a case of death associated with ingestion of liquid windshield-washer detergent

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A case of death associated with ingestion of liquid windshield-washer detergent Mihoko Ago, Kazutoshi Ago, Yoshiyuki Orihara, Mamoru Ogata * Department of Legal Medicine, Faculty of Medicine, Kagoshima University, Kagoshima 890-8520, Japan Abstract We report an autopsy case of a death associated with ingestion of liquid windshield-washer detergent. The deceased was a 49- year-old man who was found dead on a road near his truck. A bottle of liquid windshield-washer detergent containing an anionic surfactant and methanol was found under the passenger seat of the truck. At autopsy, slight abrasions and bruises were observed on his body. The small intestine contained dark greenish-brown mucoid matter with abundant froth. The mucous membranes of the esophagus, stomach and superior small intestine showed extensive necrosis, erosion, hemorrhage, edema and congestion. Using the methylene blue method to examine the contents of the small intestine, the presence of an anionic surfactant was indicated. We conclude that the cause of death was ingestion of liquid windshield-washer detergent. q 2003 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Anionic surfactant; Windshield washer detergent; Autopsy 1. Introduction Surface-active agents (surfactants) coexisting with hydrophilic and hydrophobic groups are grossly clas- sified into cationic, anionic, and non-ionic groups. Surfactants are widely used in antiseptics and clean- ing products and as spreader and emulsifier in pesti- cides and in industry. These many compounds generally have been considered to be of low toxicity and to produce few serious effects except in the case of cationic surfactants, but serious symptoms and deaths associated with the ingestion of detergents have been reported [1–6]. Among surfactants, anionic surfactants have been used particularly in insecticides, dishwashing liquid and shampoo. However, few fatal- ities resulting from the ingestion of liquid windshield- washer detergent have been reported. In this report, we describe a case of death from swallowing an unknown amount of liquid windshield-washer deter- gent. 2. Case report A 49-year-old man was found dead on a road near his truck at 07:20 h one day in February. He had been missing from his home for 5 days. A bottle of liquid windshield-washer detergent containing an anionic surfactant (23 w/w%) and methanol (50 w/w%) was found under the passenger seat of the truck. Approxi- mately half (125 ml) of the detergent remained in the bottle. He had had surgery for gastric ulcer approxi- mately 20 years previously. An autopsy was performed at 9–14 h after death. Legal Medicine 5 (2003) S135–S137 1344-6223/03/$ - see front matter q 2003 Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S1344-6223(02)00095-0 www.elsevier.com/locate/legalmed * Corresponding author. Tel.: 181-99-275-5313; fax: 181-99- 275-5315. E-mail address: [email protected] (M. Ogata).

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A case of death associated with ingestion ofliquid windshield-washer detergent

Mihoko Ago, Kazutoshi Ago, Yoshiyuki Orihara, Mamoru Ogata*

Department of Legal Medicine, Faculty of Medicine, Kagoshima University, Kagoshima 890-8520, Japan

Abstract

We report an autopsy case of a death associated with ingestion of liquid windshield-washer detergent. The deceased was a 49-

year-old man who was found dead on a road near his truck. A bottle of liquid windshield-washer detergent containing an anionic

surfactant and methanol was found under the passenger seat of the truck. At autopsy, slight abrasions and bruises were observed

on his body. The small intestine contained dark greenish-brown mucoid matter with abundant froth. The mucous membranes of

the esophagus, stomach and superior small intestine showed extensive necrosis, erosion, hemorrhage, edema and congestion.

Using the methylene blue method to examine the contents of the small intestine, the presence of an anionic surfactant was

indicated. We conclude that the cause of death was ingestion of liquid windshield-washer detergent.

q 2003 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Anionic surfactant; Windshield washer detergent; Autopsy

1. Introduction

Surface-active agents (surfactants) coexisting with

hydrophilic and hydrophobic groups are grossly clas-

sified into cationic, anionic, and non-ionic groups.

Surfactants are widely used in antiseptics and clean-

ing products and as spreader and emulsifier in pesti-

cides and in industry. These many compounds

generally have been considered to be of low toxicity

and to produce few serious effects except in the case

of cationic surfactants, but serious symptoms and

deaths associated with the ingestion of detergents

have been reported [1–6]. Among surfactants, anionic

surfactants have been used particularly in insecticides,

dishwashing liquid and shampoo. However, few fatal-

ities resulting from the ingestion of liquid windshield-

washer detergent have been reported. In this report,

we describe a case of death from swallowing an

unknown amount of liquid windshield-washer deter-

gent.

2. Case report

A 49-year-old man was found dead on a road near

his truck at 07:20 h one day in February. He had been

missing from his home for 5 days. A bottle of liquid

windshield-washer detergent containing an anionic

surfactant (23 w/w%) and methanol (50 w/w%) was

found under the passenger seat of the truck. Approxi-

mately half (125 ml) of the detergent remained in the

bottle. He had had surgery for gastric ulcer approxi-

mately 20 years previously. An autopsy was

performed at 9–14 h after death.

Legal Medicine 5 (2003) S135–S137

1344-6223/03/$ - see front matter q 2003 Elsevier Science Ireland Ltd. All rights reserved.

doi:10.1016/S1344-6223(02)00095-0

www.elsevier.com/locate/legalmed

* Corresponding author. Tel.: 181-99-275-5313; fax: 181-99-

275-5315.

E-mail address: [email protected] (M. Ogata).

3. Autopsy findings

The deceased was 165 cm tall and weighed

approximately 60 kg. External examination of his

body revealed slight abrasions and bruises on the

face, head, chest, abdomen, and upper and inferior

limbs. Postmortem rigidity was strong at all joints.

