Immunohistochemical detection of early myocardial damage in two sudden deaths due to intentional butane inhalation. Two case reports with review of literature

Butane-related deaths in post-mortem investigations: A systematic review

Volatile substance abuse is widespread among adolescents due to its easy availability and methods of consumption. Inhalant abuse represents a current problematic issue, causing significant morbidity and mortality due to direct toxicity on several target organs and displacement of gas which results in a lack of oxygen. This review aims to evaluate post-mortem and toxicological investigations in cases of suspected butane intoxication. We performed comprehensive research using the Preferred Reporting Items for Systematic Review (PRISMA) standards. Forty scientific papers fulfilled the inclusion criteria. A total of 58 cases of butane-related deaths were found. Among these, we found 11 cases of suicide (18%), 1 case of homicide (2%), 44 cases of accidental poisoning (76%), and 2 cases of work-related deaths (4%). Autopsy and post-mortem examinations were performed in 54 cases, whereas toxicological analyses were presented in 56 cases. In autopsy, pulmonary edema (51%) and poli-visceral congestion (59%) were the most common findings. When death by butane inhalation is hypothesized, autopsy and histological findings may be nonspecific, therefore toxicological investigations assume a crucial role along with attention to the methods used to collect biological samples.

A two-decade review of butane toxicity as a substance of abuse

Butane, an aliphatic hydrocarbon with explosive and flammable properties, is widely misused especially by young people. Acting as an asphyxiant gas, butane mainly targets the central nervous and cardiovascular systems. We aimed to review butane-attributed toxicities due to its harmful use or misuse reported in a two-decade period. We searched English-language publications reporting butane toxicities from 2000 up to 2021 and collected data on age, gender, route and source of exposure, country of origin, clinical presentation and outcome. Among 54 butane's harmful use/misuse cases identified in the literature, there were 11 survivors successfully discharged from the hospital. Patients were predominantly males with a mean age ± SD of 23 ± 13 years. The main route of exposure was inhalation. Manifestations were mainly cardiac and neurological. Majority of the cases were reported from Europe and Japan. To conclude, butane exposure is at risk of severe central nervous system and cardiac toxicities, which may result in a fatal outcome. Therefore, in the event of a sudden or suspicious death in a young individual, our findings suggest that butane's harmful use/misuse should be considered as a potential differential diagnosis.

Management of hydrocarbon burns: Considering mental health and biochemical abnormalities

Volatile substance misuse, particularly the inhalation of hydrocarbons, is a growing issue globally. Consequences of VSM, both acute or chronic, causes cardiovascular, respiratory, renal, metabolic and central nervous system damage. Whilst the effects of hydrocarbon abuse have been reported, the combination of intoxication with hydrocarbon and burns sustained has not yet been presented. A retrospective case series of patients who presented in the last 5 years to the Royal Adelaide Hospital with hydrocarbon-related burns in the context of illicit use was undertaken. Our aims are to present to the wider scientific community the high morbidity and mortality of hydrocarbon burn injuries and why this tertiary Burns Unit feel it most appropriate to medically stabilise these patients prior to definitive surgery for their burn. All patients that presented with acute hydrocarbon intoxication and sustained concomitant burns had significant psychiatric disorder and substance abuse history and three of five had either not eaten in several days resulting in acute malnourishment, refeeding syndrome or had evidence of chronic malnourishment with deranged electrolytes and hypoalbuminaemia. Their definitive burns surgery was delayed where appropriate in order to facilitate medical stabilisation as they were too high risk of cardiac membrane instability, electrolyte derangement and/or respiratory compromise to undergo safe general anaesthetic and burns debridement. We propose a multidisciplinary team approach, utilising not only our Burns Unit care model of physiotherapists, psychologists, social work and burns trained nurses and surgeons but also Intensive Care, Toxicology, Addiction medicine and General Medical physicians in the management of these patients.

Suicide by inhalation of butane gas through a homemade adaptation of a continuous positive airway pressure (CPAP) face mask

Fatal poisoning due to butane inhalation has been described in the clinical and forensic literature. We report the first case of a seventy-year-old obese man with a history of sleep apnea and depression, who was found dead in bed after inhaling butane gas through a homemade adaptation of his own continuous positive airway pressure (CPAP) face mask. The death scene investigation, autopsy findings and toxicological results are described. The cause of death was suspected to be due to asphyxia through butane inhalation.

