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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.forsciint.2009.09.019 Byline: Biagio Solarino (a)(b), Benno RieAelmann (c), Claas T. Buschmann (a), Michael Tsokos (a) Keywords: Tramadol; Nicotine; Multiple transdermal patches; Forensic toxicology Abstract: A fatal case of multidrug poisoning by tramadol and nicotine is reported. Tramadol is a centrally acting analgesic used in the treatment of moderate to severe acute or chronic pain. Nicotine, a lipid-soluble alkaloid, is one of the most readily available drugs in modern society. A 46-year-old man was found dead in his bed, and a suicide note was discovered near the body. He had 25 transdermal nicotine patches attached to his thorax and abdomen. Two half emptied bottles were found on the bedside table; the toxicological examination revealed that they contained tobacco and nicotine as well as other drugs such as diphenhydramine. At autopsy, areas of fresh and old myocardial infarction as well as diffuse pulmonary congestion and edema were present. The tramadol concentration was 6.6[mu]g/mL in femoral venous blood, while levels of nicotine and its primary metabolite cotinine were determined to be 0.6 and 2.0[mu]g/mL in femoral venous blood. Based on these results, we determined the cause of death to be cardiorespiratory failure induced by the additive effects of tramadol and nicotine shortly after consumption. Author Affiliation: (a) Institute of Legal Medicine and Forensic Sciences, University Medical Centre Charite, University of Berlin, Turmstr. 21, Building L, 10559 Berlin, Germany (b) Section of Legal Medicine, Department of Internal Medicine and Public Medicine, University of Bari, P.zza Giulio Cesare 11, 70124 Bari, Italy (c) Governmental Institute of Legal Medicine and Forensic Sciences, University Medical Centre Charite, Turmstr. 21, 10559 Berlin, Germany Article History: Received 26 May 2009; Revised 15 September 2009; Accepted 21 September 2009