Abstract
Sodium nitrite (NaNO2) is an inorganic compound that is commonly used as a preservative (E250) in the fish and meat industry. When ingested, sodium nitrite will lead to methemoglobinemia, hypotension, and arrhythmias. An increasing trend in the use of sodium nitrite as a suicide agent has been reported. In Belgium however it remains a rare phenomenon. The ingestion of sodium nitrite is not always apparent from the death scene investigation, especially in cases of covert administration or accidental ingestion. Hence, the forensic pathologist must be aware of this trend and the postmortem changes related to the ingestion of sodium nitrite to effectively identify these cases and determine the cause and manner of death. We describe a case of fatal self-poisoning following the oral ingestion of sodium nitrite with suicidal intent. Postmortem investigations showed signs of methemoglobinemia, such as a gray-brown discoloration of lividity and a chocolate brown discoloration of the blood. Postmortem toxicological investigation revealed methemoglobinemia (35%) in cardiac blood, hypernatremia (159.6 mmol/L) in vitreous humor, and the presence of nitrite in gastric contents (1.15 g/L) and, for the first time in a forensic case, in serum (38 µg/mL). A review of the existing literature regarding cases of sodium nitrite intoxications was performed to correlate these findings.
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The data that support the findings of this study are available from the corresponding author, [D. A.], upon reasonable request.
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Appendices
Appendix A: Cases of suicidal and accidental ingestion of sodium nitrite with fatal outcome; circumstances, toxicology results and postmortem findings.
Author and year | Sex, age, Circumstances Manner of ingestion | Toxicology, MetHb levels and biochemistry (BC) | External findings and autopsy finding |
|---|---|---|---|
Mun et al. [33] 2022 | Male 26 years old, Couple, suicide by taking 18 g of sodium nitrite (partner survived) Manner: intentional | MetHb level: 90.3% | N/A |
Bugelli et al. [19] 2022 | Male 27 years old, Found unconscious in mountainous area after calling suicide hotline, metoclopramide and white powder found in backpack. Manner: intentional | Nitrates in peripheral blood (311 µg/mL) and urine (102 µg/mL), Nitrites not detected, Metoclopramide MetHb level: >30% (upper limit) | Cyanosis, Blue-grayish livor mortis Visceral congestion, Pulmonary emphysema, 50 mL brownish jelly liquid stomach content |
Female 44 years old, Found deceased at home, a bag with inscription ‘sodium nitrite’, metoclopramide, and suicide note found at place of death. Manner: intentional | Nitrates in peripheral blood (378 µg/mL) and urine (<10 µg/mL), Nitrites not detected, Metoclopramide MetHb level: >30% (upper limit) | Cyanosis, Purple-blueish livor mortis Visceral congestion, Pulmonary stasis, and acute emphysema, Brain edema, Microscopic subarachnoid hemorrhage focus, Reddish jelly liquid stomach content | |
Male 35 years old, Deceased in bathroom, cup and spoon with residue, jar with inscription 'sodium nitrite' and metoclopramide found at scene of death. Manner: intentional | Nitrates in peripheral blood (280 µg/mL) and urine (269 µg/mL), Nitrites not detected, Mirtazapine MetHb level: unsuitable sample | Cyanosis, Purple and gray livor mortis Pulmonary edema, Visceral congestion, Brown blood, Alveolar hemorrhages, Cardiac myofibril changes | |
Male 51 years old, Deceased in bed, suicide note, paper bag with inscription 'sodium nitrite 99%' found at scene of death, phone history showed research about sodium nitrite. Manner: intentional | Nitrates in peripheral blood (460 µg/mL) and urine (48.3 µg/mL), Nitrites not detected Ethanol, alprazolam, MetHb level: >30% (upper limit) | Cyanosis, Grayish livor mortis Pulmonary edema, Visceral congestion, Brownish blood | |
