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American Journal of Forensic Medicine & Pathology:
doi: 10.1097/PAF.0b013e31827ab5f3
Case Reports

Complicated Suicide Versus Autoeroticism?: A Case Involving Multiple Drugs and a Porta-Potty

Dickerson, Evan Matthew MD*; Jones, Prentiss PhD; Wilkins, Dennis; Regnier, Janis BS; Prahlow, Joseph A. MD§

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From the *School of Medicine, Indiana University, Indianapolis; †South Bend Medical Foundation, South Bend; ‡Portage Police Department, Portage; and §School of Medicine, Indiana University–South Bend at the University of Notre Dame, South Bend, IN.

Manuscript received June 4, 2012; accepted September 10, 2012.

The authors did not receive sources of support or funding for this study.

The authors report no conflicts of interest.

Reprints: Evan Matthew Dickerson, MD, School of Medicine, Indiana University, 631 N Morton St, Bloomington, IN 47404. E-mail: evandickerson@gmail.com.

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Abstract

Abstract: In this report, a unique and bizarre case of complicated suicide is presented. The decedent was found dead in the basin of a porta-potty, wearing women’s pantyhose, jewelry, and makeup. The initial investigation was suspect for homicide. Although an autoerotic accidental death cannot be excluded, the patient’s medical history and autopsy results provided evidence for suicide, including several substances positive in his serum. Tramadol was quantified to be 140 mg/L, approximately 470 times the therapeutic range. Moreover, formaldehyde was also present, presumably absorbed from the contents of the chemical toilet. An exhaustive search could not reveal similar circumstances of suicide in a porta-potty or with the levels of tramadol found in the decedent.

Suicides and accidental deaths can mimic homicide until further investigation and pathology are reviewed. In this report, a unique case of suicide by drug overdose with possible contributing factors of positional asphyxia, hyperthermia, and exposure to the chemical contents of a “porta-potty” is described. Moreover, the circumstances surrounding the death are of importance. A search of the media and medical literature failed to reveal a similar case.

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RESULTS

A 36-year-old man was found dead in the waste receptacle of a porta-potty in a park on a late afternoon of a hot August day. Police were notified of an abandoned vehicle in the parking lot adjacent to a local park and found the body while investigating the vehicle. The vehicle was found with the front windows down. The interior and exterior were covered with hand-drawn graphic images and writings alluding to the male genitalia and to homosexual acts. The vehicle contained several articles of clothing including the decedent’s wallet, identification, cellular phone, receipts, and an open gym bag. The bag contained personal lubricant among other items. The driver’s seat contained several tubes of lipstick that matched the color of the writing on the car. Upon searching the park for the owner, the decedent was found in the tank of the portable toilet at the edge of the parking lot. The decedent’s leather jacket, vehicle keys, and additional tubes of lipstick were found inside the porta-potty.

Scene investigation revealed an obese man lying on his back slightly rotated on his left side in the fetal position with only an arm and torso visible through the opened porta-potty seat (Fig. 1). Upon closer inspection, the decedent was noted to be shirtless, wearing only women’s stockings. The body was extricated from the basin of the toilet by cutting the top periphery of the tank, allowing for further investigation and autopsy.

Figure 1
Figure 1
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At autopsy, the approximately 220-lb (100 kg) decedent was noted to have early signs of decomposition, including skin discoloration, slippage, and bloating most prominent in the face and neck but notably absent posteriorly. His head was markedly flexed with his chin touching his chest (Fig. 2). He was wearing women’s makeup, a pair of nylon leggings, and a left nylon sock. The body exhibited blue debris and had a chemical smell. No identifying scars or marks were noted.

Figure 2
Figure 2
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The flanks, back, and arms showed confluent linear, curvilinear, and irregular abrasions (Fig. 3). Irregular abrasions were present on the chest and abdomen. Multiple irregular and confluent apparent chemical burns overlapped the abrasions and were primarily present on the flanks, back, and left upper extremity; the lesions were dry, thickened, and firm.

Figure 3
Figure 3
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On internal examination, the abdominal organs showed signs of decompositional change but few other abnormalities. The aorta showed minimal areas of atherosclerosis, whereas the heart showed marked biventricular dilatation. The heart was of normal weight at 380 g. The lungs were unremarkable with no evidence of pulmonary edema. The stomach contained approximately 150 mL of brown fluid, which contained at least 3 capsules exuding a viscous material. A battery-operated vibrating device was present within the rectum (Fig. 4). With the exception of mild hepatic steatosis, the remainder of the internal examination and the microscopic examination was unremarkable. There were no external or internal neck injuries identified.

