Child Abuse: A Complex Case Report: Association of Amitriptyline Intoxication and Shaken Baby Syndrome

Abstract

This article concerns the unusual association between two kinds of mistreatment: Shaken baby Syndrome/ Abusive Head Trauma (SBS/AHT) and intentional intoxication by a tricyclic antidepressant (TCA) (amitriptyline).A six-month-old girl was hospitalized in state of coma after several episodes of malaise. The ophthalmologic exams found bilateral retinal and retrohyaloid hemorrhage, the RMI detected non-compressive subdural hematomas localized in the posterior fossa and the brain convexities and the toxicological results were positive for amitriptyline (99.4 μg/L) and its metabolite nortriptyline (154 μg/L) in the blood. All differential diagnoses were eliminated such as glutaric aciduria II, copper metabolism anomaly, and Osteogenesis Imperfecta. The police investigation reports the grand-mother and the father had an amitriptyline prescription.The toxicological analysis of the hair of the baby girl and of the parents was very useful to prove the chronical exposure. A scientific review identified few cases reports of child amitriptyline intoxication and among us, none of them enabled to compare our findings. Our description of this fact is very complete, with decrease concentration table of amitriptyline in the infant blood, permitting the comparison with another future cases. All these data confirm a singular case of Shaken baby Syndrome/Abusive Head Trauma and intentional intoxication association. This entity is not describe in the literature and poses a lot of questions especially the obligation to perform systematic toxicological analyses in case of SBS/AHT.