Stephenson et al. [18] 2022 | Male 74 years old, Deceased resident at care facility, suicide letters and sodium nitrite found at death scene. Manner: intentional | Lorazepam, fentanyl, metoclopramide, pregabaline, COHb (51%), Urine dipstick positive for nitrites MetHb level: outside of analytical limits | Blue-gray livor mortis Pulmonary edema |
Male 22 years old, Suicide note and bottle with clear substance found at death scene. Manner: intentional | Metoclopramide, ranitidine, paracetamol, COHb (24%), Urine dipstick positive for nitrites MetHb level: unable to produce a result | Blue-gray livor mortis Brown discoloration of blood | |
Female 29 years old, Found deceased after calling ambulance declaring having taken a mouthful of sodium nitrite, farewell messages on phone, suicide note and sodium nitrite container (50 g total, small amount remaining) at death scene. Manner: intentional | Naloxone, COHb (25%), Urine dipstick positive for nitrites MetHb level: no valid result | Blue- gray livor mortis Brown discoloration of blood, Pulmonary edema | |
Male 60 years old, Suicide note, sodium nitrite, bicarbonate soda and instructions at death scene. Manner: intentional | (des)Venlafaxine, buprenorphine, metformin, mirtazapine MetHb level: 87.5% | Blue-grayish livor mortis Brown discoloration of blood, Pulmonary edema | |
Male 64 years old, Sodium nitrite at death scene Manner: not clearly stated | Paracetamol, codeine, prochlorperazine, ranitidine, loperamide, COHb (34%), MetHb level: unable to produce result Urine dipstick positive for nitrites | Blue-gray livor mortis Brown discoloration of blood, Pulmonary edema, Terminal aspiration | |
Male 74 years old, Bottle of sodium nitrite and farewell messages at death scene Manner: intentional | (nor)Diazepam, (des)venlafaxine, amlodipine, prochlorperazine MetHb level: unsuitable sample | Blue-gray livor mortis Brown discoloration of blood, Pulmonary edema, White granular material in stomach contents | |
Male 40 years old, Sodium nitrite suicide kit and suicide note found at death scene. Manner: intentional | Ethanol, paracetamol, metoclopramide, Urine dipstick positive for nitrites MetHb level: N/A | Advanced putrefactive changes | |
Male 69 years old, Suicide note, bottle of wine and glass jar found at death scene. Manner: intentional | Sertraline, COHb (24%), Urine dipstick positive for nitrites MetHb level: no valid result | Blue-gray livor mortis Brown discoloration of blood, Pulmonary congestion | |
Male 64 years old, Sodium nitrite and suicide note found at death scene, cylinders of nitrogen gas found under desk and in vehicle. Manner: intentional | Ethanol, metoclopramide, paracetamol, zolpidem, COHb (40%), Urine dipstick positive for nitrites MetHb level: unable to produce a result | Early putrefactive changes, Blue-gray livor mortis Brown discoloration of blood, Pulmonary edema and congestion | |
Female 23 years old, Sodium nitrite, suicide note found at death scene, search history about suicide and sodium nitrite. Manner: intentional | Metoclopramide, quetiapine, paracetamol, COHb (51%), Urine dipstick positive for nitrites MetHb level: unable to produce a result | Blue-gray livor mortis Brown discoloration of blood, Pulmonary edema and congestion | |
Barranco et al. [31] 2021 | Male 31 years old, Found deceased in car, sodium nitrite container and precision scale in vehicle. Manner: intentional | Alprazolam, Nitrite testing not possible MetHb level: 73% | Subungual cyanosis, Blue-red livor mortis Pulmonary edema, Visceral congestion, Subpleural petechiae, Intra-alveolar hemorrhage |
