Es wird über den Fall eines 56 Jahre alt gewordenen Mannes berichtet, der durch eine in suizidaler Absicht erfolgte Monointoxikation mit Rohypnol-Filmtabletten (Flunitrazepam) zu Tode kam. Toxikologische Untersuchungen erbrachten den Nachweis einer nur kurze Zeit überlebten Flunitrazepamintoxikation. Weitere Drogen, Medikamente oder Alkohol konnten nicht nachgewiesen werden. Bei der gerichtlichen Leichenöffnung fand sich eine Durchsetzung des rechten Lungenunterlappens mit weißlichen Herden, fraglich wie bei einer Geschwulstbildung oder Lungenentzündung. Zunächst wurde dieser Befund als mittelbare Folge der Flunitrazepamintoxikation und der damit verbundenen Bewusstseinseinschränkung vermutet. Die weitere histologische Aufarbeitung ergab jedoch eine ausgedehnte, frische, aber mindestens 2–3 Tage alte Bronchopneumonie. Die Lungen zeigten darüber hinaus Zeichen einer akuten und einer chronischen Lungenstauung mit lokaler Fibrosierung sowie ein deutliches Lungenemphysem als weitere Hinweise auf vorbestehende Lungenerkrankungen. Todesursächlich war die Kombination aus vorbestehender Erkrankung (Bronchopneumonie) und Nebenwirkung des Flunitrazepams (Atemdepression). Dieser Fall unterstreicht einmal mehr, dass die Feststellung von Monointoxikationen mit Benzodiazepinen als alleinige Todesursache sehr sorgfältiger und alle Untersuchungsmöglichkeiten ausschöpfender Maßnahmen bedarf, um im Ergebnis haltbar zu sein.

The case of a 56-year-old man who died after suicidal monointoxication with rohypnol tablets (flunitrazepam) is presented. Toxicological analysis revealed a recent intoxication with flunitrazepam, which the victim survived only for a brief period. Illicit drugs, other medication or alcohol could not be detected. Autopsy revealed disseminated whitish foci in the inferior lobe of the right lung suspicious for a tumor or pneumonia. The first presumption was that this finding was an immediate consequence of limited consciousness caused by the flunitrazepam intoxication. However, histological analysis of this area demonstrated an extensive, recent, but at least 2 to 3-day-old bronchopneumonia. Furthermore, the lungs showed signs of acute and chronic stasis with local fibrosis as well as emphysema, consistent with further pre-existing lung diseases. This case is an example of a fatal monointoxication with a benzodiazepine caused by a combination of pre-existing disease (bronchopneumonia) and side effects of the medication (depression of respiration). It underlines once more that determination of monointoxication with benzodiazepines alone as the cause of death necessitates very careful and exhaustive measures with all investigative techniques to confirm this assumption.

Following the death of 16 inhabitants of a nursing home within a period of 2 weeks, the prosecution ordered legal autopsies in all of the cases, which had not yet been buried or cremated, suspecting a neglect of nursing or active euthanasia respectively. Two out of a total of ten cases revealed drug overdoses which could have explained death. However, due to concurring causes of death, the evidence could not be furnished with adequate security. In the present case, the examinations helped--already in a preliminary stage of the investigations--to prevent the authorities from more expensive proceedings as well as the respective nursing home from being unjustly suspected of having committed a criminal offense.

History and clinical findings: A 51-year-old man without relevant previous illness developed vomiting and diarrhoea, later also tingling and hypaesthesias in the limbs, as well as optical hallucinations that had occurred after a mid-day meal and drinking red wine. Neurological examination revealed variable pupillary reactions with anisocoria that would change from one side to the other. There was no paresis, muscle reflexes were brisk, more so on the right. Babinski reflex was positive on the right, there was an unsustained clonus of the right foot and the coordination tests were normal. Distal symmetrical hypaesthesias and paraesthesias were present in all limbs. An exogenous psychosis with restlessness and optical hallucinations was observed.Investigations: Routine blood count revealed leukocytosis. Serum concentrations of cGt and GPT were raised. Cerebral computed tomography and cerebrospinal fluid as well as microbiological tests of the mid-day meal were normal.Diagnosis, treatment and course: As the cause of the symptoms was initially unclear the patient was admitted to hospital and monitored without any specific treatment. Within one night all symptoms had disappeared and he was discharged the next morning without any complaints. Later the red wine which he had drunk was examined toxicologically and found to contain the >>designer drug<< DOB (2,5-dimethoxy-4-bromamphetamine).Conclusion: Accidental poisoning with DOB is probably a rare event which can hardly be included in routine differential diagnosis. If an acute cerebral organic syndrome has been excluded, only toxicological investigation can help in establishing the diagnosis in such cases.