Butane hash oil and dabbing: insights into use, amateur production techniques, and potential harm mitigation

The use of marijuana concentrates has escalated in recent years with butane extracts appearing particularly popular. The administration of butane hash oil, colloquially referred to as “dabbing,” is distinct from traditional flower cannabis usage due to the THC content of samples and the presence of impurities such as unpurged butane. While this may confer heightened risk to the user, additional significant concerns are tied to fires and explosions. Using butane as a solvent in amateur “blasting” methods may result in a flammable vapor pooling in enclosed spaces and igniting when exposed to a spark. As research on butane extract users, amateur production techniques, health risks, and legality is in its infancy, we explored existing studies on the topic to create a review of substantiated knowledge related to THC extracted using butane. The resulting assessment centers on three areas: 1) dab users including both recreational users and medical marijuana patients; 2) butane extraction techniques including illicit amateur open methods and the safer closed-loop system employed in medicinal/recreational states; and 3) risks, both related to fires and legality. We follow the presentation of this material with a summary of the (mis)information reaching the public in print and online sources so that public educational campaigns can focus on dispelling the inaccuracies and false notions of safety that may be tied to amateur production.

Death From Butane Inhalation Abuse in Teenagers: Two New Case Studies and Review of the Literature

The ready availability of butane makes butane abuse frequent. Fatalities are rare. This study presents two cases of death by butane overdose. The postmortem analyses were carried out using headspace gas chromatography-mass spectrometry. It revealed femoral blood butane concentrations of 18 and 22 mg/L, respectively, as well as specific combinations of adjuvants in each victim. In one of the victims, brain and fatty tissue also contained butane, pointing to chronic consumption. The originality of this study is to show that the identification of specific combinations of adjuvants can be helpful for identifying the brand of deodorant used. Also, sampling the skin and mucosa can help identify the method of drug delivery. The histological examination documented both the direct toxic effect of the gas on the respiratory mucosa and signs of chronic abuse. Volatile substance intoxications should be systematically considered in case of sudden death in a teenager.

A Rare Case of Poisoning with a Volatile Substance: Quantitative Determination of n-Butane in Postmortem Tissue

Poisoning with volatile substances remains exceptional. Authors report the case of a married couple who were found in a car with a butane gas bottle: the woman was dead and her husband alleged it was an unsuccessful suicide pact. A specific research of volatile substances on postmortem samples with headspace gas chromatography-mass spectrometry following a quantitative determination was performed. The n-butane concentrations detected were composed of 610 μg/L (cardiac blood), 50 μg/kg (brain), 134 μg/kg (lungs), 285 μg/kg (liver), and 4090 μg/kg (heart) and were compatible with the rare lethal concentrations evoked in the literature. The cause of death was determined to be asphyxiation through n-butane criminal poisoning. Authors recommendation therefore is to take samples immediately and place them in properly sealed containers and hence analyzing the samples as soon as possible after collecting them or storing them under -30°C (-22°F) if analyses cannot be performed immediately.

Forensic medical evaluation of deaths resulting from inhalation of cigarette lighter refill fuel in Turkey

Voluntary inhalation/abuse of volatile substances is an important public health problem which especially affects adolescent and young populations worldwide and may be encountered in all socioeconomic and cultural levels. Lighter gas abuse-related death is still an important health problem in Turkey. In this study, 25,265 case files and final reports submitted to the Institute of Forensic Medicine of the First Specialization Board between January 2011 and December 2015 were evaluated retrospectively. In 56 of these cases, lighter gas inhalation (n-butane, propane, isobutane) was recorded as the cause of death. All subjects were male with a mean age of 16.8years. According to eyewitness and crime scene investigation reports, in 48 (85.7%) of the cases, a lighter refill container was found at the scene. It was determined that 21.4% of the cases used a plastic bag to increase the effects of lighter gas and 76.8% inhaled the lighter gas via their mouth and nose. The toxicological analysis of the samples taken while hospitalized showed no lighter refill components (n-butane, propane, isobutane) in 66% of the cases, n-butane in 32.1% of the cases, and n-butane+propane+isobutane in 1.9% of the cases. The importance of lighter gas inhalation-related deaths in Turkey has been increasing. Strict measures against the abuse of these very dangerous substances should be undertaken by the mutual efforts of medical specialists and legislators.

