Methylenedioxypyrovalerone (“Bath Salts”),Related Death: Case Report and Review of the Literature,

Cathinone derivatives (bath salts) have emerged as the latest drugs of abuse. 3,4‐methylenedioxypyrovalerone (MDPV) is the primary active ingredient in bath salts used in this country. This article presents the second reported cause of death by MDPV intoxication alone. In April 2011, a delusional man was emergently brought to a hospital, where he self‐reported bath salt usage. He became agitated, developed ventricular tachycardia, hyperthermia, and died. Comprehensive alcohol and drug testing was performed. Using the alkaline drug screen, heart blood contained 0.7 mg/L MDPV and peripheral blood contained 1.0 mg/L MDPV. His bizarre behavior with life‐threatening hyperthermia was consistent with an MDPV‐induced excited delirium state. MDPV is not yet found by routine immunoassay toxicology screens. Testing for MDPV should be considered in cases with a history of polysubstance abuse with stimulant type drugs, report of acute onset of psychogenic symptoms, excited delirium syndrome, or presentation in a hyperthermic state.     

Sudden Death Due to Undiagnosed Rheumatic Heart Disease in a Child

We report the case of a 5‐year‐old boy who died from complications of rheumatic heart disease with atypical presentation. He was hospitalized for recent inflammatory and neurological symptoms. He was diagnosed with viral encephalitis. He died the day after he was discharged. The macroscopic autopsy findings were unremarkable. Histology revealed typical rheumatic heart disease. Neuropathology showed cerebral infarction due to an embolic event linked with the rheumatic valvulitis. The cause of death was determined as heart failure due to rheumatic heart disease secondary to an undiagnosed acute rheumatic fever. It is related to an autoimmune response to infection with group A streptococcus. It mainly affects children in developing countries. In our case, viral encephalitis was consistent with the medical history and the proper diagnosis was made on histological analysis. Forensic pathologists should consider this diagnosis facing a sudden unexpected death in childhood, even in industrialized countries.     

An unusual case of accidental poisoning: fatal methadone inhalation

In this report, the authors present a case of unusual, accidental methadone intoxication in a 40-year-old man, who had inhaled methadone powder. The drug dealer was a pharmacy technician; methadone had been stolen from a pharmacy and sold as cocaine. After having inhaled methadone powder, he suffered cardiopulmonary arrest. He was admitted to hospital where he died after 24 h of intensive care. The autopsy revealed congestion of internal organs and cerebral and pulmonary edema. Microscopically, the heart showed no changes. The toxicological analyses performed on blood and urine taken at the hospital revealed methadone, cannabinoids, and ethanol. The blood methadone concentration was 290 μg/L. The urine methadone concentration was 160 μg/L. Midazolam and lidocaine, which were administered to the patient at the hospital, were also detected in the blood. The cause of death was determined to be methadone intoxication. The literature has been reviewed and discussed. To date, and to our knowledge, only very few cases of accidental death resulting from methadone inhalation have been described up to the case presented herein.     

Post-mortem investigation of calcium content in liver, heart, and skeletal muscle in accidental hypothermia cases

The identification of hypothermia as cause of the death was always quite problematic in the field of forensic medicine. The aim of the present study was to verify the determination of calcium content in post-mortem liver, heart, and skeletal muscle samples as the biochemical marker defining hypothermia as the cause of death. The study involved 43 autopsy cases in which the circumstances of death indicated the effects of overcooling. The control group consisted of material collected from the corpses of 30 persons who were not exposed to low temperatures but died due to technical injuries (n = 5), asphyxia (n = 6), intoxication with ethanol and other substances (n = 8), and acute myocardial infarction/ischemia (n = 11). The concentration of calcium in autopsy samples was determined applying flame atomic absorption spectroscopy. Our study showed no significant differences of calcium content in tissues of persons who died due to hypothermia, over those who died in normothermic conditions.     

Sudden cardiac death in a young woman: tumor of the atrioventricular (AV) node or citalopram intoxication?

