Vomiting, diarrhea, and sudden death with recent Southeast Asian travel: Fatal colchicine toxicity

A 41-year-old male was referred for autopsy from a hospital with a diagnosis of sepsis of uncertain etiology. As he had recently been attached to a military base in Southeast Asia, and had only just returned home, there was considerable concern that an unknown infectious agent may have been involved, which would necessitate screening of coworkers and contacts, with possible quarantine of the facilities where he had been working. His clinical history included a day of vomiting and diarrhea. Despite rehydration and antibiotic therapy, he died within hours of hospitalization. His only past medical history was of gout, for which he was prescribed allopurinol. At autopsy there was evidence of multiorgan failure but no focal sepsis. Postmortem microbiological tests including blood cultures, lung swab, colonic fecal culture, and a small intestinal swab were negative. Histological examination of small intestinal mucosa demonstrated numerous mitotic figures, which, in concert with the presentation, raised the possibility of colchicine toxicity. Subsequent reinterview of family members confirmed that the deceased had ingested an unknown quantity of colchicine on the day prior to his illness and toxicological evaluation demonstrated a toxic/potentially lethal level of 0.05 mg/L of colchicine in the blood. Death was therefore attributed to colchicine toxicity and not to occult sepsis. This case clearly demonstrates that causes of gastrointestinal illness other than sepsis need to be considered when patients have presented with vomiting and diarrhea. There may also be considerable public health implications if a death is incorrectly attributed to sepsis and then a specific infectious agent is not identified. Maintaining a broad approach to diagnostic possibilities is essential if forensic practitioners are to maintain a useful role in the investigation of unexpected deaths.