015, Springer-Verlag Berlin Heidelberg.


McIntyre I.M.,Forensic Toxicology Laboratory | Nelson C.L.,County of San Diego Medical Examiners Office | Schaber B.,County of San Diego Medical Examiners Office | Hamm C.E.,Forensic Toxicology Laboratory
Journal of Analytical Toxicology | Year: 2013

We compare antemortem whole-blood to postmortem peripheral blood concentrations of methamphetamine and its metabolite amphetamine in three medical examiner cases. Antemortem specimens, initially screened positive for methamphetamine by ELISA, were subsequently confirmed, together with the postmortem specimens, by GC-MS analysis following solid-phase extraction. Methamphetamine peripheral blood to antemortem blood ratios averaged 1.51 (±0.049; n 5 3) and amphetamine peripheral blood to antemortem blood ratios averaged 1.50 (n 5 2). These data show that postmortem redistribution occurs for both methamphetamine and amphetamine, revealing that postmortem blood concentrations are ~1.5 times greater than antemortem concentrations. Furthermore, as both methamphetamine and amphetamine have previously been shown to have liver/peripheral blood (L/P) ratios of 5-8, it can be proposed that drugs displaying L/P ratios ranging from 5 to 10 may exhibit postmortem concentrations up to twice those concentrations circulating in blood before death. © The Author [2013]. Published by Oxford University Press. All rights reserved.


McIntyre I.M.,County of San Diego Medical Examiners Office | Hamm C.E.,County of San Diego Medical Examiners Office | Aldridge L.,County of San Diego Medical Examiners Office | Nelson C.L.,County of San Diego Medical Examiners Office
Forensic Science International | Year: 2013

A 19-year-old woman who was known to use illicit drugs (ecstasy and marijuana) was found floating in the ocean 100 yards from the beach. When last seen the previous evening, she had said to a friend that she was going to "get in the water." Reports to police indicated that she "may have been on ecstasy." There were no notes of a suicidal nature, illicit drugs, drug paraphernalia, tobacco cigarettes, or alcoholic beverages at the scene. Autopsy findings were consistent with drowning. Postmortem blood initially screened positive for methamphetamine and cannabinoids by ELISA and was subsequently confirmed for methylone by a specific GC-MS SIM analysis following solid-phase extraction. Concentrations found in the peripheral blood, central blood, vitreous, liver and gastric contents were measured at 3.4 mg/L 3.4 mg/L, 4.3 mg/L, 11 mg/kg, and 1.7 mg, respectively. No other amphetamine-like compound (including ecstasy) was detected. These results are discussed in relation to previous cases of toxicity, and the lack of potential for substantial methylone postmortem redistribution. © 2013.


McIntyre I.M.,County of San Diego Medical Examiners Office | Mallett P.,County of San Diego Medical Examiners Office | Trochta A.,County of San Diego Medical Examiners Office | Morhaime J.,County of San Diego Medical Examiners Office
Forensic Science International | Year: 2013

Hydroxyzine is an antihistaminic with sedative properties used in the control of anxiety and emesis. Peripheral blood hydroxyzine concentrations are compared to central blood and liver concentrations in 10 medical examiner cases. Specimens were initially screened for alcohol and simple volatiles by GC-FID headspace analysis, ELISA for drugs of abuse, and alkaline drugs by GC/MS. Hydroxyzine, when detected by the alkaline drug screen, was subsequently confirmed and quantified by a specific GC-NPD procedure. Data suggest that postmortem peripheral blood hydroxyzine concentrations may be considered therapeutic to at least 0.24. mg/L and corresponding liver concentrations to at least 4.9. mg/kg. Hydroxyzine concentrations ranged 0.07-3.0. mg/L in peripheral blood, 0.04-3.8. mg/L in central blood, and 0.88-55. mg/kg in liver. Hydroxyzine central blood to peripheral blood ratios averaged 0.92. ±. 0.25 (±standard deviation; N=. 6). Liver to peripheral blood ratios, on the other hand, were higher and averaged 13.8. ±. 6.2 (±standard deviation; N=. 10). Given that a liver to peripheral blood ratio less than 5 is consistent with little to no postmortem redistribution while exceeding 20-30 is indicative of propensity for significant postmortem redistribution, these data suggest that hydroxyzine is prone to a moderate degree of postmortem redistribution. © 2013 Elsevier Ireland Ltd.


Mcintyre I.M.,County of San Diego Medical Examiners Office | Mallett P.,County of San Diego Medical Examiners Office | Burton C.G.,County of San Diego Medical Examiners Office | Morhaime J.,County of San Diego Medical Examiners Office
Journal of Forensic Sciences | Year: 2014

A woman was found unresponsive with an empty bottle of Cogentin® prescribed to another. Admitted to an area hospital, her condition steadily declined until death 29 h after admission. Following toxicological screening on hospital (admission) whole blood, the only significant compound detected was benztropine. Benztropine was confirmed at 0.28 mg/L - the highest antemortem blood concentration recorded in a case of toxicity or fatality uniquely associated with benztropine. A second serum antemortem specimen showed a benztropine concentration of 0.19 mg/L. Despite over 24 h in the hospital, benztropine was also found in the postmortem specimens collected at autopsy. Peripheral blood, central blood, liver, and gastric concentrations were 0.47 mg/L, 0.36 mg/L, 9.6 mg/kg, and 44 mg, respectively. These results indicate that benztropine exhibited a potential difference between whole-blood and serum (plasma) concentrations. Additionally, in consideration of literature data, benztropine was found indicative of a compound prone to at least some postmortem redistribution. © 2014 American Academy of Forensic Sciences.