Atrioventricular (AV) node tumor is a very rare lesion of the cardiac conduction system. Clinically, it is associated with complete AV block and sudden cardiac death, often in apparently healthy young people.We report a case of a 24-year-old woman who developed ventricular fibrillation during sexual intercourse and died before admittance to the hospital. The woman had a medical history of depression and was treated with citalopram.At first, no macroscopic or microscopic pathologic changes were found. Toxicologic analysis showed a toxic level of citalopram in the blood. Further microscopic examination of the cardiac conduction system disclosed a tumor of the AV node. Immunohistochemical staining confirmed endodermal origin in accordance with the latest hypothesis of the pathogenesis of this tumor.It was concluded that this young woman died of cardiac arrhythmia due to the AV tumor and not from citalopram intoxication, as first suspected. This case emphasizes the importance of a microscopic examination of the cardiac conduction system in cases of sudden unexpected death, even in cases with a plausible cause and manner of death at first glance.     

Homicidal Poisoning in China Using Several Anesthetic Drugs

The authors describe a case of a well‐designed homicidal poisoning in China. A male was treated with starvation, intravenous fluids and antibiotics while in the hospital for acute diarrhea. He suddenly suffered from shortness of breath and subsequently died. A forensic autopsy was carried out, and several specimens were collected for toxicological screening. Propofol was tentatively identified in the blood by GC‐MS. Based on the presence of propofol in the blood, a suspect confessed that two other drugs, namely midazolam and vecuronium, were involved in this murder. Analytical drug quantification was then performed by GC‐MS and LC‐MS/MS. Blood analysis revealed the following: propofol at 0.5 μg/mL, midazolam at 0.098 μg/mL, and vecuronium at 0.10 μg/mL. These results suggest that the cause of death was respiratory depression due to the acute combined effect of several anesthetic drugs administered by the victim's companion.     

Two cases of death associated with the use of lithium carbonate

Two cases of death associated with the use of lithium carbonate are described. The first one concerns a 39-year-old man who was found suddenly dead on his hospital bed. Toxicologic analysis revealed "therapeutic" levels of lithium, nitrazepam, flurazepam, and phenobarbital. The second case involves a 54-year-old woman initially treated for acute cardiac failure and hypertension, who was finally recognized as a case of lithium intoxication; she died of cardiac arrest without evident cardiac lesions and without lithium ions in serum and urine. The medicolegal aspects of both cases are discussed, with reference to the problems of diagnosis, clinical and toxicological correlations, and the medical responsibility.     

Acute selenium poisoning: suicide by ingestion

Selenium is a ubiquitous element in the environment essential to the human diet and widely utilized in industrial processes. Fatal human selenium intoxication is rare. The authors report a case in which investigators recovered a bottle of gun-bluing agent beside a 24-year-old man. He exhibited signs and symptoms typical of acute selenium intoxication presenting with nausea and vomiting, followed by pulmonary edema and rapid cardiovascular collapse approximately 3 to 4 h after ingestion. Classic electrocardiographic (EKG) changes, which have been reported to occur in acute selenium intoxication, included sinus tachycardia with ST wave alteration. Toxicological results confirmed elevated blood and tissue concentrations. The cause of death was ascribed to acute selenium intoxication, which ensued rapidly after oral consumption. The manner of death was suicide. This case report, which presents an overview of acute and chronic selenium poisoning, underscores the value of thorough toxicologic analyses of tissue and body fluids in humans.     

Coronal cleft vertebra initially suspected as an abusive fracture in an infant

A case of a four-month-old male infant is described who was found unresponsive at home and brought to the emergency room. He lived for four days. During his hospital admission he was diagnosed by radiography with a fracture of the third lumbar vertebra that was presumed abusive in nature. Autopsy examination failed to confirm a fracture. However, a defect in the development of the vertebral bodies was discovered. He was diagnosed with possible failure of the notochord to regress, a condition with no significant sequelae. The cause of death was certified as sudden infant death syndrome after full investigation, and all autopsy studies were negative.     

