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Toxicological identification of diphenhydramine (DPH) in suicide

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Abstract

Diphenhydramine (DPH), an H1-antihistamine, is identified during postmortem toxicological analyses on a relatively rare but still regular basis. This study examines suicidal intoxications with DPH by analyzing blood and gastric content concentration levels. Twenty cases of DPH intoxications within a 10-year period (2000–2010) were discovered by screening the autopsy records of the Institute of Legal Medicine and Forensic Sciences (ILMFS) in Berlin, Germany. In four cases, DPH levels were lower than 1 μg/mL and hence were not considered likely to be responsible for causing death. In 11 cases, DPH played a role in the fatal episode, and five of these cases were monointoxications. Considering that more than 8,000 autopsies were performed by the ILMFS within the time period under examination, there is only one monointoxication case every 2 years, which makes it a rare occurrence. In two of these intoxications, DPH was only measured in toxic but not “lethal” concentrations in blood, with a concentration of 5 μg/mL being generally used as the cut off between categories according to forensic literature. This raises the question as to whether a strict boundary for a “lethal” blood concentration, as suggested in some literature, can be set and applied in any of these cases. This study shows that an individual interpretation of each case is of utmost importance for correct classification. A thorough toxicological analysis of peripheral venous blood and gastric content, as well as a detailed work-up of the death circumstances, are the basis of an exact interpretation of intoxications with DPH.

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References

  1. Simons FER. Advances in H1-antihistamines. N Engl J Med. 2004;351(21):2203–17.

    Article  PubMed  CAS  Google Scholar 

  2. Nine JS, Rund CR. Fatality from diphenhydramine monointoxication: a case report and review of the infant, pediatric, and adult literature. Am J Forensic Med Pathol. 2006;27(1):36–41.

    Article  PubMed  Google Scholar 

  3. Church MK, Maurer M, Simons FER, Bindslev-Jensen C, van Cauwenberge P, Bousquet J, Holgate ST, Zubier T. Global allergy and asthma European network. Risk of first-generation H(1)-antihistamines: a GA(2)LEN position paper. Allergy. 2010;65(4):459–66.

    Article  PubMed  CAS  Google Scholar 

  4. Scavone JM, Luna BG, Harmatz JS, von Moltke L, Greenblatt DJ. Diphenhydramine kinetics following intravenous, oral, and sublingual dimenhydrinate administration. Biopharm Drug Dispos. 1990;11(3):185–9.

    Article  PubMed  CAS  Google Scholar 

  5. Estelle F, Simons R. H1-receptor antagonists: safety issues. Ann Allergy Asthma Immunol. 1999;83(5):481–8.

    Article  PubMed  CAS  Google Scholar 

  6. Backer RC, Pisano RV, Sopher IM. Diphenhydramine suicide—case report. J Anal Toxicol. 1977;1(5):227–8.

    CAS  Google Scholar 

  7. Winn RE, McDonnell KP. Fatality secondary to massive overdose of dimenhydrinate. Ann Emerg Med. 1993;22(9):1481–4.

    Article  PubMed  CAS  Google Scholar 

  8. Altorfer R. Diphenhydramine poisoning (author’s transl). Schweiz Rundsch Med Prax. 1981;70(16):711–6.

    PubMed  CAS  Google Scholar 

  9. Radovanovic D, Meier PJ, Guirguis M, Lorent JP, Kupferschmidt H. Dose-dependent toxicity of diphenhydramine overdose. Hum Exp Toxicol. 2000;19(9):489–95.

    Article  PubMed  CAS  Google Scholar 

  10. Pragst F, Herre S, Bakdash A. Poisonings with diphenhydramine—a survey of 68 clinical and 55 death cases. Forensic Sci Int. 2006;161(2–3):189–97.

    Article  PubMed  CAS  Google Scholar 

  11. Ramjan KA, Williams AJ, Isbister GK, Elliott EJ. “Red as a beet and blind as a bat” Anticholinergic delirium in adolescents: lessons for the paediatrician. J Paediatr Child Health. 2007;43(11):779–80.

    Article  PubMed  Google Scholar 

  12. Jeffery AD, Lytle-Saddler T. Diphenhydramine overdose in a 26-year-old woman. J Emerg Nurs. 2008;34(6):543–4.

    Article  PubMed  Google Scholar 

  13. Husain Z, Hussain K, Nair R, Steinman R. Diphenhydramine induced QT prolongation and torsade de pointes: an uncommon effect of a common drug. Cardiol J. 2010;17:509–11.

    PubMed  Google Scholar 

  14. Zareba W, Moss AJ, Rosero SZ, Hajj-Ali R, Konecki J, Andrews M. Electrocardiographic findings in patients with diphenhydramine overdose. Am J Cardiol. 1997;80:1168–73.

