Last performance with VIAGRA®:: post-mortem identification of sildenafil and its metabolites in biological specimens including hair sample

A 43-year-old man was found dead in a hotel room during a sexual relation with a colleague. He was treated both for cardiovascular disease and for erectile dysfunction with VIAGRA(R). A pillbox was found in the room with several tablets of verapamil (Isoptine(R)), trimetazidine (Vastarel((R)), yohimbine and bromazepam (Lexomil(R)). A box of VIAGRA(R)) 25 mg was found in his raincoat and two tablets were missing. His wife declared during the investigation that he was also treated by trinitrine. Autopsy revealed severe coronary artery sclerosis as well as signs of previous myocardial infarctions. Blood, urine, bile, gastric content and hair and representative tissues for histology were collected for toxicological analysis. Sildenafil and yohimbine were screened with liquid chromatography/mass spectrometry (LC/MS) and trinitrine with headspace injection (HS)/GC/MS. Verapamil and trimetazidine were identified and quantified with LC/diode array detection (DAD). Sildenafil was identified in blood, urine, bile and gastric content at 105, 246, 1206 and 754 ng/ml, respectively. Hair concentration was 177 pg/mg. The desmethyl metabolite was quantified in urine at 143 ng/ml. Blood concentrations of verapamil and trimetazidine were measured at 659 and 2133 ng/ml, respectively and were above therapeutic ranges. Trinitrine and yohimbine were not identified. These results confirm the absorption of sildenafil, verapamil and trimetazidine before the death and hair analysis indicates the chronic use of sildenafil. To the author's knowledge, this is the first report of a fatal sildenafil-verapamil association, probably by hypotension and cardiac dysrhythmia. (C) 2002 Elsevier Science Ireland Ltd. All rights reserved.