Figure 4
Figure 4
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Urine, serum, bile, and vitreous fluid samples were submitted for toxicologic testing. The urine drug screen was positive for amphetamine, tramadol, methylphenidate, nicotine, cotinine, and caffeine. Serum drug testing revealed the presence of ethanol, formic acid, tramadol, O-desmethyltramadol, methylphenidate, ritalinic acid, D-amphetamine, and L-amphetamine. Routine drug testing was not performed on the bile and vitreous samples; however, both samples were analyzed for tramadol and amphetamine. Drug concentrations are presented in Table 1.

Table 1
Table 1
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Subsequent police investigation failed to reveal any evidence that suggested someone other than the decedent was involved in this death. Family members denied knowledge of homosexual tendencies and suicidal ideation. DNA analysis was run on several samples collected from the lipstick, swabs of the porta-potty, and body swabs; the results matched the DNA of the decedent. Upon investigating the decedent’s home, numerous prescriptions and over-the-counter medications were obtained. Included in these was a 240-tablet tramadol HCl 50 mg prescription bottle containing 213 tablets; it was filled on the night of the decedent’s death.

Based on the autopsy findings and the historical and investigative information surrounding the case, the cause of death was listed as the combined toxic effects of formaldehyde, amphetamine, and tramadol with possible contributing factors of positional asphyxia and hyperthermia. The manner of death was ruled “suicide.”

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DISCUSSION

Cases of suicide can mimic homicide upon initial investigation.1 Nevertheless, the unique presentation of this case is of importance. An exhaustive literature/media search was unable to obtain a similar case with the manner of death reported here. Cases of individuals getting trapped in the basins of chemical toilets have been reported in the media,2,3 but none of which resulted in fatality. Provided the immediate evidence—the decedent was found dead in the basin of a chemical toilet; the vehicle was found abandoned with extensive graffiti/vandalism present; blunt force trauma was evident about the flank, back, and abdomen—homicide must be suspected. Furthermore, it is possible to conceive that a “hate-crime” against an individual who practices alternative sexual lifestyles occurred: the decedent being assaulted, dressed in women’s clothing, forced into a porta-potty, and the vehicle vandalized.

The results of police investigation, autopsy, and toxicology indicated otherwise. The pattern of the flank and other abrasions was isolated to the area of central obesity, indicating a methodic approach to minimize injury when entering the relatively small opening within the toilet seat. No other evidence of trauma was present at autopsy. At largest thoracic diameter, the decedent was approximated to be 42 cm, whereas the toilet lid opening was approximated to be 28 by 38 cm (Fig. 5). Ultimately, the habitus of the man would likely have prevented an assailant from forcing the body through the opening without excessive trauma being incurred (or the assailant simply giving-up because of the difficult task at hand).

Figure 5
Figure 5
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It is important to note the bizarre circumstances surrounding the decedent’s death. Paraphilia is occasionally described in the forensic literature and may be evident at scenes of suicide.4 Paraphilias are a group of sexual disorders characterized by sexual arousal in response to objects or situations that are not part of normal human arousal activity patterns.5 Although the family reported no known history of cross-dressing, it is likely that the decedent had a history of partaking in practices of transvestitism because he was found with an anal vibrator while wearing women’s clothing and makeup, indicating a level of sexual arousal associated with the act. Moreover, it is possible that these acts were of a more common practice; the decedent perhaps found sexual excitement from contact with feces thus partaking in coprolagnia.6

Accidental death must be considered given the circumstances. The scene suggests that a degree of autoeroticism may have been involved. The anal vibrator and transvestitism with the possibility of coprolagnia draws question to the decedent’s intention for climbing into the portable toilet. It is possible to conceive that the decedent purposefully forced himself into the tight quarters but was then unable to get back out. Moreover, he could have been overcome by the toxic fumes and lost consciousness. In addition, the ingested medications found in the decedent’s serum could have been taken to enhance the eroticism but also could have added to the patient unexpectedly losing consciousness. All of the previously mentioned scenarios are possible and would suggest that the decedent did not possess the intention to commit suicide. Ultimately, it is a manner of death that must not be immediately excluded from the investigation.

