A 44-year-old woman with a past medical history of ethanol abuse, anorexia, and suicidal ideation was found unresponsive in bed at home. Emergency medical services were summoned but resuscitation efforts were unsuccessful. Although she had been prescribed medications for the treatment of bipolar disorder, she was known to be noncompliant and was extraordinarily secretive about her medical and psychiatric conditions. When interviewed, her husband reported that she had threatened to commit suicide on multiple occasions in the recent and remote past but had never described a specific plan to do so. At autopsy, examination of her gastric contents revealed approximately 200 mL of gray-brown, semi-digested liquid and multiple clumps of white, light-blue, green, minty-smelling material weighing 72 g in aggregate.
The light-colored material was grossly identified as toothpaste. Toxicologic analysis of the decedent’s femoral blood revealed toxic concentrations of quetiapine, topiramate, and diphenhydramine. The identification of toothpaste among the gastric contents spurred a request for specialty testing for fluoride of the submitted samples. A concentration of 230.0 mg/L was quantified in a femoral blood sample (normal reference range .01–.2 mg/L). Cause of death was certified as “acute toxicity due to the combined effects of fluoride, quetiapine, topiramate and diphenhydramine,” and her manner of death was certified as suicide.
Most cases of lethal fluoride toxicity are accidental and involve the ingestion of insecticides or rodenticides. However, fluoride is directly cardiotoxic in large quantities through dysrhythmias, causes respiratory paralysis, and can lead to multiorgan failure. Detection of lethal fluoride toxicity requires a high index of suspicion because it is not among those substances included in the standard or extended drug screening panel used for medicolegal autopsies.