Slightly purplish-red postmortem hypostasis was

evident on the dorsal aspect of his body. There were

two petechiae of millet-seed size in the inferior

conjunctiva of the right eye and several petechiae

under the scalp. The heart weighed 320 g, and large

amounts of dark-red liquid blood and lardy coagulated

blood were retained in the heart. The left and right

lungs weighed 300 and 330 g, respectively, with

emptiness in the hilar bronchi. The esophagus

contained a small amount of brownish-yellow mucoid

material with foam, and the folds of the lower esopha-

gus showed extensive necrosis. The portion of the

stomach that remained after gastrectomy contained a

small amount of dark greenish-brown mucoid matter

and there was extensive erosion on the inner

membrane (Fig. 1). The small intestine contained a

large amount of foamy mucoid material (about 140

g), and the folds of inner membrane were eroded. A

large number of petechial bleeding sites were under

the mucous membranes. The large intestine was

almost empty and the inner membrane was pallid.

The brain weighed 1450 g, and no abnormalities

were noted. Examination of the organs revealed ische-

mia. No other abnormalities were detected elsewhere

in the body.

Histological examinations revealed severe necro-

sis, erosion, hemorrhage, edema and congestion in

the mucous membrane of the esophagus, stomach

(Fig. 2) and the upper small intestine. Findings of

pathology of the other organs were not remarkable

except findings already described.

4. Toxicological findings

Drug screening by Triagew (Biosite Diagnostics,

San Diego, CA, USA) of urine samples from the

deceased was negative. Concentrations of ethanol

and methanol in specimens were determined using

headspace gas chromatography. Ethanol levels in the

blood and urine were established to be 1.5 and 1.9 mg/

ml, respectively, and methanol was not detected in

either blood or urine (limit of detection, 0.1 mg/ml).

Through use of the methylene blue method to examine

the contents of the small intestine, the presence of an

anionic surfactant was indicated.

5. Discussion

The action of the surfactant against protein on the

cell membrane is solubilization and degeneration.

M. Ago et al. / Legal Medicine 5 (2003) S135–S137S136

Fig. 1. Mucosa of the portion of the stomach remaining after

gastrectomy.

Fig. 2. Histopathological findings of gastric mucosa showing exten-

sive necrosis, severe edema and hemorrhage (H-E staining, £ 25).

When surfactants interact with the cell membrane, the

surfactants introduce the membrane lipid or

membrane protein into the micelles and destroy the

cell membrane. This action is the cause of toxic mani-

festations. Accordingly, with ingestion of material

containing high concentrations of surfactant, distur-

bance of the mucous membranes in the digestive

tract has been thought to be due to a direct corrosive

action. In this case, the examination by the methylene

blue method was positive for anionic surfactant.

Although anionic surfactant has been thought to

have low toxicity, several cases of serious symptoms

and even death associated with the ingestion of deter-

gent have been reported [1–6]. In surfactant poisoning

through oral dosage (shampoo and spreader), hypovo-

lemia, depressed cardiac function and decreased

peripheral vascular resistance have been reported as

the basic pathophysiologic effects. The increased

vascular permeability results in hypovolemia [4].

Ischemia was evident in various organs in our case

of detergent poisoning. Gunji et al. [5] reported two

poisoning cases (anionic and non-ionic surfactant)

associated with surfactants in agricultural chemicals.

The patients had increased vascular permeability,

decreased peripheral vascular resistance and severe

circulatory disturbance. These symptoms were

considered to be grave results of surfactant ingestion.

Kimura et al. [6] reported that among macroscopic

findings of surfactant poisoning, hemorrhage and

congestion of the lungs, hyperemia and erosion of

the digestive tract were found, and the change in the

jejunum was particularly remarkable. They suggested

the presence of selective toxicity against the smooth

muscle. In the present case, the extensive necrosis

reached the muscular layer of the esophageal mucosa,

gastric mucosa and mucosa of the small intestine.

Severe edema, congestion and hemorrhage were also

found. These findings are thought to be due to the

toxic effect of detergent on the digestive tract.

The necrosis of mucous membranes in the esopha-

gus, stomach and small intestine would have inhibited

the absorption of coexisting methanol in the bottle.

We conclude that the cause of death was due to the

ingestion of liquid windshield-washer detergent. The

present case leads us to emphasize the risk of death

from the ingestion of an anionic surfactant.

References

[1] Hogberg J, Rajs J. Sudden unexpected child death associated

with ingestion of fluid dish detergent. Z Rechtsmed

1982;89:51–55.

[2] Katsura S, Niitsu H, Kumagai R, Nakayashiki N, Tajima M. A

judgement case of suspected death by oral giving of a large

amount of surfactants. Res Pract Forens Med 1987;30:105–111.

[3] Okumura T, Suzuki K, Yamane K, Kumada K, Kobayashi R,

Fukuda A, Fujii C, Kohama A. Intravenous detergent poison-

ing. Clin Toxicol 2000;38:347–350.

[4] Sawada Y, Yamamoto I, Kamiyama M, Abe Y, Yoshihara H,

Fukuzako T. Surface active agents poisoning. Jpn J Acute Med

1988;12:1413–1418.

[5] Gunji H, Matsumoto Y, Fujii M. Two cases of surfactant

poisoning. Jpn J Toxicol 1990;3:245–248.

[6] Kimura S, Okada Y, Seno B. A case of surfactant poisoning

with hypothermia and necrosis of the bowel. Jpn J Toxicol

1990;3:241–244.

M. Ago et al. / Legal Medicine 5 (2003) S135–S137 S137