Four cases of sodium nitrite suicidal ingestion: A new trend and a relevant Forensic Pathology and Toxicology challenge

Special Report from the CDC: Suicide rates, sodium nitrite-related suicides, and online content, United States

BACKGROUND

In 2022, suicide ranked as the 11th leading cause of death in the United States with 49,513 deaths. Provisional mortality data from 2022 indicate a 2.8% increase in the number of suicides compared to 2021. This paper examines overall suicide trends, sodium nitrite ingestion as an emerging suicide method, and the role that online forums play in sharing information about suicide methods (including sodium nitrite ingestion).

METHODS

Suicides were identified from CDC's National Vital Statistics System (2018-July 2023 provisional) multiple cause-of-death mortality files using International Classification of Diseases (ICD), Tenth Revision underlying cause-of-death codes U03, X60-X84, and Y87.0 and T code T50.6 (antidotes and chelating agents). Google search popularity metrics were captured from January 2019 to January 2023. Case reports of sodium nitrite related suicide and suicide attempts (through February 2024) were identified in the medical and forensic literature.

RESULTS

At least 768 suicides involving antidotes and chelating agents (including sodium nitrite) occurred between 2018 and July 2023, set in the context of 268,972 total suicides during that period. Overall, suicides involving antidotes and chelating agents (including sodium nitrite) represent <1% of all suicides, however, numbers are rising.

CONCLUSIONS

Suicide methods are known to change over time. These changes can be influenced by, among other factors, online forums and means accessibility, such as internet purchase availability. CDC remains committed to prevention through comprehensive public health strategies that protect individuals, families, and communities.

PRACTICAL APPLICATIONS

States and community partners might consider leveraging physicians, emergency responders, and other appropriate crisis response groups to disseminate information on sodium nitrite self-poisoning and its antidote, methylene blue. Efforts should be part of a comprehensive public health approach to suicide prevention.

Modern suicide trend from internet

INTRODUCTION

The most common suicide methods vary slightly from country to country, partly related to the availability of effective means. Societal development over the years and especially the advent of the Internet has enabled the sudden spread of new suicide methods. Recently, especially since 2019, intentional sodium nitrite poisoning has appeared on many social networks as an increasingly popular method of suicide.

MATERIAL AND METHODS

There was performed a retrospective-prospective study of the autopsy protocols of the Medico-Legal Departments of the Healthcare Surveillance Authority in Slovakia, in a period of 15 years (2008-2022). We performed the analysis of cases of death due to nitrite poisoning, focusing on cases of intentional self-harm. In all selected cases, we present complete information, including photo documentation from the place of death, as well as the results of the performed autopsy and the results of additional laboratory examinations.

RESULTS

We did not record any fatal cases of unintentional, accidental consumption of sodium nitrite in Slovakia, nor any fatal cases of homicidal poisoning by this substance. However, there were three cases of intentional self-harm (completed suicide) by sodium nitrite poisoning (in 2019, 2020 and 2022).

CONCLUSIONS

The correct diagnosis of the cases of sodium nitrite poisoning deaths is possible only based on evaluating all the information obtained, a thorough examination of the body and the crime scene, and the correct interpretation of the findings found during a subsequent autopsy and the results of the toxicological analysis.

Systematic Review of Fatal Sodium Nitrite Ingestion Cases: Toxicological and Forensic Implications

Documented cases of sodium nitrite toxicity are almost exclusively caused by accidental ingestion; however, self-poisoning with sodium nitrite represents an increasing trend in nitrate-related deaths. This systematic review summarizes the most crucial evidence regarding the fatal toxicity of sodium nitrite. It identifies gaps and differences in the diagnostic forensic approaches and the detection methods of sodium nitrite intoxication. A total of eleven research articles were selected for qualitative and quantitative data. Most of the studies (6/11) were case reports. Fifty-three cases of fatal intoxication with sodium nitrite were chosen for the review. More research is required to develop cost-effective techniques and uniform cutoffs for blood nitrite and nitrate levels in the event of deadly sodium nitrite poisoning. There is still a lack of critical information on other matrices and the impact of time since death on toxicological results in such situations. The available evidence provides useful recommendations for forensic pathologists and health practitioners engaged in instances of sodium nitrite poisoning or death. The data should also set off alarm bells in the public health system, in prosecutor's offices, and for policymakers so that they may undertake preventative measures to stop and restrict the unregulated market for these substances.