The crime scene and information obtained from the decedent’s family support suicide as the manner of death. According to family, the decedent frequently referred to his vehicle as “his baby.” It is unlikely the decedent would have defaced “his baby” if he was planning to return to the vehicle and drive it. Clearly, there was intent and purpose in the drawings and in leaving the vehicle in the parking lot. In addition, 4 cigarette butts were found on the pavement behind the vehicle, all of which matched the decedent’s DNA, indicating that there may have been hesitation while he forged his resolve to enter the porta-potty.

An interview with a friend revealed that the decedent was having homosexual thoughts. While at a truck stop, the decedent went into the men’s bathroom planning to perform oral sex on another male. He did not perform the act but did reveal his thoughts and actions to his friend. Struggling with such tendencies helps to provide an explanation for the vulgarities the decedent drew on his vehicle—they were an expression of his frustration and search for identity. Among other explicit drawings expressing the desire to perform homosexual acts, the text “I am gay” was drawn on several locations.

The family reported that the decedent had been battling with depression and was being treated with medication. The medications found in his home were paroxetine, trazodone, and tramadol; stolen prescriptions from his father for paroxetine, gabapentin, and cyclobenzaprine were also present. Of the 240-tablet tramadol prescription filled on the night of the decedent’s death, 27 tramadol were missing and thus were likely ingested that night. The large quantity consumed further supports the intention of the decedent to commit suicide. In addition, according to family, he was struggling with a recent breakup with his girlfriend. This life stressor in combination with his sexual identity struggles likely contributed to his depression, providing greater support for suicide as the manner of death.

The primary component of many chemical toilets, including the one in this case, is formaldehyde.7 Formaldehyde is a colorless gas at room temperature but is commonly used in aqueous solutions such as in disinfectants, preservatives, and fixatives. Formaldehyde is a highly reactive chemical known to be oxidized to formic acid via red blood cells and the liver.8 Exposure to formaldehyde results in damage by 2 mechanisms. First, formaldehyde itself is an irritant that can be absorbed systemically through multiple routes—ingestion, inhalation, or direct contact.9 At autopsy, firm (formalin-fixed), chemical burns were noted over several parts of the body. The skin hardening was essentially due to the fixing of the tissue and is reported in other cases discussing formaldehyde exposure.10 Although the mechanism of inhalational injury with formaldehyde is unknown, inhalation of the vapors can result in asthma and pneumonitis and acute respiratory distress syndrome.9 None of these was evident at autopsy, but it is reasonable to presume that there might have been formaldehyde-initiated respiratory irritability before death. Ingestion, conversely, results in a combination of liquefaction and coagulation necrosis,11,12 neither of which was present in the reported case, therefore indicating minimal formaldehyde exposure via ingestion.

The primary metabolite of formaldehyde, formic acid, provides the second mechanism of injury in cases of formaldehyde exposure. Formaldehyde is rapidly metabolized, within 90 seconds of absorption into the blood, to formic acid.9 The possible toxic effects of formic acid include the following mechanisms: an enzyme inhibitor of multiple metabolic pathways, decreased blood pH resulting in metabolic acidosis, and renal tubular necrosis leading to anuria.9 Normal formic acid levels range between 0 to 12 mg/L (with an absolute level of toxicity not being reported).13 The decedent’s formic acid level was 45 mg/L, well above the reference range, indicating that systemic absorption of formaldehyde had occurred. Whether some of the formic acid production occurred postmortem cannot be stated with absolute certainty; however, because the remainder of the investigation leads to the conclusion that the decedent managed to maneuver himself into the toilet basin, it is reasonable to presume that at least some formaldehyde exposure and toxicity occurred before death.

Amphetamine is a chemical that promotes stimulation of the sympathetic nervous system. More specifically, amphetamine is a sympathomimetic amine that exerts a stimulatory effect on the sympathetic or thoracolumbar nerves to organs of the body.14 Structurally, amphetamine resembles the body’s naturally occurring stimulatory neurotransmitters norepinephrine and dopamine. Amphetamine causes increased release of norepinephrine and also blocks its reuptake by nerve endings thereby resulting in increased levels of norepinephrine that may be cardiotoxic.15 Tolerance to amphetamine occurs rapidly, thus making interpretation of results a challenge. Fatal outcomes attributed solely to amphetamine have been observed in a wide range of blood amphetamine concentrations. In a review of 17 fatalities attributed solely to amphetamine, the peripheral blood concentration ranged from 1.1 to 7.4 mg/L.16 Although it is impossible to determine the degree of tolerance to amphetamine the decedent may have acquired and despite the possibility of postmortem redistribution, the high concentration of amphetamine (13.5 mg/L) reported herein is remarkable.

