Fatal fluoxetine intoxication with markedly elevated central blood, vitreous, and liver concentrations

Since being introduced into clinical practice 20 years ago, fluoxetine, a serotonin-reuptake inhibitor, has remained one of the most popular antidepressants prescribed in the United States. Upon reviewing the literature, the highest reported postmortem central blood fluoxetine and norfluoxetine concentrations are 22 and 6.8 mg/L, respectively, and reported liver fluoxetine and norfluoxetine concentrations are 29-128 and 17 mg/kg, respectively. A 31-year-old female with convulsive activity was found at home by her husband. Emergency services was contacted, and responders found the patient unresponsive with agonal respirations, a pulse of 20 bpm, and no measurable blood pressure. Despite all resuscitative efforts, the patient expired. Postmortem analyses revealed concentrations of 33 mg/L fluoxetine and 12 mg/L norfluoxetine in central blood and 400 mg/kg fluoxetine and 460 mg/kg norfluoxetine in liver. Vitreous fluoxetine and norfluoxetine concentrations were 5.2 and 2.2 mg/L, respectively. Utilizing a sensitive and specific analytical procedure, we report the highest recorded central blood and liver fluoxetine and norfluoxetine concentrations.