Dangers of Chemsex: an autopsy case report

Background

"Chemsex" is an emerging practice all over the world, sometimes fatal for its users. The victim, a 36-year-old martial arts athlete, was found lifeless lying on his back on the ground in the woods, with a rope tied around the neck, passing over the branch of a tree 2 m from the ground, the other end of the ligature being held in the dead body’s right hand. A third party (a male prostitute) was present at the time of death.

Material and methods

A forensic autopsy was performed 48 h after death, including a complete histologic examination of most organs and toxicological analyses. Blood, hair, and organs were analysed for drugs and narcotics (LC-MS/MS and GC-MS), and alcohol was determined by GC-FID.

Results and discussion

Autopsy findings showed moderate asphyxia syndrome without clear skin ligature marks, but there were deep cervical contusions. Other contusions were found including deep bruises in the dorsal area and superficial hemorrhagic infiltration of the medial surface of both wrists. Focal bruising of the tongue was found. Organs showed no significant pathology. There was a residual thymus, suggesting chronic drug addiction. Histological examination showed frank signs of hemodynamic shock. Foci of contusions found during autopsy were confirmed, showing no inflammatory reaction. Foci of granular cylinders were present in renal tubules. Heart showed focal non-specific endocardial fibrosis. Toxicological findings were the following ones: (1) peripheral blood: THC at 0.1 ng/mL, THC-COOH at 1 ng/mL, with no 11-OH-THC, indicating last use more than 12 h before death; 3-MMC, NPS-type cathinone at 960 ng/mL, a high, potentially lethal concentration; GHB (gamma-hydroxybutyric acid) at 24 mg/L, a medium concentration, but consistent with last use in the hours before death; ethanol at 0.73 g/L, a relatively low concentration, but which potentiates the toxic effects of the associated molecules. (2) Hair: 3-MMC at 1986 pg/mg, consistent with chronic use in the last few months. (3) Viscera: 3-MMC at 700 ng/mg in the brain, suggesting a cerebral distribution of this molecule. The cardio-femoral ratio of 7.6 was consistent with post mortem release from the heart and/or diffusion from the stomach and/or reservoir organs.

Conclusion

We present a case of lethal mechanical asphyxia by atypical hanging, which occurred after recent consumption of 3-MMC and GHB, which contributed to the death in a context of chemsex, which is sometimes associated with sadomasochistic practices such as strangulation. As there was a third-party present at the time of death, according to the police investigation, manner of death was undetermined, as homicide possibly by strangulation was not formally ruled out. This autopsy case illustrates the need to carefully confront police investigations with complete forensic investigations, including exhaustive toxicological analyses.