Multi-drug intoxication fatality involving atorvastatin: A case report.
Mixed antihypertensive drug intoxication poses a significant risk for patient mortality. In tandem to antihypertensives, hypolipidemic medicines (especially statins) are often prescribed. Among their well-known adverse effects belongs rhabdomyolysis. We report a case of fatal multi-drug overdose in a 65-year-old female alcoholic. The patient was unconscious at admission. Empty blister packs indicated the abuse of 250 tablets of urapidil, 42 tablets of verapamil/trandolapril, 50 tablets of moxonidin, 80 tablets of atorvastatin and 80 tablets of diacerein. Standard measures (gastric lavage, activated charcoal, mechanical ventilation, massive doses of vasopressors, volume expansion, diuretics and alkalinization) failed to provide sufficient drug elimination and hemodynamic support and the sufferer deceased on the fourth day. Dramatic elevations of serum myoglobin (34,020 μg/L) and creatine kinase (219 μkat/L) were accompanied by rise in cardiac troponin I and creatinine. Gas chromatography revealed ethanol 1.17 g/kg (blood) and 2.81 g/kg (urine). Thin layer chromatography and gas chromatography of gastric content and urine verified verapamil, moxonidin and urapidil fragment (diacerein method was unavailable). Atorvastatin and trandolapril concentrations (LC-MS(n)) equaled 277.7 μg/L and 57.5 μg/L, resp. (serum) and 8.15 μg/L and 602.3 μg/L, resp. (urine). Histology confirmed precipitates of myoglobin with acute necrosis of proximal renal tubules in association with striated muscle rhabdomyolysis and myocardial dystrophy. Cardiogenic-distributive shock in conjunction with acute renal failure due to the combined self-poisoning with vasoactive agents and atorvastatin were determined to be this decedent's immediate cause of death. The manner of death was assigned to be suicidal.
3(rd) Department of Internal Medicine-Nephrology, Rheumatology and Endocrinology, Palacky University Olomouc, Faculty of Medicine and Dentistry, Hněvotínská 3, 775 15 Olomouc, Czech Republic.
Lubica
L
Cibickova
Department of Anesthesiology and Resuscitation, Hospital Hranice, Zborovská 1245, 753 22 Hranice, Czech Republic.
Tomas
T
Caran
Department of Forensic Medicine and Medical Law, University Hospital Olomouc, Hněvotínská 3, 775 09 Olomouc, Czech Republic.
Martin
M
Dobias
Department of Forensic Medicine and Medical Law, University Hospital Olomouc, Hněvotínská 3, 775 09 Olomouc, Czech Republic.
Peter
P
Ondra
Institute of Clinical Biochemistry and Diagnostics, Charles University in Prague, Faculty of Medicine and University Hospital in Hradec Králové, Sokolská 581, 500 05 Hradec Králové, Czech Republic.
Viktor
V
Vorisek
Department of Medical Chemistry and Biochemistry, Palacky University Olomouc, Faculty of Medicine and Dentistry, Hněvotínská 3, 775 15 Olomouc, Czech Republic. Electronic address: norbert.cibicek@upol.cz.
Norbert
N
Cibicek
D058186:Acute Kidney Injury / Q000139:chemically induced; D000368:Aged; D057229:Alcoholics; D000880:Anthraquinones / Q000032:analysis / Q000506:poisoning; D000893:Anti-Inflammatory Agents / Q000032:analysis / Q000506:poisoning; D000959:Antihypertensive Agents / Q000032:analysis / Q000506:poisoning; D000069059:Atorvastatin / Q000032:analysis / Q000506:poisoning*; D062787:Drug Overdose; D005260:Female; D053593:Forensic Toxicology; D005766:Gastrointestinal Contents / Q000737:chemistry; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000032:analysis / Q000506:poisoning*; D007093:Imidazoles / Q000032:analysis / Q000506:poisoning; D007211:Indoles / Q000032:analysis / Q000506:poisoning; D010879:Piperazines / Q000032:analysis / Q000506:poisoning; D012206:Rhabdomyolysis / Q000139:chemically induced / Q000473:pathology; D013405:Suicide; D014665:Vasodilator Agents / Q000032:analysis / Q000506:poisoning; D014700:Verapamil / Q000032:analysis / Q000506:poisoning
D000880:Anthraquinones; D000893:Anti-Inflammatory Agents; D000959:Antihypertensive Agents; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D007093:Imidazoles; D007211:Indoles; D010879:Piperazines; D014665:Vasodilator Agents; C052035:trandolapril; C025292:diacerein; D000069059:Atorvastatin; C015568:urapidil; C043482:moxonidine; D014700:Verapamil
Alcohol; Antihypertensive; Hypolipidemic; Intoxication; Rhabdomyolysis; Suicide