Cybersuicide with “homemade Valium”

To the Editor:

The use of the Internet to research methods for committing suicide “cybersuicide” has been well described.¹,2 Many websites, chat rooms, and blogs contain information advocating the use of a variety of substances ranging from ubiquitous compounds, like acetaminophen, to more esoteric substances such as helium and hydrogen sulfide. Cases of successful suicide utilizing such obscure methods have recently been published.³,⁴ We report an unusual case of reported cybersuicide involving “homemade Valium”.

A previously healthy, 30-year-old female graduate chemistry student of Chinese descent text-messaged a friend that she had taken 40 g of “homemade Valium” in a suicide attempt at an undetermined time the previous night. By the time, emergency services responded to her residence, the patient was found unconscious and was immediately transported to an emergency department.

Upon arrival, the patient experienced asystolic arrest and was successfully resuscitated. However, despite being treated with aggressive supportive care including mechanical ventilation, fluid resuscitation, and multiple vasopressors, her clinical status deteriorated and she expired on hospital day 2. Flumazenil was not administered.

Examination of the decedent's home and personal effects revealed an unlabeled baggie of white crystalline powder. She appeared to have consulted an online Chinese translation of the book The Complete Manual of Suicide. In the text, the suggested lethal dose of bromisovalum is 20 g which is noteworthy because the decedent stated that she ingested “40 g” or twice the reported lethal dose. The decedent's laboratory and work computer were examined, but there was no evidence of her either obtaining or synthesizing the drugs themselves or their precursors.

Postmortem femoral blood and a sample of the powder were sent to a reference laboratory where they were analyzed via spectrophotometry for acidic, basic, and neutral drugs, volatile substances, and cyanide. Because bromisovalum is not commercial availability in the United States (US), the referral laboratory initially had no reference standard for bromisovalum and it took approximately 9 months for the toxicology results to return. They revealed only the presence of bromisovalum and lorazepam and the unknown powder was confirmed to be bromisovalum.

Bromisovalum (bromoisovalerylurea, bromvalerylurea) is a brominated sedative–hypnotic agent that has been available both by prescription and over-the-counter outside of the US since 1908.⁵ Acute poisonings have rarely been described and life-threatening symptoms have been attributed to a failure of the circulatory system⁶ and are consistent with what was seen in our patient.

While it was not determined how the bromisovalum and lorazepam were obtained or the relative contributions that each played in the death of our patient, it is clear that an internet resource on suicide influenced her choice to use an obscure substance to end her life. This case is a reminder that varieties of Internet suicide resources with detailed information are readily accessible and may result in healthcare providers managing unusual self-poisonings.