Forensic Science International 149 (2005) 289291 www.elsevier.

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Interpretation of postmortem alcohol concentrations

Sotiris Athanaselis, Maria Stefanidou*, Antonis Koutselinis
Department of Forensic Medicine and Toxicology, School of Medicine, University of Athens, Mikras Asias Str., Athens 115.27, Greece Accepted 14 April 2003 Available online 1 October 2004

Blood alcohol concentrations (BACs) are regularly used as evidence in criminal and civil litigation. The forensic toxicologist is frequently asked, during his routine work or during court testimony, to give an expert opinion on the question as to whether alcohol concentrations measured in postmortem blood represent alcohol ingested prior to death or were formed postmortem [14]. The interpretation may be critical to the thorough investigation of different kind of forensic cases, like driving under inuence, homicides etc. When putrefaction has occurred, one must exercise extreme caution in interpreting alcohol levels obtained by analysis of such putrid samples. During the putrefactive process alcohol may be lost due to evaporation or produced by microbial activity, primarily on glucose and to a lesser extent on lactate, amino or fatty acids [5,6]. The alcohol production may occur either in the intact body between death and autopsy or in vitro in body uids, especially blood, collected at autopsy. If the body had been kept at a low temperature, no postmortem alcohol production takes place during the rst 24 h (approximately) [7]. The alcohol concentration in heart blood collected from a cadaver does not always show the concentration at the time of death. Postmortem production of alcohol occurs in a putried cadaver, as already mentioned or postmortem diffusion of alcohol from the stomach contents may occur in cases where stomach alcohol concentration (SAC) is much higher than BAC [8]. In any alcohol related case there are three possibilities:

1. The death occured immediately after drinking and BAC and SAC are due only to drinking. 2. SAC is due to postmortem production (food fermentation) and BAC is due to postmortem production and/or postmortem diffusion. 3. BAC and SAC are due to a combination of drinking and postmortem production. Thus, in order to interprete correctly the detected BAC and SAC and especially if putrefaction is present, it is recommended that, in addition to blood and stomach content, several different specimens should be collected and analyzed for alcohol, such as vitreous humor, bile, synovial uid, cerebrospinal, chest or intra-abdominal uid, inner ear uid and/or urine [2,3,917]. These body uids are isolated and protected in different body cavities with rm tissue structures and are less subject to putrefactive changes due to bacterial propagation or alcohol diffusion. Unfortunately, the above-described uids are not always available for analysis. Something important to be kept in mind is that bleeding from injured liver containing a high concentration of ethanol or peritonitis (microorganism contamination) due to an abdominal stab wound can give signicant alcohol concentrations in the intraperitoneal uid that are produced even in a living body and can be detected postmortem even in a living body and can be detected postmortem even if no signs of putrefaction exist. If the victim had been hospitalized and glucose was administered antemortem or blood transfusion took place, these concentrations can be signicantly higher than the respective BACs [17]. Blood sampling by cardiac puncture from outside the chest wall, where inadvertent puncture of the stomach can take place, or withdrawal of pericardial uid or chest uid

* Corresponding author. Tel.: +30 210 746 2415; fax: +30 210 770 6868. E-mail address: mstefan@med.uoa.gr (M. Stefanidou).

