Acetaminophen pharmacobezoar following a massive suicidal ingestion

A 61-year-old woman died in intensive care 3 days after a massive acetaminophen intoxication with suicidal intent. Investigations at the scene revealed at least 350 empty 500 mg capsule shells, whose content had presumably been consumed. A forensic autopsy, whole-body computed tomography, toxicological screening, and histopathological analysis were performed. The postmortem CT imaging and autopsy revealed a 10 × 9 × 7 cm pharmacobezoar in the gastric lumen. The formation of such a concretion is unusual for a moderately water-soluble drug such as acetaminophen. However, the massive amount of drug ingested and simultaneous alcohol consumption may have contributed to the phenomenon. Magnesium stearate, present as an excipient, may have also concurred by lowering the drug's solubility. The toxicological analysis identified a toxic acetaminophen femoral blood level of 690 mg/L, suggesting delayed absorption of the substance due to the bezoar. This case supports the hypothesis that acetaminophen pharmacobezoars may be responsible for the Bactrian (or "double-hump") pharmacokinetics sometimes observed in massive overdoses. Second, while the cause of death was attributed to acetaminophen toxicity, no liver necrosis was observed on histopathological analysis, casting doubt on the hypothesis of acute liver failure. Although the present report is limited by the unavailability of the medical records, it suggests that the intoxication may have caused death through another mechanism.