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Murder by poison is not confined to history and detective fiction. The case reported here highlights the need at least to consider foul play in a patient who has symptoms compatible with toxicity and in whom no firm diagnosis has been made. Case reportA previously healthy 46 year old man was admitted to hospital with a four week history of illness. He complained of a sudden onset of profuse watery diarrhoea and vomiting. This had subsided after one week but returned a week later. The second episode was more severe-and accompanied by abdominal cramps and loss of weight. He gave no relevant medical history and had never been abroad. He was a divorcee now living with his girlfriend.On admission physical examination yielded normal results, though a strong odour of garlic was noticed on his breath. Haematological and biochemical investigations yielded normal results. No pathogenic organisms were isolated on repeated examination of stool samples. Shortly after admission his scalp hair began to fall out. Four days later, however, his bowel motions were normal, his vomiting had stopped, and he was putting on weight. He was discharged from hospital feeling quite well but was readmitted two weeks later with a recurrence of his symptoms. His alopecia was quite distinct, and he was found to have a purple-red discolouration at the base ofhis fingernails and toenails. He was also dehydrated and mildly jaundiced. The table shows the results of investigations. He was rehydrated with intravenous fluids, and once again his symptoms resolved and he was eating normally within two days. Sigmoid biopsy specimens showed a mild non-specific inflammation of the colonic mucosa. A barium enema and a barium meal and follow through examination both yielded normal results.A dermatological opinion was sought on the changes in his nails and hair. These were considered to be a response to severe illness. His gut hormones were screened to exclude a tumour that was secreting hormones, but concentrations were normal. Two weeks later he felt quite well again and was discharged. He was readmitted after three days with an acute recurrence of identical symptoms.At this time the question of criminal poisoning was raised with the patient. Although he dismissed this possibility and could think of no one with sufficient motive, samples of blood and urine were sent to Guy's Hospital for measurement of arsenic and thallium concentrations (thallium causes alopecia and nail dysResults of general investigations in man later thought to have been poisoned with selenium Concentration

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