Tomsia et al. [29] 2021 | Male 23 years old, Deceased on bathroom floor, sodium nitrite container and farewell letter found at scene of death. Manner: intentional | Nitrites in blood (0.2 µg/ml), urine (24.6 µg/ml), gastric contents (2.2 g/L), liver tissue (0.3 µg/g), kidney tissue (3.6 µg/g), costal cartilage (3.4 µg/g), and vitreous humor (57.7 µg/mL) MetHb level: N/A | Cyanosis, Brown livor mortis Bloody content intestines, Bloodshot stomach and intestinal walls |
Hwang et al. [28] 2021 | Male 28 years old, Suicidal note posted online stating he had ingested 84 g of sodium nitrite. Manner: intentional | Nitrate in peripheral blood (220.6 mg/L), cardiac blood (218.5 mg/L), pericardial fluid (91.7 mg/L), cerebrospinal fluid (50.5 mg/L), and stomach content (137.8 mg/L) Nitrite in gastric content (11.2 g/L) and pericardial fluid (181 mg/L), not detected in peripheral/cardiac blood or cerebrospinal fluid MetHb level: 26% Postmortem BC (vitreous humor): ‘unremarkable’ | Dark brownish face, Cyanosis Reddish-purple livor mortis Congestion, Pulmonary edema |
McCann et al. [4] 2021 | Male 22 years old, ED visit after reportedly ingesting sodium nitrite. Manner: intentional | MetHb level: 30% | Clinically: hypotension & cardiac arrest |
Female 17 years old, Brought to ED after taking 'sodium something' pills bought online with suicidal intent Manner: intentional | MetHb level: 84% | Chocolate brown blood drawn, Cyanotic, Unresponsive, Cardiac arrest clinically | |
Male 35 years old, Presented in the ED with cardiac arrest, reported suicide attempt by ingesting sodium nitrite. Manner: intentional | MetHb level: N/A | Dark brown blood drawn, Cyanosis, Respiratory distress, Cardiac arrest clinically | |
Dean et al. [27] 2021 | Female 24 years old, Found deceased on matrass, white powder labeled as sodium nitrite nearby. Manner: intentional | Negative Nitrite testing not possible MetHb level: 62% | Early putrefaction (postmortem interval estimated to be at least a week), Purple-gray livor mortis White foam trachea, swollen brain, Congested / decomposed organs, Deep red–purple colored blood ‘typical of decomposition’ |
Male 22 years old, Found unresponsive on bathroom floor after vomiting, suicide note and bottle labeled sodium nitrite found at death scene. Manner: intentional | Negative MetHb level: 33% Postmortem BC (vitreous humor): Elevated levels of sodium (148 mmol/L) and chloride (124 mmol/L) | Blue-gray discoloration of the skin, Brown color of the blood, Linear hemorrhages in stomach and intestines, Brown kidneys, Purple hemorrhages beneath the scalp, No edema | |
Male 39 years old, Suicidal man found unresponsive by his parents, digital scale and white powder found at death scene. Manner: intentional | Negative (postmortem samples) MetHb level: 44% Powder contained sodium nitrite | Foam on the nose, Gunmetal gray discoloration of the skin and lips, Red-purple and gray livor mortis Brown blood, Brown internal organs (especially liver, kidney, and heart), Pulmonary edema, Brain edema, Hemorrhagic gastritis, Congested liver and spleen | |
Durão et al. [34] 2021 | Female 37 years old, Found deceased in bed next to a flask containing sodium nitrite and suicide note Manner: intentional | Nitrites in gastric contents (8.8 g/L) and cardiac blood (35 µg/mL), MetHb level: N/A Codeine, quetiapine, tramadol, topiramate, diazepam, olanzapine | Facial cyanosis, Grayish livor mortis Brown foam in trachea, Bronchial aspiration of vomiting, Pulmonary edema |
Neth et al. [26] 2021 | Female 17 years old, ED visit after reportedly ingesting 1 tablespoon of sodium nitrite followed by vomiting and becoming unresponsive. Purchased 100 grams of sodium nitrite online 2 weeks prior. Manner: intentional | MetHb: 48% Trazodone, aripiprazole, midazolam | Foam coming from mouth, Cyanotic, Chocolate brown blood drawn, Clinically: hypotension and cardiac arrest No autopsy performed |