    Article  PubMed  CAS  Google Scholar 

  15. Thakur AC, Aslam AK, Aslam AF, Vasavada BC, Sacchi TJ, Khan IA. QT interval prolongation in diphenhydramine toxicity. Int J Cardiol. 2005;98:341–3.

    Article  PubMed  Google Scholar 

  16. Jang DH, Manini AF, Trueger NS, Duque D, Nestor NB, Nelson LS, Hoffman RS. Status epilepticus and wide-complex tachycardia secondary to diphenhydramine overdose. Clin Toxicol (Phila). 2010;48(9):945–8.

    Article  CAS  Google Scholar 

  17. Cole JB, Stellpflug SJ, Gross EA, Smith SW. Wide complex tachycardia in a pediatric diphenhydramine overdose treated with sodium bicarbonate. Pediatr Emerg Care. 2011;27(12):1175–7.

    Article  PubMed  Google Scholar 

  18. Hausmann E, Wewer H, Wellhöner HH, Weller JP. Lethal intoxication with diphenhydramine. Report of a case with analytical follow-up. Arch Toxicol. 1983;53(1):33–9.

    Article  PubMed  CAS  Google Scholar 

  19. Karch SB. Diphenhydramine toxicity: comparisons of postmortem findings in diphenhydramine-, cocaine-, and heroin-related deaths. Am J Forensic Med Pathol. 1998;19(2):143–7.

    Article  PubMed  CAS  Google Scholar 

  20. Jones J, Dougherty J, Cannon L. Diphenhydramine-induced toxic psychosis. Am J Emerg Med. 1986;4(4):369–71.

    Article  PubMed  CAS  Google Scholar 

  21. Levine B, Klette K, Radentz S, Smith ML, Smialek JE. Antihistamine concentrations in postmortem blood and liver specimens. Forensic Sci Int. 1996;81(1):73–6.

    Article  PubMed  CAS  Google Scholar 

  22. Schulz M, Schmoldt A. Therapeutic and toxic blood concentrations of more than 800 drugs and other xenobiotics. Pharmazie. 2003;58(7):447–74.

    PubMed  CAS  Google Scholar 

  23. Köppel C, Ibe K, Tenczer J. Clinical symptomatology of diphenhydramine overdose: an evaluation of 136 cases in 1982 to 1985. J Toxicol Clin Toxicol. 1987;25(1–2):53–70.

    Article  PubMed  Google Scholar 

  24. Jones GR, Pounder DJ. Site dependence of drug concentrations in postmortem blood-a case study. J Anal Toxicol. 1987;11(5):186–90.

    PubMed  CAS  Google Scholar 

  25. Aderjan R, Bösche J, Schmidt G. Poisoning by diphenhydramine—forensic-toxicologic interpretation of analytic results. Z Rechtsmed. 1982;88(4):263–70.

    Article  PubMed  CAS  Google Scholar 

  26. Wyngaarden JB, Seevers MH. The toxic effects of anti-histaminic drugs. J Am Med Assoc. 1951;145(5):277–82.

    Article  PubMed  CAS  Google Scholar 

  27. Lapierre YD. A review of trimipramine. 30 years of clinical use. Drugs. 1989;38(Suppl 1):17–24. discussion 49–50.

    Article  PubMed  Google Scholar 

  28. Wogoman H, Steinberg M, Jenkins AJ. Acute intoxication with guaifenesin, diphenhydramine, and chlorpheniramine. Am J Forensic Med Pathol. 1999;20(2):199–202.

    Article  PubMed  CAS  Google Scholar 

  29. Kamijo Y, Soma K, Sato C, Kurihara K. Fatal diphenhydramine poisoning with increased vascular permeability including late pulmonary congestion refractory to percutaneous cardiovascular support. Clin Toxicol (Phila). 2008;46(9):864–8.

    Article  CAS  Google Scholar 

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Acknowledgments

Dr. René Gapert’s stay at the Institute of Legal Medicine and Forensic Sciences in Berlin was supported by a DAAD Research Scholarship (Deutscher Akademischer Austausch Dienst—German Academic Exchange Service Research Grant A/11/75955).

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Authors and Affiliations

  1. Institute of Legal Medicine and Forensic Sciences, Charité-University Medicine Berlin, Berlin, Germany

    Lena Eckes, Michael Tsokos, Sieglinde Herre, René Gapert & Sven Hartwig

  2. Human Anatomy Laboratory, UCD School of Medicine and Medical Science, University College Dublin, Dublin, Ireland

    René Gapert

Authors
  1. Lena Eckes
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  2. Michael Tsokos
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  3. Sieglinde Herre
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  4. René Gapert
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  5. Sven Hartwig
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Correspondence to René Gapert.

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Eckes, L., Tsokos, M., Herre, S. et al. Toxicological identification of diphenhydramine (DPH) in suicide. Forensic Sci Med Pathol 9, 145–153 (2013). https://doi.org/10.1007/s12024-012-9383-5

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