Sodium nitrite suicide and social media influence

ABSTRACT

This article addresses the increase in suicide rates in the US, emphasizing the emergence of sodium nitrite ingestion as a method of self-harm, particularly among adolescents and young adults influenced by social media. Given the rising incidence of sodium nitrite-related suicide attempts, healthcare providers must remain vigilant and prepared to respond effectively.

Nitrites: An Old Poison or a Current Hazard? Epidemiology of Intoxications Covering the Last 100 Years and Evaluation of Analytical Methods

In recent times, there has been a concerning and noteworthy rise in the global use of sodium nitrite for suicidal purposes. This is facilitated either through the employment of specialized "suicide kits" or by acquiring sodium nitrite through alternative means. Additionally, another occurrence contributing to nitrite poisoning is the recreational utilization of nitrites in the form of volatile aliphatic esters of nitrous acid, commonly referred to as "poppers". Based on current available papers and reports on the subject of nitrates, nitrites, and poppers intoxications, an epidemiological analysis and evaluation of analytical methods were performed. A total of 128 papers, documenting a collective count of 492 intoxication cases, were identified. Additionally, in order to complete the epidemiological profile of nitrite poisoning, the authors briefly examined six cases of nitrite intoxication that were under investigation in our laboratory. Furthermore, a review of nitrite poisoning cases over the past 100 years shows that the old poison is still in use and poses a substantial risk to society.

A fatal suicidal sodium nitrite ingestion determined six days after death

Sodium nitrite (SN) is an inorganic salt that appears as a slightly yellowish crystalline solid, odorless, and highly soluble in water at room temperature. It is highly toxic to humans at specific doses because it can oxidize hemoglobin to methemoglobin, causing severe tissue hypoxia. A 20-year-old woman was unconscious in her bedroom and died shortly after that. Two days later, following the discovery of a jar of SN and a paper in which were written instructions on how to take it (and the website from which the procedure was learned) in the same room were death occurred, the Judicial Authority ordered the execution of the autopsy on the exhumed body of the young woman. The autopsy procedure was performed ∼ 2h after exhumation. It showed greyish-purple hypostasis, labial cyanosis, stomach distension and greenish color but empty, subpleural petechiae, brownish fluid in the pleural cavities (∼300 ml), congested and edematous lungs and diffuse visceral congestion. At autopsy, foamy liquid was observed at the lung section and subsequent squeezing. In addition, the autopsy showed edema and hemorrhagic petechiae of the laryngeal, glottal, and tracheal submucosa and green-brownish foamy liquid in the tracheal lumen. The cause of death was attributed tocardiac arrest induced by anoxia resulting from acute methemoglobinemia caused by sodium nitrite poisoning, intensified by severe malnutrition. Manner of death was suicidal.

Sodium Nitrite Intoxication and Death: Summarizing Evidence to Facilitate Diagnosis

BACKGROUND

Over the years, forensic pathology has registered the spread of new methods of suicide, such as the ingestion of sodium nitrite. Sodium nitrite causes increased methemoglobin, resulting in systemic hypoxia, metabolic acidosis, and cyanosis. Since sodium nitrite is a preservative, the ingestion of foods containing an excessive amount of this substance can also cause acute intoxication up to death. The present review is aimed at guiding health professionals in the identification and management of sodium-nitrite-related intoxications and deaths.

METHODS

A systematic literature search was carried out on PubMed by following the PRISMA statement's criteria. A total of 35 studies with 132 cases were enrolled, and the data were cataloged in Microsoft Excel. To establish the causal correlation between sodium nitrite ingestion and death, the Naranjo Adverse Drug Reaction Probability Scale was used.

RESULTS

In addition to the small number of cases that have currently been published, the study demonstrated that there was a general methodological discrepancy in the diagnostic process. However, some interesting results have emerged, especially in post-mortem diagnostics.

CONCLUSION

Sodium-nitrite-related deaths represent a challenge for forensic pathologists; therefore, it is important to promptly recognize the essential features and perform the necessary and unrepeatable examinations for the correct diagnosis of the cause of death.