Bei der Begutachtung einer drogenbedingten Fahruntüchtigkeit sind auch rauschmittelbedingte Folgeerscheinungen zu beachten. Anhand von 37 Fällen des Fahrens unter dem Einfluß von Amphetamin bzw. Amphetamin-Derivaten aus den Jahren 1995–1998 wurde die Erschöpfungsreaktion nach Wirkende untersucht. Hierzu wurden die von Polizei und/oder untersuchendem Arzt festgestellten Auffälligkeiten im Leistungsbild ausgewertet und einer Erschöpfungsreaktion bzw. einer Stimulationsphase zugeordnet und schließlich mit den Analysebefunden verglichen. Es zeigt sich, daß bei niedrigem Amphetamin- bzw. Amphetamin-Derivat-Blutspiegel Symptome einer Erschöpfungsreaktion im Leistungsbild beschrieben wurden. Auch zeigten die Fahrzeuglenker in der Erschöpfungsreaktion tendenziell häufiger Fahrunsicherheiten.

HISTORY AND CLINICAL FINDINGS:A 51-year-old man without relevant previous illness developed vomiting and diarrhoea, later also tingling and hypaesthesias in the limbs, as well as optical hallucinations that had occurred after a mid-day meal and drinking red wine. Neurological examination revealed variable pupillary reactions with anisocoria that would change from one side to the other. There was no paresis, muscle reflexes were brisk, more so on the right. Babinski reflex was positive on the right, there was an unsustained clonus of the right foot and the coordination tests were normal. Distal symmetrical hypaesthesias and paraesthesias were present in all limbs. An exogenous psychosis with restlessness and optical hallucinations was observed.INVESTIGATIONS:Routine blood count revealed leukocytosis. Serum concentrations of cGt and GPT were raised. Cerebral computed tomography and cerebrospinal fluid as well as microbiological tests of the mid-day meal were normal.DIAGNOSIS, TREATMENT AND COURSE:As the cause of the symptoms was initially unclear the patient was admitted to hospital and monitored without any specific treatment. Within one night all symptoms had disappeared and he was discharged the next morning without any complaints. Later the red wine which he had drunk was examined toxicologically and found to contain the "designer drug" DOB (2,5-dimethoxy-4-bromamphetamine).CONCLUSION:Accidental poisoning with DOB is probably a rare event which can hardly be included in routine differential diagnosis. If an acute cerebral organic syndrome has been excluded, only toxicological investigation can help in establishing the diagnosis in such cases.

Scientific Affairs, Abbott GmbH Diagnostika, Wiesbaden, Germany1; Dept. of Toxicology, Center of Legal Medicine, JW-Goethe-University, Frankfurt, Germany2.

BACKGROUND AND OBJECTIVE Angel's trumpet (Species Brugmansia) is widely used as a garden plant because it is easily kept and the luxuriance of its flowering. Belonging to the Family Solanacea it contains a large amount of alkaloids (parasympatholytics). Because of its hallucinogenic action, its leaves and flowers are increasingly used by young people as a substitute for the hallucinogen LSD (lysergic acid diethylamide). In the summer of 1997, one of a group of youths died after they had ingested its flowers which they had gathered from front gardens. An investigation was undertaken to identify the alkaloids and measure their concentration in the various parts of the plant. METHODS Four young and one eight-year old plant were kept outdoors from May until October, and its flowers and leaves were removed for analysis weekly. All samples were deep-frozen at -20 degrees C and later, at the same time, thawed out, weighed and extracted in methanol. The alkaloids were identified by high pressure liquid chromatography (HPLC), diode array detector, separated by means of a Hypersil HyPurity cartridge, and measured at a wave-length of 220 nm. RESULTS All 66 flowers, 32 leaves and 2 speed capsules contained tropane alkaloids, mainly scopolamine. The highest concentrations were found in the seed capsules, lower ones in the flowers, while the leaves contained only small amounts. Total alkaloid content per flower of the younger plants averaged 0.94 mg, of the younger ones 1.81 mg. The flowers of the old plant contained up to 3 mg scopolamine. CONCLUSION The ingestion of even a few flowers of Angel's trumpet can cause symptoms of poisoning. Easy availability of the plant thus presents a danger. Because of the increasing incidence of deliberate ingestion by young people, poisoning by Angel's trumpet should be included in the differential diagnosis in patients with confusion and hallucinations of uncertain origin, especially during the summer months.

