Downloaded from http://journals.lww.com/amjforensicmedicine by BhDMf5ePHKbH4TTImqenVIiuKVF7qTxsUisrGCKh3Ia1VEDyXqUTrxASC1WGb9QPRx3ZEO8+wpk= on 10/23/2020 The Diagnosis of a Case of Household Cleaner Fatality Siddhartha Das, MD,* Nisreen Abdul Rahman, MD,† Srinivas Bheemanathi Hanuman, MD,‡ and Suresh Nandagopal, MSc§ Abstract: Household cleaners are an unavoidable entity in our routine domestic life. They are available either in company-labeled bottles or lo- cally made unlabeled bottles especially in the developing countries. In this report, we are discussing a case of fatal ingestion of household cleaner, which was stored in an unlabeled bottle. The deceased developed features of gastrointestinal irritation, such as vomiting and pain in throat and abdo- men. He also had features of aspiration such as cough and chest crepitation. Finally, he developed metabolic acidosis, gastric perforation, respiratory failure, and died within a day. The autopsy features such as teeth discolor- ation, corrosion of mouth and lips, and histopathological findings helped us in concluding that the ingredients contained some corrosive mineral acid. This case highlights the importance of histopathological examination of viscera in alleged cases of household cleaner poisoning where toxicolog- ical analysis of viscera gives negative results. Key Words: household cleaner, corrosive mineral acid, gastric perforation, histopathology (Am J Forensic Med Pathol 2020;41: 203–206) A corrosive agent is a substance that produces both functional and histological damage in contact with the body. In devel- oped countries, higher levels of education and increased product regulation have decreased the morbidity and mortality from corro- sive exposures. However, in underdeveloped and developing countries, poisoning with corrosive agents remains a major issue. 1 Ingestion of such substances causes severe chemical injuries of the upper gastrointestinal tract, such as the esophagus and stom- ach. It presents with a variety of clinical signs, and there is diffi- culty in doing investigations, which usually makes the treatment and outcome uncertain. 2 The circumstances of corrosive injury are different in pediatric (80% due to accidental) and adult popu- lations (mostly suicidal attempts). 3 In our report, we discuss a case of household cleaner ingestion where the findings helped us in concluding the chemical constituent of the liquid. CASE REPORT A male security guard was admitted to a local hospital with an alleged history of suicidal ingestion of floor cleaner liquid that was stored in an unlabeled mineral water bottle. He had 4 to 5 ep- isodes of vomiting and burning abdominal pain. Because his con- dition did not improve, he was referred to our hospital the next day. While being transported to our hospital he had vomiting and productive cough with pain in the chest and abdomen. At the time of admission, there was no history of headache, hematemesis, or decreased urine output. On examination, he was conscious, oriented, and afebrile and vitals were stable. The oral cavity showed erythematous patches on the tongue and con- gestion of palate. The respiratory system showed equal air entry with crepitations of both lungs. There was mild tenderness in the abdomen, but guarding and rigidity were absent. Bowel sounds were heard on auscultation. Ultrasonography of the abdomen was normal, and the radiograph showed pneumoperitoneum. After 1 to 2 hours, he became drowsy and developed audible grunting. He was intubated after a fall in the oxygen saturation and was planned for contrast-enhanced computerized tomogra- phy, but because of deterioration of general condition, he was shifted to the surgical intensive care unit where he died before the procedure. At autopsy, the oral cavity showed a dirty white discoloration at the junction between teeth and gum and also on the anterior teeth of both the jaws (Fig. 1). Nail bed was cyanosed. On internal examination, the epiglottis and tracheal mucosa were found congested. The esophageal mucosa was diffusely hemorrhagic and eroded. Blackish discoloration was found over the lower one-third of the esophagus and gastroesophageal junction (Fig. 1). Pleural cavities showed approximately 300 to 400 mL of blood-tinged fluid on both sides. Both the lungs were congested, edematous, and showed multiple petechial hemor- rhages on the surface. On opening the abdomen, greenish discol- oration of greater omentum was noticed. Peritoneal cavity contained approximately 500 mL of blood-tinged fluid. The stom- ach showed a perforation of size 7 Â 5 cm over the posterior sur- face located 5 cm distal to the gastroesophageal junction (Fig. 1). The stomach contained approximately 50 mL of dark green fluid without any food particles and emitted a peculiar odor. The mu- cosa was diffusely hemorrhagic, black, and very prone to disin- tegrate on touching (Fig. 1). The liver showed greenish discoloration over the anteroinferior surface of the left lobe. Routine viscera and blood were sent to the Regional Forensic Science Laboratory for chemical analysis, and the result was neg- ative for any poisonous substance. The toxicology division of the laboratory examined the samples by using the fundamental meso- scale qualitative analysis method to look for the presence of poi- sonous substances as alleged. 4 Different tests were used for detecting the mineral acids. Gunzberg test and silver nitrate test was used for hydrochloric acid; brucine, ferrous sulfate, and di- phenylamine test for nitric acid and nitrates; and barium chloride test for sulfates. Lime water and calcium chloride test was used for oxalic acid and oxalates, and zinc uranyl test to look for the cation part of alkali. Bits from both lungs, the lower end of the esophagus, stomach wall along with perforated segment, liver, and kidneys were sent for histopathological examination. Histopa- thology showed superficial mucosal erosions in the esophagus, transmural infarction with necrosis and bile pigments in the stom- ach, fresh intra alveolar hemorrhages in the lungs, and centrizonal hemorrhagic necrosis and macrovesicular steatosis of the liver (Fig. 2). The cause of death was chemical peritonitis after stomach perforation due to corrosive mineral acid ingestion. Manuscript received December 4, 2019; accepted April 7, 2020. From the *Department of Forensic Medicine & Toxicology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry; †Department of Forensic Medicine & Toxicology, KMCT Medical College, Kozhikode, Kerala; ‡Department of Pathology, JIPMER, Pondicherry; and §Forensic Sciences Department, Chennai, India. The authors report no conflict of interest. Reprints: Nisreen Abdul Rahman, MD, Department of Forensic Medicine & Toxicology, KMCT Medical College, Manassery, Kozhikode, Kerala, India 673602. E-mail: nisrali2@gmail.com. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0195-7910/20/4103–0203 DOI: 10.1097/PAF.0000000000000566 CASE REPORT Am J Forensic Med Pathol • Volume 41, Number 3, September 2020 www.amjforensicmedicine.com 203 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.