Serial neuropsychological assessment of an adolescent girl after suffering a sudden out-of-hospital-cardiac-arrest following recreational inhalant use

Sudden out-of-hospital-cardiac-arrest (OHCA) following recreational inhalant use is well documented in the literature. The present case study reports the long-term neuropsychological sequelae of a 14-year-old girl who suffered an OHCA secondary to recreational butane gas inhalation. The patient was assessed on day-13 as an inpatient, and again at 3- and 12-month outpatient follow-ups. Acutely the patient demonstrated significant impairment on tasks associated with verbal and non-verbal memory and executive functioning. Re-testing at 3-months post-acute state suggested improved executive and non-verbal functions while showing continued deficits in verbal memory. At 12-months she was cognitively performing at levels expected for her age. This case is reported for its rarity in successfully being able to track the patient's clinical course from hospital discharge to the successful reintegration back into school and community settings.

Is it worth carrying out determination of N-butane in postmortem samples? A case report and a comprehensive review of the literature

The aim of this article is to illustrate the importance of N-butane determination in postmortem samples through a case report and to propose actions and precautions to be taken into consideration when butane is suspected to be involved in cases of death. The case concerns a 15-year-old boy found dead after sniffing a cigarette lighter refill. Toxicological investigation revealed the presence of butane in the heart and femoral blood (1280 and 1170 μg/L, respectively), in the gastric contents (326 μg/L), and in the liver (1010 μg/kg) and lung tissues (210 μg/kg). Propane was present only in the blood samples at concentrations tenfolds lower.Butane can be involved in three kinds of fatalities: deliberate inhalations including volatile substance abuse (VSA), involuntary exposure, and homicides. A fatal outcome of butane inhalation can be caused by asphyxia and/or cardiac arrhythmia. In the context where butane exposure is evidenced by non-toxicological investigations, the usefulness of the determination of butane in postmortem samples is often questionable. However, it is admitted that butane-related deaths are generally underreported. Several difficulties including sample handling and storage, substantial variation in tissue concentrations, and lack of a lethal threshold make the interpretation of butane results challenging. In our opinion, systematic toxicological methods should be developed in order to analyze butane, at least when it concerns a typical VSA victim, even when butane is not actually suspected to be the cause of death.

A Case of Sudden Infant Death Due to Incomplete Kawasaki Disease

Although Kawasaki disease (KD) is a self-limiting disease, it may cause sudden cardiac death. Diagnosis of KD is principally based on clinical signs; however, some infant cases do not meet the criteria. Such cases are identified as incomplete KD. The sudden death risk in incomplete KD cases is similar to conventional KD. In our 5-month-old case, he had been admitted to a hospital for a fever and suppuration at the site of Bacille de Calmette et Guerin (BCG) vaccination. However, after discharge from the hospital, his C-reactive protein (CRP) levels declined, he got indisposed and died suddenly. A medico-legal autopsy revealed myocarditis, coronaritis, platelet-aggregated emboli in coronary arteries, and myocardial degeneration, suggesting that the fatal myocardial infarction was due to thrombus emboli in the coronary arteries. Forensic pathologists therefore should pay attention to the cardiac pathology originated from incomplete KD as a potential cause in cases of sudden infant death.

Intensive care management following defibrillation of an adolescent girl after recreational inhalant use: a case report and review of the literature

We report the successful out-of-hospital defibrillation and intensive care management of a 14-year-old girl who developed ventricular fibrillation following the inhalation of two 150-mL butane cigarette lighter refill canisters. Following ambulance transport to the nearest tertiary pediatric health care facility, her acute clinical course consisted of sinus tachycardia, fluctuating consciousness, and severe cerebral agitation and combativeness. Over a period of 2 weeks, her neurological function significantly improved to the point she was able to be discharged back into the community, however, not without a number of formally identified neurological deficits. Inhalant gasses, through as yet unclear mechanisms, can cause the myocardium cell membrane to become unusually sensitive to catecholamines which in turn can sometimes lead to fatal arrhythmias. This case is reported for its rarity in terms of the patient being able to be discharged back into the community and to create awareness of the sudden and potentially devastating consequences of butane inhalant use for critical care physicians and prehospital health-care personnel.