Fatal water intoxication during olanzapine treatment: A case report

Variance in intraindividual stability of vitreous humor for thanatochemistry

INTRODUCTION

This study investigates the intraindividual variability and ex-vivo stability of vitreous humor (VH) analytes for forensic thanatochemistry. VH, an anatomically isolated and robust postmortem fluid, provides valuable insights into the postmortem interval (PMI) and potential antemortem medical conditions.

MATERIALS AND METHODS

A total of 207 VH samples were collected from 36 cases and divided into three cohorts: serial sampling across three days postmortem, intraindividual variability assessment using triplicates, and ex-vivo stability evaluation through freeze-thaw cycles.

RESULTS

Linear relationships between PMI and potassium, calcium, creatinine, and lactate were identified, but their non-linear trends limited PMI estimation accuracy. Sodium, chloride, and glucose demonstrated variations linked to cardiovascular and infectious conditions, while elevated urea and creatinine correlated with renal or multi-organ failure. The study highlighted the importance of interpreting these biochemical markers in conjunction with clinical and environmental factors to improve reliability.

DISCUSSION

Ex-vivo stability testing revealed relevant variations in VH levels, emphasizing the need for standardized pre-analytical handling. Overall, while VH analytes offer promising forensic applications, their use for PMI estimation and medical diagnoses requires cautious interpretation within a multidisciplinary context.

Comparison of lithium levels between suicide and non-suicide fatalities: Cross-sectional study

Ecological studies have suggested the protective effect of micro-dose lithium in drinking water against suicide, however, the association between body lithium level and suicide is unknown. We aimed to compare body lithium levels between suicide and non-suicide fatalities. This cross-sectional study included 12 suicides and 16 non-suicides who were examined or dissected at the Tokyo Medical Examiner's Office from March 2018 to June 2021. The aqueous humor lithium concentration was measured twice using inductively coupled plasma mass spectrometry. Analysis of covariance (ANCOVA) was used to compare the lithium concentration between suicides and non-suicides. Mixed-effects model was conducted to account for all lithium concentration data. The aqueous humor lithium concentration did not change after death (t(7) = -0.70, [Formula: see text], SE = 0.03, 95% CI = [-0.09, 0.05], P = 0.51, Cohen's d = 0.01). The aqueous humor lithium concentration was lower in suicides (mean 0.50 μg/L (variance s² 0.04)) than in non-suicides (mean 0.9² μg/L (s² 0.07)) (t(26) = 4.47, [Formula: see text], SE = 0.09, 95% CI = [0.22 to 0.61], P < 0.001, Cohen's d = 1.71). The ANCOVA showed that death by suicide was significantly associated with lower lithium concentration (F(1, 24) = 8.57, P = 0.007), and the effect size was large (η_p² = 0.26). The random intercept model showed a significant effect of suicide on aqueous humor lithium concentration (b = -0.261, SE = 0.102, 95% CI = [-0.471 to -0.051], t(24) = -2.568, P = 0.017). The results of this study demonstrate that even micro-dose lithium is associated with suicide death. Clinical studies are warranted to examine the effects of micro-dose lithium on suicide prevention.

Clinical characteristics and outcomes of hyponatraemia associated with oral water intake in adults: a systematic review

INTRODUCTION

Excessive water intake is rarely associated with life-threatening hyponatraemia. The aim of this study was to determine the clinical characteristics and outcomes of hyponatraemia associated with excess water intake.

METHODS

This review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All studies (case reports, observational or interventional studies) reporting excess water intake and hyponatraemia in adults (1946-2019) were included.

RESULTS

A total of 2970 articles were identified and 177 were included (88.7% case reports), consisting of 590 patients. The mean age was 46±16 years (95% CI 44 to 48 years), 47% female, 52% had a chronic psychiatric disorder and 31% had no underlying condition. The median volume of water consumed and serum sodium at presentation was 8 L/day (95% CI 8.9 to 12.2 L/day) and 118 mmol/L (95% CI 116 to 118 mmol/L), respectively. The motivator for increased water consumption was psychogenic polydipsia (55%); iatrogenic (13%); exercise (12%); habitual/dipsogenic polydipsia (7%) and other reasons (13%). The clinical features on presentation were severe in 53% (seizures, coma); moderate in 35% (confusion, vomiting, agitation) and mild in 5% (dizziness, lethargy, cognitive deficit) and not reported in 5% of studies. Treatment was supportive in 41% of studies (fluid restriction, treatment of the underlying cause, emergency care), and isotonic and hypertonic saline was used in 18% and 28% of cases, respectively. Treatment-related complications included osmotic demyelination (3%) and rhabdomyolysis (7%), and death occurred in 13% of cases.

