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