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which may contain higher concentrations of alcohol than were present in the blood at the time of death because of diffusion from the stomach can be a real problem. In such cases where doubts exist, during the interpretation of the results of alcohol analysis, the values obtained for BAC should be substantiated by analysis of alternative to blood specimens, as described above [18]. To these alternative testicles [19] and uid from putrefactive blisters [4] should also be added. The difculties in the interpretation of a BAC found are more profound when the body has signs of putrefaction and the determined blood alcohol concentration is low. According to older literature, advanced putrefaction may give production to alcohol levels as high as 200 mg/dl. In the experience of these authors, quantities greater than 60 mg/dl are rarely encoutered due solely to postmortem production, and any greater than 120 mg/dl is assumed to have resulted from antemortem alcohol consumption [5,20]. Zumwalt et al. [10] examined the uids of 130 putreed bodies for the presence of alcohol. The degree of putrefaction was specied in the study and characterized by an objectively dened putrefaction score, SMELLBAD. This study concluded that alcohol should be considered as endogenously produced when alcohol concentrations of equal to or greater than 10 mg/dl are detected in blood or chest uid but not in vitreous humor or urine. Decomposing uid from the chest will commonly contain alcohol, so it is not a reliable specimen to test to determine if alcohol ingestion has occurred. However, concentrations higher than 150 mg/dl may be suggestive for ingestion [15]. A review of the circumstances of each case might provide information to facilitate interpretation of the analytical ndings. A hospital blood sample with a positive antemortem blood alcohol or witnessed drinking clearly indicate alcohol consumption prior to death [12]. Cases where the deceased was diabetic should be examined with extreme caution, since the combination of high glucose in blood and microorganisms can cause the production of large amounts of alcohol in blood or urine. In such cases, the assumption is that the detection of alcohol in vitreous humor and urine indicates antemortem consumption and not post mortem formation of alcohol. Glucose is present in the vitreous humor but microorganism contamination of the uid is limited during the early stages of the decomposition process. In healthy individuals, urine contains no glucose. Urine should also be free of microorganism contamination. Only one report exists in the literature concerning in vitro formation of alcohol in urine of a diabetic patient infected with Candida albicans [21]. In every other case, if the individual was in the absorptive phase, the pattern that is expected is a BAC higher than the alcohol concentration in vitreous humor which would be higher than the respective concentration in urine [12]. According to more recent literature, specic difculties arise when BAC is less than 40 mg/dl. In such cases, in the

absence of alternative specimen or historical information, one can reasonably predict that a blood alcohol concentration of 40 mg/dl resulted from alcohol consumption [12]. Values less than 10 mg/dl were reported as negative, while values between 10 and 40 mg/dl were considered to correspond to real blood values, at least when advanced putrefaction is excluded [4]. All body tissues can form alcohol postmortem and the amounts formed in organs are usually greater than those in blood. A good indication of putrefactive processes in tissue is the presence of other C3 alcohols and especially n-propanol [15,22]. A concomitant determination of n-propanol in blood or tissues can distinguish between cases in which alcohol was formed postmortem and those in which it was present antemortem [23]. In badly decomposed bodies, muscle tissue is likely the optimal specimen for alcohol analysis due to its low liability for postmortem production of alcohol in comparison with other body organs. The postmortem production of ethanol is signicantly higher in blood than in muscle, whereas the production of npropanol is essentially equal in both tissues. It has been claried that the ratio of the concentration of endogenous ethanol to that of n-propanol is less than 10:1 in muscle and less than 20:1 in blood [17]. Another complicated problem in alcohol analysis is the previous embalming of the bodies. In cases involving investigation of death after disinterment or after the transport of the corpse from the location of death to the location of burial, it is impossible to avoid an embalming process. It is assumed that the chemical constituents of embalming uid may diffuse in vitreous humor, bile or urine after the body has been embalmed. Fortunately, almost all commercial embalming uids are free of ethanol, although most of them contain methanol [14]. In such cases, it is imperative that a sample of any embalming uid used in preparing the body for burial be used as control should any positive result be obtained. A positive result for alcohol in vitreous humor and urine indicates antemortem consumption and not postmortem alcohol production [12], although a case is described where the embalmer cleaned the globus of the eye with ethanol in a cotton swab prior to placing the eye cap into position and this caused a postmortem elevation of vitreous ethanol from 0 to 340 mg/dl [24,25]. Due to all the above-described reasons, alternative samples should always be collected during autopsy and analyzed for alcohol in order to safely and correctly verify the antemortem consumption of alcohol. It must always be kept in mind that severe damage of the body often exposes specimens to microorganisms that can produce alcohol under proper circumstances. Thus, part of the determined alcohol concentrations or the total of them can be due to endogenous production [6]. The interpretation of the signicance of the analytical results of blood, urine, bile, vitrous humor, synovial or cerbrospinal uid must always take place with extreme

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caution and always taking into account the autopsy ndings, the circumstances of death and the recent history of the descendent. Two people are not biologically equal, so two corpses do not have the same potential ethanol production [10]. In any case, as Pounder and Jones [14] state, to attempt to interpret the signicance of an alcohol level in a single and sole autopsy blood sample, without additional information, analytical or not, is to invite a medico-legal disaster.

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