CONCLUSION

Water intoxication is associated with significant morbidity and mortality and requires daily intake to substantially exceed population-based recommendations. The limitations of this analysis are the low quality and high risk of bias of the included studies.

PROSPERO REGISTRATION NUMBER

A pre-existing protocol in the international prospective register of systematic reviews was updated to incorporate any new amendments and reregistered at http://www.crd.york.ac.uk/PROSPERO (registration no. CRD42019129809).

Analysis of the Frequency and Onset Time of Hyponatremia/Syndrome of Inappropriate Antidiuretic Hormone Induced by Antidepressants or Antipsychotics

BACKGROUND

Hyponatremia and syndrome of inappropriate antidiuretic hormone (SIADH) is a potentially fatal adverse effect of antidepressants (ADs) and antipsychotics (APs), although its frequency and onset time have not been well documented.

OBJECTIVE

To analyze the frequency and onset time of AD- or AP-induced hyponatremia/SIADH.

METHODS

We used plural data-mining techniques to search the US Food and Drug Administration Adverse Event Reporting System (FAERS) database for reports on hyponatremia/SIADH induced by psychotropic drugs from January 2004 to June 2020. For each item, we assessed the reporting odds ratio, 95% CI, median onset time, and Weibull distribution parameters.

RESULTS

We identified 36 422 reports related to hyponatremia/SIADH. Signals were detected for all psychotropic drugs that we analyzed, except for clozapine. The median onset time of total AD-induced hyponatremia/SIADH was shorter than that of AP. For all ADs and APs except clozapine, hazards were considered to be the early failure type. In contrast, the hazard of clozapine was considered to be the random failure type. The limitations of this study included several reporting biases and the presence of confounding variables, particularly age.

CONCLUSION AND RELEVANCE

Most ADs and APs were found to be associated with a risk for hyponatremia/SIADH. In addition, sufficient attention should be paid to signs of hyponatremia/SIADH in the early phase when most ADs and APs are administered. These data are potentially useful for determining AD- or AP-induced hyponatremia/SIADH in the early stage and for preventing its further aggravation into a serious condition.

Vitreous humor endogenous compounds analysis for post-mortem forensic investigation

The chemical and biochemical analysis of bodily fluids after death is an important thanatochemical approach to assess the cause and time since death. Vitreous humor (VH) has been used as a biofluid for forensic purposes since the 1960s. Due to its established relevance in toxicology, a literature review highlighting the use of VH with an emphasis on endogenous compounds has not yet been undertaken. VH is a chemically complex aqueous solution of carbohydrates, proteins, electrolytes and other small molecules present in living organisms; this biofluid is useful tool for its isolated environment, preserved from bacterial contamination, decomposition, autolysis, and metabolic reactions. The post-mortem analysis of VH provides an important tool for the estimation of the post-mortem interval (PMI), which can be helpful in determining the cause of death. Consequently, the present review evaluates the recent chemical and biochemical advances with particular importance on the endogenous compounds present at the time of death and their modification over time, which are valuable for the PMI prediction and to identify the cause of death.

Relationship between polydipsia and antipsychotics: A systematic review of clinical studies and case reports

OBJECTIVE

This systematic review aimed to elucidate the relationship between polydipsia and antipsychotics.

METHODS

We systematically searched MEDLINE, Embase, and PsycINFO, and included clinical studies and case reports on polydipsia induced or improved by antipsychotics.

RESULTS

We identified 61 articles: 1 double-blind randomized controlled trial (RCT), 4 single-arm trials, 1 cross-sectional study, 3 case series, and 52 case reports. The double-blind RCT demonstrated no significant difference in improvement in polydipsia between olanzapine and haloperidol. Two single-arm trials showed that polydipsia improved during clozapine treatment, whereas the other 2 showed that risperidone did not improve polydipsia. The cross-sectional study showed the prevalence of hyponatremia with first-generation antipsychotics (FGAs: 26.1%) and second-generation antipsychotics (SGAs: 4.9%). Two case series reported that clozapine improved polydipsia; the other one indicated that patients with polydipsia who were treated with FGAs had schizophrenia (70.4%) and mental retardation (25.9%). Of 90 cases in the case reports, 67 (75.3%) were diagnosed with schizophrenia. Of 83 cases in which antipsychotic treatment started before the onset of polydipsia, 75 (90.3%) received FGAs, particularly haloperidol (n = 24, 28.9%), and 11 (13.3%) received risperidone. Among 40 cases in which polydipsia was improved following antipsychotic treatment, 36 (90.0%) received SGAs, primarily clozapine (n = 14, 35.0%).