Mudan et al. [25] 2020 | Male 27 years old, Presented to the ED after ingesting 15 g of sodium nitrite. Manner: intentional | MetHb level: >32.4% (upper detection limit) | Cyanosis Cardiac arrest clinically |
Male 25 years old, ED visit after ingesting 113 g of sodium nitrite. Manner: intentional | MetHb level: 29% | Chocolate brown blood | |
Female 16 years old, ED visit after ingestion of sodium nitrite purchased online. Manner: intentional | MetHb level: >30% (upper detection limit) | Cyanosis Cardiac arrest clinically | |
Durão et al. [24] 2020 | Male 37 years old, Found deceased in car next to a box that contained primperan, ranitidine, and package of 35 g sodium nitrite; depression. Manner: intentional | Nitrites in gastric content (16 g/L) and peripheral blood (30 ng/mL) Sodium nitrite in gastric content (24 g/L) MetHb: N/A Citalopram, trazodone | Cyanosis, Brown-gray-blue-red livor mortis Tardieu petechiae, Chocolate brown blood, Visceral congestion, Pulmonary edema |
Workum et al. [23] 2019 | Male 27 years old, Found unconscious by the nursing staff during psychiatric admission, ordered sodium nitrite online weeks prior. Manner: intentional | MetHb level: 89.9% | Blue discoloration of the skin (cyanosis) |
Cvetković et al. [15] 2019 | Male 70 years old, Admission after eating ill prepared homemade sausages with too much sodium nitrite followed by symptoms and collapse 7 hours after ingestion. Manner: accidental | Nitrites in blood (24.6 ng/ml), stomach content (93.91 mg/kg) and liver & kidney mixture (0.003 mg/kg) MetHb level: 9.87% | Dark-blueish-red livor mortis Complaints before collapse: headache, malaise, dizziness, walking instability, nausea Advanced hypertensive and atherosclerotic heart disease, Pulmonary edema, Fatty liver |
Harvey et al. [22] 2010 | Male 76 years old, Collapse after ingestion of sodium nitrite. Manner: intentional | Sodium nitrite identified as the major component of ingestion MetHb level: 82.6% In vivo biochemistry (arterial blood gas): - Sodium 146 mmol/L - Potassium 5.4 mmol/L - Lactate 9.6 mmol/L | Cyanosis, Chocolate brown blood drawn; Brady-asystolic arrest clinically |
Appendix B: Cases of survived suicide attempts and accidental ingestion of sodium nitrite; circumstances, clinical findings, MetHb, and treatment.
Author and year | Sex, age Circumstances Manner of ingestion | Clinical findings / symptoms and MetHb (max) | Treatment |
|---|---|---|---|
Mun et al. [33] 2022 | Female 20 years old, Couple suicide attempt by taking 12.5 g of sodium nitrite (partner deceased) Manner: intentional | Cyanotic, Dyspnea, vomiting MetHb level: 54.6% | Methylene blue |
Matin et al. [20] 2022 | Male 23 years old, ED visit after waking up in vomit and feces 6 hours after ingesting 2 teaspoons of sodium nitrite purchased online. Manner: intentional | Gray skin / cyanosis, Tachycardia, Nausea, incontinence, abdominal pain MetHb level: 26.3% | Methylene blue |
Yoon and Kim [17] 2022 | Female 24 years old, Admission to ED 30 min after ingesting 10 g of sodium nitrite following instructions from a suicide blog. Manner: intentional | Acute dyspnea, Cyanosis MetHb level: 40.9% | Methylene blue |
Male 20 years old, Admission to ED 1 hour after ingestion of 750 mg of sodium nitrite, obtained information from online forum. Manner: intentional | Mild nausea, Normal physical examination MetHb level: 4.8% | Supportive treatment | |
Saleh et al. [16] 2022 | Male 20 years old, Admission to ED 1 hour after ingestion of 21 grams of sodium nitrite purchased online as a suicide kit. Manner: intentional | Comatose, Cyanosis, Chocolate brown blood drawn MetHb level: >29% (upper detection limit) | Intubation, Gastric lavage, Activated charcoal, Methylene blue |
