To affirm illicit drugs and alcohol intoxication as the cause of death is very difficult for forensic pathologists. As a result, rhabdomyolysis eventuating in acute renal failure can help forensic pathologists to ascertain that the cause of death should be from illicit drugs and alcohol intoxication. As seen from many studies, various clinicians have indicated that drugs and alcohol are frequent causative agents in patients who develop rhabdomyolysis (Hohenegger, 2012; Ishigami et al., 2003; Welte et al., 2004; Richards, 2000; Melli et al., 2005).
The mechanism from using illicit drugs and alcohol has both a direct effect on the myocyte function or an indirect effect that predisposes the myocyte to develop injury (Richards, 2000; Melli et al., 2005; Curry et al., 1989). The direct effect is altering the calcium ion in the sarcoplasmic reticulum which causes the impairment of muscle adenosine triphosphate production (Richards, 2000; Melli et al., 2005; Curry et al., 1989; Pasnoor et al., 2014). This can cause a rupture in the cell membrane and a creatinine kinase leakage (Richards, 2000). Furthermore, the body’s thermoregulatory mechanisms of heat production may fail, and the myocyte would not be able to maintain its function after using some drugs like stimulants (Ishigami et al., 2003; Liapis et al., 2016; Welte et al., 2004; Schulz et al., 2012; Winek et al., 2001; Richards, 2000; Melli et al., 2005; Curry et al., 1989; Pasnoor et al., 2014). There are several drugs that induce injury from the hypermetabolic mechanism including antipsychotics. Other stimulants like ketamine hydrochloride, as well as phencyclidine, can produce agitation and prolonged muscular activity that may contribute to muscle damage (Pasnoor et al., 2014).
This research showed rhabdomyolysis in the intoxication death group (study group) in which all were caused from drugs and ethanol-induced because all cases were selected by strict criteria. First, the illicit drugs and ethanol level displayed the toxic level or multiple illicit drugs in the blood. Then, the cases which had a history of infection or exertional activity before death were excluded. The trauma cases, which could induce a major cause of rhabdomyolysis (Zutt et al., 2014), were placed in the control group.
In the positive cases of the study group, the most common substance detected in the blood was ethanol like the previous study about drug and toxin-induced rhabdomyolysis (Curry et al., 1989).
Ethanol can cause rhabdomyolysis from a direct and secondary effect. The main mechanism in short-term alcoholic intoxication can alter the mental status, result in loss of consciousness, and sedation that can lead to prolonged immobilization and muscle compression. On the other hand, long-term alcohol consumption can present a history of poor nutrition, hypokalaemia, and hypophosphatemia, which can predispose the patient to rhabdomyolysis (Qiu et al., 2004; Papadatos et al., 2015).
The second most substance is opioids in which consumption can cause a prolonged phase of unconsciousness until developing pressure-induced necrosis of the muscle. If the position is maintained for a long time, the necrosis that develops will be high (Welte et al., 2004).
The next substance detected is methamphetamine. It stimulates sympathetic mechanisms to increase catecholamines, which induce muscular hyperactivity and severe hyperthermia and prolonged seizures. All of this can cause rhabdomyolysis (Ishigami et al., 2003; Welte et al., 2004; Pasnoor et al., 2014).
Compared with the control group, about 60% of the study group had rhabdomyolysis, which was significantly higher than the control group at 20%, although both groups were detected with toxic levels. This emphasized that detection of rhabdomyolysis in the cases that had no definite cause of death to be useful in concluding that death was a result from drug intoxication-induced rhabdomyolysis.
Various studies about rhabdomyolysis from drug-related deaths have been found in the forensic aspect. For example, Welte and Bohnert’s study about the prevalence of rhabdomyolysis in 103 drug death cases in Germany in 2004 found rhabdomyolysis in 51 cases (50%) that was a higher number than the control groups (10%) (Welte et al., 2004). The diagnostic test for rhabdomyolysis applied the same method. Thus, this was a very useful diagnostic test in the autopsy case whereby there may be no other specimen like urine or blood.
In addition, Kock and Simonsen detected 20% of renal myoglobin from 62 drug addicts (Kock et al., 1994). A number of cases were detected with a lower level that may be due to the fact that the study cases were chronic drug addicts. As such, the cause of death may not be from the direct effect of the drugs. Unlike this research, selected cases that have toxic levels of drugs can produce rhabdomyolysis.
In the cases that only ethanol was found, rhabdomyolysis in the study group was significantly higher than the control group. Four of eight positive myoglobin cases had an ethanol level greater than 150 mg% but not more than 200 mg%, which was the cause of obvious intoxication with nausea or a staggering gait, but no symptoms of stupor or coma. The remaining cases were found with an ethanol level greater than 200, but they did not have more than 350 mg% in which there was no respiratory center paralysis (Saukko & Knight, 2016). This emphasizes that the ethanol levels of 150–350 mg% could be the cause of death. In addition, one previous research found rhabdomyolysis in cases with 222 mg% of ethanol as well as diphenhydramine (Haas et al., 2003), but in the current study, only ethanol was found. However, ethanol metabolism depends on many factors and the multiple pathways of ethanol metabolism; therefore, the pathologist needs to evaluate each case.
The researchers of the present study also found multiple drug use but no quantitation in seven out of 17 cases. There were many types of substances found, which could cause death. Thus, the detection of rhabdomyolysis helped to confirm the cause of death, although there was no quantitation.
From Table 7, the current researchers also found that six out of the 12 cases had a history of drug addiction or heavy alcohol drinking. This means that rhabdomyolysis was not necessarily specific in people who used drugs or alcohol regularly. This supported the prevalence of rhabdomyolysis in this study more than Kock and Simonsen’s study (Kock et al., 1994) about drug addicts.
The researchers also established that there was a history of drinking alcohol before death in only four of eight cases and only two out of eight cases with a history of drug use before death. This showed that the history and circumstance of death that indicated death from drug intoxication were often very rare. Therefore, the detection of rhabdomyolysis helped to find the cause of death in the absence of this section.