Tramadol is a synthetic analog of codeine that possesses opiate-like properties. Tramadol is a mu-opioid receptor agonist that has a unique dual mechanism of action. It possesses central opiate receptor agonist activity and also exerts norepinephrine and serotonin reuptake inhibition in the central nervous system.17 Tramadol is typically considered to exhibit a lower adverse effect profile and abuse potential compared with other opiates.18 The primary metabolite O-desmethyltramadol is 2 to 6 times more potent than the parent drug and reaches peak serum level in 2 to 3 hours, allowing for a delayed onset of action.18,19 Common adverse effects reported include nausea, vomiting, constipation, and somnolence.18,20 Furthermore, in cases of poisoning, seizures, respiratory failure, pulmonary edema, coma, and liver failure have occurred.18,20 In a study that evaluated the role of tramadol and its metabolites in drug-related deaths and drug impairment, it was suggested that interactions of tramadol with other drugs might contribute to fatalities.21 Although fatal intoxication with tramadol is rare, several cases have been previously reported.18,22 The highest reported blood tramadol level for cases of tramadol intoxication alone was reported to be 15.1 mg/L.18 In a separate case of multiple drug intoxication, the highest reported blood tramadol level was 38.3 mg/L,23 at least 100 times the therapeutic range of 0.1 to 0.3 mg/L.18–20

The decedent reported in this case had a tramadol level of 140 mg/L, which is approximately 470 times the therapeutic range. In no other case could such a level of tramadol be found in the literature. It should be noted that the source for sampling was from the heart and thus was not peripheral; however, tramadol does not typically exhibit postmortem redistribution.20,24 Moreover, months after the reference laboratory value was obtained, the results were verified from a separate tube of blood and were within 20% of the reference laboratory value.

With no anatomical explanation for death but a sufficient toxicologic explanation, it would be reasonable to rule this death as simply being caused by the combined toxic effects of the several drugs and toxins identified. However, because of the unique body position and the history of an extremely hot outdoor environmental temperature, it is reasonable to consider positional asphyxia and hyperthermia as potential contributing factors in this death. Positional asphyxia occurs when mechanical respiration cannot occur because of contortion or positioning of the body.25 Environmental hyperthermia occurs when a body’s temperature-regulating capacity cannot cool the body sufficiently, the body core temperature elevates, and central nervous system and cardiac failure ensue.26,27 Neither positional asphyxia nor hyperthermia can be considered definite contributing factors in this death; nevertheless, their potential contribution to death cannot be dismissed.

In a “complex suicide,” more than 1 mechanism is applied resulting in death.28 The case presented exhibits multiple factors contributing to the decedent’s death; however, the secondary insult resulting from the constraints of the toilet basin, heat, and chemical contents of the toilet were possibly unintentional mechanisms contributing to death. Therefore, the suicide more likely represents a “complicated suicide”—the initial insult resulting in suicide (the substances ingested) allows for a secondary insult that was not originally planned as part of the suicide.28

The current case is of interest to the forensic community for a variety of reasons. The case emphasizes the importance for forensic investigators and police to be aware of unorthodox practices and paraphilias. The bizarre practices of the decedent in this case produced a scene that suggested the possibility of a homicide or an autoerotic demise. Whenever scene investigation suggests the possibility of a homicide, it is imperative that a thorough investigation be performed, including the performance of an autopsy. Careful correlation of autopsy findings and death scene investigation are essential in determining how a death may have occurred. Accurate toxicology findings can provide abundant evidence regarding not only the cause of death but also the manner of death. In the current case, the history of depression and the extremely high level of tramadol in combination with amphetamine provide a tremendous amount of evidence for suicidal overdose.

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REFERENCES

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27. Lifschultz BD, Donoghue ER. Forensic pathology of heat-and cold-related injuries. Clin Lab Med. 1998; 18 (1): 77–90.

28. Toro K, Pollak S. Complex suicide versus complicated suicide. Forensic Sci Int. 2009; 184: 6–9.

Keywords:

paraphilia; porta-potty; suicide; tramadol; transvestitism

© 2013 Lippincott Williams & Wilkins, Inc.

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