title: Suicidal overdose with relapsing clomipramine concentrations due to a large gastric pharmacobezoar.
abstract: The paper presents a case of fatal intoxication after massive sustained-release clomipramine overdosage with prolonged toxicity related to a large gastric pharmacobezoar. 42-year-old female was admitted to the toxicology unit 14 h after drugs ingestion. At admission patient was deeply unconscious, required controlled mechanical ventilation. Serum total level of TCAs was 1955 ng/mL. Gastric lavage revealed no pills. Within the next 12h the patient's clinical condition improved. TCAs level decreased to 999 ng/mL. However, after another 10h the clinical condition started deteriorating again and the patient went into a deep coma requiring controlled mechanical ventilation. TCAs level increased to 2011 ng/mL. X-ray and computed tomography revealed large pharmacobezoar consisted from radio-opaque pills. In the 28th h of hospitalization gastrotomy was performed, confirming presence of pharmacobezoar formed from Anafranil SR tablets. After surgery TCAs level was gradually decreasing. However, the patient's condition did not improve, she died 32 h after gastrotomy. Post-mortem analyses revealed drug and its metabolite toxic levels in blood (clomipramine - 1729 ng/mL, norclomipramine - 431 ng/mL) and toxic levels in internal organs: myocardium (clomipramine - 14,420 ng/g, norclomipramine - 35,930 ng/g), vitreous humor (clomipramine - 1000 ng/mL, norclomipramine - 3110 ng/mL). Described case report indicates that sustained release clomipramine tablets may form pharmacobezoar. X-ray and computed tomography examinations should be considered in cases of massive abuse of sustained release clomipramine, particularly if symptoms of intoxication are recurrent or persistent.
authors.affiliation: Toxicological Unit, T Marciniak Hospital, Wroclaw, Poland.
authors.forename: Jan
authors.initials: J
authors.lastname: Magdalan
authors.forename: Marcin
authors.initials: M
authors.lastname: Zawadzki
authors.forename: Tomasz
authors.initials: T
authors.lastname: Słoka
authors.forename: Tomasz
authors.initials: T
authors.lastname: Sozański
mesh_terms: D000328:Adult; D000929:Antidepressive Agents, Tricyclic / Q000032:analysis / Q000506:poisoning*; D001630:Bezoars / Q000139:chemically induced* / Q000473:pathology; D002997:Clomipramine / Q000032:analysis / Q000506:poisoning*; D003692:Delayed-Action Preparations; D004316:Doxepin / Q000032:analysis / Q000506:poisoning; D062787:Drug Overdose; D005260:Female; D049429:Forensic Pathology; D053593:Forensic Toxicology; D006801:Humans; D009102:Multiple Organ Failure / Q000139:chemically induced; D009206:Myocardium / Q000737:chemistry; D013270:Stomach / Q000473:pathology*; D013405:Suicide; D014057:Tomography, X-Ray Computed; D014822:Vitreous Body / Q000737:chemistry
chemical_list: D000929:Antidepressive Agents, Tricyclic; D003692:Delayed-Action Preparations; D004316:Doxepin; D002997:Clomipramine