CONCLUSIONS

Although the causal relationship between polydipsia and antipsychotics remains unclear because of the paucity of high-quality studies, antipsychotics with high affinity to dopamine D₂ receptors may be associated with an increased risk of polydipsia while clozapine may be effective for treating polydipsia.

[Exercise-Associated Hyponatremia in Endurance Performance]

Exercise-Associated Hyponatremia in Endurance Performance Abstract. Exercise-associated hyponatremia is defined as a plasma sodium concentration of <135 mmol/l and was first described by Timothy Noakes at the Comrades Marathon in South Africa in the mid-1980s. A decrease in plasma sodium <135 mmol/l occurs with excessive fluid intake. Risk factors include long to very long endurance performance, extreme climatic conditions, female gender and competitions in the USA. Regarding its prevalence by sport, exercise-associated hyponatraemia tends to occur while swimming and running, but rarely when cycling. While mild exercise-associated hyponatremia does not lead to clinical symptoms, severe hyponatremia due to cerebral edema can lead to neurological deficits and even death. The best prevention of exercise-associated hyponatremia is the reduction of fluid intake during exercise.

Olanzapine-Induced Fatal Ketoacidosis with Pneumomediastinum and Subcutaneous Emphysema

We report a case of fatal olanzapine-induced ketoacidosis in which pneumomediastinum (PM) and subcutaneous emphysema (SE) were detected on postmortem computed tomographic (CT) images. A man in his forties was found in a state of cardiopulmonary arrest with profuse perspiration, and 50 empty capsules of olanzapine (10 mg) and flunitrazepam (1 mg) were found in his room. The major findings of postmortem CT prior to autopsy were PM and SE from the lower half of the face to the height of the first rib. The results of autopsy, biochemical tests, and toxicological analyses indicated the cause of death to be fatal ketoacidosis induced by olanzapine intoxication. No injuries, medical interventions, or particular diseases were evident, suggesting that PM and SE were caused by ketoacidosis. Our findings indicated that toxicological analyses should be performed when PM and SE are detected on CT images.

Hyponatremia in Association With Second-Generation Antipsychotics: A Systematic Review of Case Reports

BACKGROUND

Hyponatremia is generally defined as a serum sodium level <135 mmol/L and is considered severe if serum sodium is <125 mmol/L. Hyponatremia is a potentially life-threatening medical comorbidity for patients with schizophrenia. The incidence of hyponatremia in patients with schizophrenia who are taking second-generation antipsychotics (SGAs) has not been well established.

METHODS

We conducted a systematic review of case reports of hyponatremia associated with the use of SGAs in patients with schizophrenia. We searched MEDLINE (from 1946 through September 2016) using the medical subject headings antipsychotic agents, hyponatremia, and water intoxication to identify reported diagnoses of hyponatremia following treatment with SGAs in patients with schizophrenia.

RESULTS

We abstracted 12 potentially relevant case reports from 157 records. Nine case reports met the selection criteria. Three cases involved the use of aripiprazole (Abilify), 3 involved the use of risperidone (Risperdal), and the other 3 cases involved ziprasidone, olanzapine, and clozapine. Approximately equal numbers of males and females were represented, and 2 of the 9 patients were aged ≥60 years. The average patient age was 47 years, and the average time to the hyponatremia event was 17 days. The average serum sodium was 138 mmol/L at baseline, 112 mmol/L at treatment nadir, and 138 mmol/L after treatment discontinuation.

CONCLUSION

Hyponatremia can result from the use of SGAs in patients with schizophrenia and can be avoided with proper management of treatment. Physicians, psychiatrists, and other healthcare workers should be aware of the potential for severe hyponatremia with the use of commonly prescribed SGAs. SGA-induced hyponatremia is generally reversible after discontinuing treatment.

Postmortem diagnosis of hyponatremia: case report and literature review

Hyponatremia is defined as a plasma sodium concentration less than 135 or 130 mEq/L (or mmol/L) and may be responsible for life threatening symptoms that can be observed in a variety of medical conditions. Cases of fatal hyponatremia have been reported in both clinical and forensic literature in situations of water intoxication due to psychogenic polydipsia, amphetamine derivative drug intake, high-endurance exercise, iatrogenic causes, and exceptional cases of child abuse by forced water intoxication. Vitreous sodium levels have been determined to be relatively stable during the early postmortem period and similar to levels found in normal serum of living subjects. Nevertheless, there are relatively few cases of fatal hyponatremia described in literature that underwent exhaustive postmortem biochemical investigations. A case of fatal water intoxication in a psychiatric patient who underwent medicolegal investigations, including postmortem biochemistry, was chosen as a starting point to a literature review of deaths by hyponatremia that may be encountered in the forensic setting.