Der Keto-Diabur Test 5000 (Boehringer Mannheim) ist ein Schnelltest zur Bestimmung von Glucose- und Ketonkörpern im Urin. Mit diesem routinemäßig durchgeführten Test wurden bei der Obduktion von drei eindeutig infolge Erfrierens bzw. Unterkühlung verstorbener Personen stark positive Resultate für Ketone erhalten, ohne daß gleichzeitig die Glucose im Harn erhöht war. Mittels Headspace-Gaschromatographie konnten in allen drei Urinproben überhöhte Aceton-Konzentrationen von 140, 1004 und 2703 mg/L festgestellt werden. Ein stark positiver Keto-Diabur-Test 5000 bei normalem Glucose-Befund im Urin kann somit als diagnostische Hilfe zur Erkennung eines Todes infolge Unterkühlung dienen.

Two GC/MS-procedures for the detection of amphetamine and its methylenedioxy-derivatives (MDA, MDMA and MDE) in hair are presented. In these methods a methanol sonication extraction technique was applied. The extracted drugs were derivatized either with propionic acid anhydride (PSA) or trifluoroacetic acid anhydride (TFA). PSA-derivatives are more stable than TFA-derivatives, but the latter provide more specific mass-spectrometric information, and, therefore, seem to be preferable for amphetamine determination. The detection limit for all compounds was in a range of about 0.01 ng/mg, if at least 50–100 mg of hair were analyzed, independent of the derivatization used.

Der Neurotransmitter Serotonin (5-Hydroxytryptamin, 5-HT) spielt bei psychiatrischen Erkrankungen, insbesondere bei affektiven Störungen, eine bedeutende Rolle. Bisher wurde hauptsächlich in vivo im Liquor der Metabolit von Serotonin, die 5-Hydroxyindolessigsäure (5-HIAA), bestimmt. Die meisten Untersuchungen konnten eine erniedrigte 5-HIAA Liquorkonzentration bei depressiven Patienten im Vergleich zu Kontrollen zeigen. Ebenso ergaben sich Hinweise über eine Korrelation von niedrigen 5-HIAA Liquorkonzentrationen und Suicidalität bzw. aggressivem und autoaggressivem Verhalten (v. Praag 1983). Postmortal wurden bei Suicidopfern erniedrigte (v. Praag 1988), aber auch z. T. erhöhte 5-HT Spiegel im Liquor gefunden (Kauert 1988).

A gas chromatographic-mass fragmentographic method using ammonia chemical ionization for the determination of dimethindene in human plasma is described. The drug was isolated from plasma by liquid-liquid extraction with hexane-2-methylbutanol. Plasma components were separated on a capillary column coated with chemically bonded methyl silicone. For detection of dimethindene, its quasi-molecular ion (M + H+) was mass fragmentographically monitored after chemical ionization with ammonia as reagent gas. Dimethindene was quantified using methaqualone as the internal standard: the quantification limit in plasma was 0.2 ng/ml, the within-run precision was 8.0% and the inter-run precision 5.6%. The plasma concentration-time profile was established after a single dose of 4 mg of dimethindene with an average maximum concentration of 5.5 ng/ml, detectable up to 48 h post application.

*: Institute of Legal Medicine, University of Munich **: SYNTHELABO RECHERCHE (LERS),Munich +: Psychiatric Clinic, University of Munich

During the intensive medical treatment of a finally fatal parathion poisoning (survival time 7 days) with shock symptoms (lung and kidney) the kinetic profiles of both plasma and urinary catecholamines were taken up. In addition the parathion concentrations of the same plasma samples were measured. There could been found plasma catecholamine profiles exhibiting peak concentrations in the initial phase, followed by a period of 4 days without any detectable plasma epinephrine and finally an extreme elevation of both catecholamines in the last period before death. The excretion patterns confirmed the plasma results. Imaginable pathophysiological mechanisms in consideration of the shock induced renal insufficiency are discussed. The question is raised wether the kinetics of plasma catecholamines may be a possible marker for the prognosis of organophosphate poisoning.