Disopyramide and Mianserin Intoxication: A Unique Fatal Case – Review of the Literature

Lethal occurrence is exceptional after disopyramide or mianserin poisoning. A case of intentional lethal intoxication with these drugs was reported, as well as a review of the literature. Pre‐ and postmortem blood concentrations of disopyramide or mianserin were assessed in a woman who died from acute cardiac failure after ingestion. The premortem blood concentration of disopyramide alone was considered lethal, and a toxic premortem concentration of mianserin was observed that may have increased cardiovascular failure induced by disopyramide because the metabolism of both drugs is mediated via cytochrome P450. Moreover, it was shown that the postmortem redistribution of disopyramide was limited, as pre‐ and postmortem concentrations were 48 and 65 mg/L, respectively. As regards mianserin, redistribution was observed after death with pre‐ and portmortem concentrations at 0.23 and 0.79 mg/L, respectively. This case illustrates that if postmortem blood concentration of disopyramide is known, the premortem concentration can be deduced.     

A Rare Case of Sudden Death Due to Hypotension during Cesarean Section in a Woman Suffering from Pheochromocytoma and Neurofibromatosis

Sudden death following acute hypotension due to an undiagnosed pheochromocytoma (PHEO) is a rare event. Moreover, histopathology of the myocardium in such cases is rarely reported. We present a case of a woman who died during delivery. A 37‐year‐old parturient, who was 38 weeks pregnant, suffering from neurofibromatosis underwent a cesarean section following peridural anesthesia. Acute hypotension, acute intra‐operative pulmonary edema and supraventricular paroxysmal tachyarrhythmia occurred during delivery, followed by death. The autopsy revealed the presence of a PHEO, confirmed immunohistochemically with chromogranin‐A (CgA), CD20 antibody (L26), anti‐Keratocan antibody (KER‐1) and neuron‐specific enolase (NSE), and a PHEO‐induced cardiomyopathy. The physiopathology of both stress‐induced cardiomyopathy and PHEO‐induced cardiomyopathy, as well as the role of anesthesia in provoking the death, are discussed. The association of an undiagnosed PHEO with neurofibromatosis as the cause of sudden death in pregnancy is an obstetric urgency that raises forensic pathology issues.     

Increased risk of fatal intoxication and polypharmacy among psychiatric patients at death

Patients suffering from psychiatric disorders have an excess mortality and a shorter life span expectancy compared to the general population. Furthermore, they are treated with multiple drugs and are known to have an increased risk of drug abuse. In this study, we aimed at investigating the pharmaceutical drug and drug of abuse profiles of the deceased included in the Danish prospective autopsy‐based forensic study on psychiatric patients, SURVIVE. Using the postmortem systematic toxicological analysis results, we identified 129 different consumed compounds in our population (n = 443). Polypharmacy (≥5 compounds) was detected in 39.5% of the deceased. Deceased with a psychiatric diagnosis or who died from a fatal intoxication had significantly more compounds at the time of their death compared to having either no psychiatric diagnosis or another cause of death, respectively. Evidence of drug abuse was present, as 29.8% of our total population had consumed either methadone or illicit drugs of abuse, excluding tetrahydrocannabinol. Of those deceased with a psychiatric diagnosis, 33.6% had either consumed methadone or illicit drugs of abuse, a greater number than those without a psychiatric diagnosis. Fatal intoxication was the most frequent cause of death (40.6%) with methadone as the major intoxicant. Here, we found that those without a psychiatric diagnosis had fewer fatal pharmaceutical drug intoxications compared to the psychiatric diagnosis groups. Our findings add further context to understanding the excess mortality of psychiatric patents, since there is an increased occurrence of fatal intoxication, polypharmacy, and drug abuse in this population.     

The ultrastructural indices of the morphofunctional state of the heart in acute and chronic alcoholic intoxication

Morphofunctional myocardial characteristics in subjects who died of acute and chronic alcoholic intoxication were studied at ultrastructural level. The resulting new data enhance the level of diagnosis concerning the cause of death, the grounds of thanatogenesis. Possibilities for using the results of investigation in scientific and practical work are shown.     

Sudden Unexpected Death Due to Left Subclavian Artery‐esophageal Fistula Caused by Fish Bone

A 53‐year‐old woman was admitted to the hospital due to unexpected dizziness and died the following morning. To investigate the cause of death, a forensic autopsy along with histological examination was performed 3 days after her death. The major findings of the autopsy were that a fish bone had pierced the left subclavian artery after perforating the esophagus with 680 mL of blood in the stomach and bloody and tarry contents were present in the intestines, and the cause of death was confirmed to be subsequent hemorrhagic shock. Unfortunately, none of her family realized that she had eaten a fish 4 days before the tragedy until the fish bone was found. The present case is rare and instructive. The histopathological findings of left subclavian artery‐esophageal fistula induced by a fish bone can be used as a reference in forensic practice.     

