A fatal case by a suicide kit containing sodium nitrite ordered on the internet

Abstract

Fatal sodium nitrite poisonings are rare in the forensic context. The present work describes a first fatal case of sodium nitrite contained in a suicide kit that the victim acquired over the internet. The results of the autopsy showed general signs of asphyxia, such as intense cyanosis of the extremities, brown-gray-blue-red livor mortis, and some Tardieu petechiae in addition to intense visceral congestion. It is clear that forensic experts must be aware of the proliferation of this market and the risks of improper selling of these substances through suicide support networks available on the internet. The lack of knowledge of this reality may become unidentifiable, when toxicological analysis contemplates only the most classical and frequent substances involved in poisoning and reinforce the importance of a careful analysis of the death scene.

Fatal methemoglobinemia in three suicidal sodium nitrite poisonings

“…However, several authors have reported sodium nitrite ingestions, both intentional and accidental, albeit very few, in the past few years. These reports have come from the US, Europe, and Japan [2][3][4][5][6]. The report of one victim had intractable hypoxemia (peripheral capillary oxygen saturation (SpO 2 ) as low as 74%) and brown blood upon venipuncture.…”

“…Researchers in Portugal report a suicide by sodium nitrite purchased as a "suicide kit" containing metoclopramide, ranitidine, and a 35 gram package of sodium nitrite. The first two medications were likely included to minimize gastric reflux, nausea, and vomiting [3]. The same research group reported the death of a woman who ordered sodium nitrite and other medications from online merchants [2].…”

Commentary on: Dean DE, Looman KB, Topmiller RG. Fatal methemoglobinemia in three suicidal sodium nitrite poisonings. J Forensic Sci. doi: 10.1111/1556‐4029.14689. Epub 2021 Feb 17.

“…These new cases raise up our recent concern since we also detected at two cases in a very short period [2,3]. While accidental intoxications by contaminated water and food have been reported throughout the last years, intentional intoxication cases by sodium nitrite are becoming motive of alert.…”

“…Although there are very limited epidemiological studies regarding the emergency of new intoxication tendencies as suicide methods, the advertisement by the Internet may contribute to disseminate this burden, predisposing to be more commonly encountered in the emergency department and by forensic experts [2][3][4]. However, for most of the recent reported cases, it was impossible to know where victims found information for this suicide method [2][3][4][5].…”

“…On other point of view, these cases might perhaps be already happening before but failure to include sodium nitrite in regular toxicological analysis it may be hypothesized some previous false-negative results. In this regard, the inclusion of methemoglobin, nitrite, and nitrate quantification should be considered if clinical and crime scene is particularly suggestive [2,3]. Indeed, this product is much more controlled and analyzed in food regulatory toxicology, and some forensic laboratories do not have yet included validated techniques for analysis in their portfolio as they have for medicines, psychoactive substances, pesticides, and other xenobiotics.…”