McIntyre I.M.,County of San Diego Medical Examiners Office | Mallett P.,County of San Diego Medical Examiners Office
Forensic Science International | Year: 2012

Sertraline is a commonly prescribed selective inhibitor of serotonin uptake used for the treatment of mental depression and anxiety. Central blood and liver concentrations of sertraline (norsertraline) are compared to levels in peripheral blood in nine medical examiner cases. Specimens were initially screened for alcohol and simple volatiles by GC-FID headspace analysis, ELISA for drugs of abuse, and alkaline drugs by GC/MS. Sertraline, when detected by the alkaline drug screen, was subsequently confirmed and quantified by a specific GC-NPD procedure. Data suggest that when ingested with other medications, sertraline may be a contributing factor in death. Sertraline (norsertraline) concentrations ranged from 0.13 (0.11) to 2.1 (6.0). mg/L in peripheral blood, from 0.18 (0.12) to 2.0 (6.7). mg/L in central blood, and 21 to 160. mg/kg in liver. Sertraline central blood to peripheral blood ratios averaged 1.22 ± 0.85 (mean ± standard deviation). The liver to peripheral blood ratios, on the other hand, were markedly higher and averaged 97 ± 40 (mean ± standard deviation). Given that a liver to peripheral blood ratio exceeding 20 is indicative of propensity for significant postmortem redistribution, these data confirm that sertraline is prone to marked postmortem redistribution. © 2012.


McIntyre I.M.,Forensic Toxicology | Sherrard J.,Forensic Toxicology | Lucas J.,County of San Diego Medical Examiners Office
Journal of Analytical Toxicology | Year: 2012

Carisoprodol is a therapeutic and occasionally abused centrally acting muscle relaxant. We compare central blood and liver concentrations of carisoprodol and the metabolite meprobamate to concentrations in peripheral blood in 11 medical examiner cases. Specimens were initially screened for alcohol and simple volatiles by gas chromatography (GC)-flame ionization detection headspace analysis, enzyme-linked immunosorbent array for drugs of abuse, and therapeutic drugs by GC-mass spectrometry (MS). Carisoprodol, when detected by the therapeutic drug screen, was confirmed and quantified by a specific GC-MS procedure. The results suggest that when ingested with other medications, carisoprodol may be a contributing factor in death, even when present at therapeutic concentrations. Considering the cases studied, together with previously published therapeutic and fatal concentrations, blood carisoprodol concentrations greater than 15 mg/L and liver concentrations greater than 50 mg/kg may be considered excessive and potentially fatal. Carisoprodol central blood to peripheral blood ratios averaged 1.31 1 0.33 (mean+standard deviation), and liver to peripheral blood, 2.83±1.51. Meprobamate central blood to peripheral blood ratios averaged 0.92±0.22, and liver to peripheral blood, 1.25±0.69. The low liver to peripheral blood ratio (less than 5), taken together with the low central blood to peripheral blood ratio, is an indicator that both carisoprodol and meprobamate lack the potential to exhibit postmortem redistribution. © The Author [2012]. Published by Oxford University Press. All rights reserved.


Vance C.,County of San Diego Medical Examiners Office
Journal of analytical toxicology | Year: 2012

Intentional abuse of 1,1-difluoroethane has been reported to cause transient symptoms such as confusion, tremors, pulmonary irritation, loss of consciousness and, rarely, coma. In the last five years, 17 cases from the San Diego County Medical Examiner's Office showed the presence of 1,1-difluoroethane in postmortem tissues, and the gas was cited in the cause of death in 13 of those cases. Detected during routine ethanol screening, 1,1-difluoroethane was evaluated for concentrations in peripheral blood, central blood and vitreous humor by a slightly modified method published by Avella et al. In many cases, death from abuse of 1,1-difluoroethane seemed to occur within minutes of intentional abuse; large concentrations (>100 mg/L) of the gas were still in the blood. It is important that forensic toxicology laboratories have routine screening procedures to detect 1,1-difluoroethane because cases exist in which evidence of use from cans may not be present in proximity to the decedent, or may be undiscovered in the debris of a motor vehicle accident. It is also important to quantify concentrations of 1,1-difluoroethane in both peripheral blood and central blood, whose ratio may be useful in interpreting how recently the use of the 1,1-difluoroethane occurred.


McIntyre I.M.,County of San Diego Medical Examiners Office | Trochta A.,County of San Diego Medical Examiners Office | Stolberg S.,County of San Diego Medical Examiners Office | Campman S.C.,County of San Diego Medical Examiners Office
Journal of Analytical Toxicology | Year: 2015

A 24-year-old man whose medical history was significant for alcohol abuse and depression was found unresponsive in bed. He had several prior suicide attempts with 'pills' and had also been hospitalized for an accidental overdose on a previous occasion. Autopsy findings were unremarkable apart from pulmonary edema and congestion, and urinary retention. Postmortem peripheral blood initially screened positive for mitragynine 'Kratom' (by routine alkaline drug screen by gas chromatography-mass spectrometry, GC-MS), which was subsequently confirmed by a specific GC-MS selective ion mode analysis following solid-phase extraction. Concentrations were determined in the peripheral blood (0.23 mg/L), central blood (0.19 mg/L), liver (0.43 mg/kg), vitreous (<0.05 mg/L), urine (0.37 mg/L) and was not detected in the gastric. Therapeutic concentrations of venlafaxine, diphenhydramine and mirtazapine were also detected together with a negligible ethanol of 0.02% (w/v). The results are discussed in relation to previous cases of toxicity, and the lack of potential for mitragynine postmortem redistribution. © The Author 2014. Published by Oxford University Press.

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