Subaortic Pseudoaneurysm of the Left Ventricle Complicating Staphyloccal Endocarditis*

Abstract: Subaortic pseudoaneurysms are rare but can be a cause of sudden death in young individuals. This case report involves a 20‐year‐old Vietnamese male who died suddenly from rupture of a subaortic pseudoaneurysm with resultant hemopericardium with tamponade. He had a history of bicuspid aortic valve with recent but healed Staphylococcal endocarditis. A review of the literature reveals few similar cases and enlightens the association between aortic bicuspid valve, endocarditis, and subvalvular aortic aneurysm. The pathogenesis as well as recent studies that identified aneurysm predisposing genes in patients with bicuspid aortic valve will be discussed.     

Traumatic rupture of the basilar artery: report of two cases and review of the literature

Two cases of traumatic rupture of the basilar artery are reported. In the first case, severe basal subarachnoid hemorrhage (SAH) due to a complete transverse tear of the basilar artery was observed in a 53-year-old restrained male driver who was involved in a head-on collision while intoxicated and drowsy. He lost consciousness shortly after the accident and was admitted to hospital in cardiopulmonary arrest. Intensive resuscitative therapies produced cardiac response, but he died 50 minutes after the accident. The ethanol concentration in his blood and urine was 0.35 and 0.55 mg/ml, respectively. In the second case, SAH due to a similar tear of the basilar artery was observed in a 47-year-old man who received several fist blows to the face while intoxicated. He suddenly lost consciousness after the final blow and was admitted to hospital in cardiopulmonary arrest. Intensive resuscitative therapies produced cardiac response, but he died 6 hours after the event. In these cases, the mechanism of the traumatic rupture of the basilar artery is thought to be overstretching due to hyperextension of the head, and intoxication, drowsiness, or both may have interfered with the decedents' ability to protect themselves; thus, the hyperextension of the head may have been rather forceful.     

Investigations on the cause of death in a polytoxicomanic patient treated with wires and intermaxillary fixation for a chronic, infected mandibular fracture

The case of a 36-year-old male and former patient is presented who died for initially unknown reasons, with intermaxillary wire fixation for the treatment of an infected mandibular fracture still in place. The combined investigation of forensic experts and maxillofacial surgeons excluded aspiration and asphyxia as cause of death. Evidence was found for lethal methadone concentrations after intravenous drug abuse and a broncho pneumonia. Despite the clear evidence of a fatal intoxication in this case, caution must be exercised when dealing with individuals carrying intermaxillary fixation.     

A case of Ebstein's anomaly with double mitral valve

A 5-month-old male infant with no history of serious illness died suddenly and unexpectedly. He was found dead under a heavy 'futon', a coverlet, which covered the whole of his body. As it was suspected he may have been smothered, a medicolegal autopsy was performed, and it was discovered that the infant had Ebstein's anomaly with double mitral valve. The cause of death appeared to be due to heart failure caused by this congenital heart disease.     

Fatal Myocarditis Following Treatment with the PD‐1 Inhibitor Nivolumab

Therapeutic antibodies targeting the programmed cell death protein 1 (PD‐1) pathway function as immune checkpoint inhibitors, allowing the immune system to recognize tumors which otherwise escape immune surveillance. However, these agents can also elicit an autoimmune response by inhibiting the ability of non‐neoplastic tissues and regulatory cells to suppress the immune system. Here we present a fatal case of active myocarditis in a 55‐year‐old man with non‐small‐cell lung cancer which occurred following monotherapy with the PD‐1 inhibitor nivolumab (Opdivo). He presented with acute right‐sided heart failure and died 1 day after admission. Postmortem examination revealed multiple gelatinous lesions in the myocardium of the interventricular septum and the bilateral atria and ventricles which had microscopic features diagnostic of myocarditis. Subsequent studies failed to identify an infectious cause. Immune checkpoint inhibitors are an increasingly common addition to anticancer regimens and they should be considered in the evaluation of acute myocarditis.