Case 39

This 18-month-old girl was found dead in bed in the morning. The toddler lived with her biological mother and the latter’s boyfriend, not her father. The child was in the care of the boyfriend since her mother worked at night. He claimed to be unaware of anything amiss when the mother came in from work in the morning. Emergency medical services was called when she did not awake in the morning, but it was apparent that there was some rigidity and lividity. No prolonged resuscitation was attempted. Weight was 9.2 kg (less than fifth percentile) and height was 73 cm (less than third percentile). During autopsy, there was no evidence of injury externally or internally. No pathologic evidence of disease was identified (Images 39a and 39b). Toxicology testing from peripheral blood revealed morphine (130 ng/mL) and was also positive for quinine, nicotine and caffeine. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig39a.jpg"/> https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig39b.jpg"/>

What is significant about the toxicology results?

What is the source of the morphine?

What are the cause and manner of death? What is the mechanism of death?

What else may be inferred from the data presented here?

90The most significant finding is the confirmed blood concentration of morphine. It is rare for children of this age to receive morphine for medical reasons. This is a high morphine concentration even when considering post-mortem redistribution (the main cause of the change on a drug concentration post-mortem, often causing drug concentrations to rise) since the specimen was from peripheral blood. There was no documented prescription for morphine and it is safe to assume the child was not previously exposed to opiates. It is also rare to find positive results for caffeine, nicotine and quinine. There was no medical indication for quinine in this child, and the source must have an explanation.

The most likely source of the morphine in the toxicology result is from a by-product of heroin metabolism until proven otherwise. Quinine is an antimalarial agent often used to cut heroin and when found with morphine, this points to heroin as its source. Heroin and its immediate metabolite, 6-acetylmorphine, have very short half-lives but are highly lipid soluble and readily penetrate the blood-brain barrier. The active metabolite of heroin is morphine. It is common to find only morphine in post-mortem toxicology analysis after heroin use and the source can be further confirmed by looking for cutting agents.

The cause of death is acute opiate intoxication. Because this child must have had heroin administered to her, the manner of death was certified as homicide in the absence of any definitive evidence of accidental ingestion. Questioning of the adults in the home disclosed the male had a history of heroin abuse, but he denied having any in his possession on the night this toddler died. The mechanism of death is suppression of respiration by morphine. The effect is probably more intense in naïve users of narcotic analgesics, such as this child.

This toddler was also the victim of neglect. Her height and weight were low, but her parents were adults of average size and weight. The nicotine in the blood most likely originated from indirect exposure to tobacco smoke. The use of drugs to control children has been documented in the literature. ¹