O'Neill et al. [32] 2021 | Female 31 years old, Accidental ingestion of sodium nitrite at restaurant, mislabeled container Manner: accidental | Cyanosis, Vision loss, headache, nausea, Shortness of breath MetHb level: 19.9% | Methylene blue |
Female 32 years old, Accidental ingestion of sodium nitrite at restaurant, mislabeled container Manner: accidental | Cyanosis, Confusion, vomiting MetHb level: 28.3% | Methylene blue | |
McCann et al. [4] 2021 | Male 24 years old, ED presentation after ingesting 1 cup of sodium nitrite purchased online, as recommended on a Facebook support group. Manner: intentional | Cyanosis, Hypotension MetHb level: 69% | Methylene blue |
Female 17 years old, ED presentation after ingesting 21 g of sodium nitrite, ibuprofen, and bismuth subsalicylate (recommendations found online) Manner: intentional | Cyanotic and pale MetHb level: >28% (upper detection limit) | Methylene blue | |
Mudan et al. [25] 2020 | Male 18 years old, Suicide attempt following online found instructions, ingesting 15 g of sodium nitrite and 100 mg of dimethyl sulfoxide Manner: intentional | Cyanosis, Confusion MetHb level: 70.8% | Methylene blue |
Female 16 years old, Suicide attempt following online found instructions, ingesting 60 g of sodium nitrite purchased online. Manner: intentional | Cyanotic, Somnolent, hypoxic, hypotension MetHb level: 73% | Methylene blue, Intubation, Red blood cell transfusion | |
Male 31 years old, ED presentation after ingestion of sodium nitrite ordered online. Manner: intentional | Cyanosis, Confusion MetHb level: 58.9% | Methylene blue | |
Cvetković et al. [15] 2019 | Female 53 years old, Family members presented at hospital after eating homemade sausages prepared with sodium nitrite. Manner: accidental | Headache, malaise, dizziness, walking instability, nausea, vomiting MetHb level: 33.7% | Oxygen treatment |
Female 67 years old, Family members presented at hospital after eating homemade sausages prepared with sodium nitrite. Manner: accidental | ‘similar symptoms’ (see above) MetHb level: 20.4% | Oxygen treatment | |
Voga et al. [14] 2016 | Male 28 years old, ED admission after loss of consciousness and cyanosis after ingesting 15 g of sodium nitrite. Manner: intentional | Hypotension, Blue-gray discoloration of the skin MetHb level: 92.5% Biochemistry (arterial blood gas analysis and blood tests): - Sodium 137 mmol/L - Potassium 3.2 mmol/L - Lactate 12.1 mmol/L | Intubation, Gastric lavage, Methylene blue, Oxygen treatment, Charcoal |
Maric et al. [30] 2008 | Female, age not reported, Couple develo** symptoms after consuming homemade cookies containing sodium nitrite. Manner: accidental | Chocolate brown blood drawn, Cyanosis, dyspnea MetHb level: 21% | Oxygen treatment |
Male, age not reported, Couple develo** symptoms after consuming homemade cookies containing sodium nitrite. Manner: accidental | Chocolate brown blood drawn, Cyanosis, dyspnea MetHb level: 57% | Methylene blue | |
3 cases, age and sex not reported, 3 family members develo** symptoms after eating pork dish containing sodium nitrite. Manner: accidental | ‘Identical symptoms’ MetHb level: 39-51% | Methylene blue | |
Tung et al. [21] 2006 | Male 67 years old, Collapse after eating meal prepared with sodium nitrite instead of common salts. Manner: accidental | Cyanosis Blue-gray discoloration of the skin; Chocolate brown blood drawn; MetHb level: 77.6% | Intubation and oxygen treatment, Methylene blue |
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Andelhofs, D., Van Den Bogaert, W., Lepla, B. et al. Suicidal sodium nitrite intoxication: a case report focusing on the postmortem findings and toxicological analyses—review of the literature. Forensic Sci Med Pathol (2023). https://doi.org/10.1007/s12024-023-00664-9
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DOI: https://doi.org/10.1007/s12024-023-00664-9