an unexpected sudden death by oral tramadol intoxication: a case not reported earlier

background: tramadol is a widely used centrally acting opioid analgesic and due to its ease of access in iran as an over-the- counter drug, reported cases of intoxication are rising. case: a 19-year-old male who was referred to our center, noor hospital, isfahan university of medical sciences, isfahan, iran, because of confusion, ataxia, agitation and an episode of seizure, followed by intentional ingestion of one hundred 100mg tablets of tramadol . on admission, he was confused, in hypotensive state, and with tachycardia. suddenly, a generalized tonic colonic seizure occurred and resulted in cyanosis and a decrease in o2 saturation. by prompt management, he improved to some extent but unexpectedly 3 hours after admission he succumbed to cardiopulmonary arrest. laboratory analysis, ecg, and postmortem pathology reports were normal. semi-quantitative toxicological analysis (by thin layer chromatography: tlc) was highly positive for tramadol, in all viscera, gastric contents and urine. conclusion: contrary to previous beliefs, tramadol poisoning might cause sudden death even in oral form. it is not long since tramadol has become widely available as a rather safe analgesic nevertheless, it seems that available data concerning its toxicity is limited and to assist physicians in anticipating unexpected situations in tramadol overdose, scrutiny into its side effects is mandatory.