Acute Bacterial Meningitis with Coincident Methamphetamine Use: A Case Report and Review of the Literature

Methamphetamine is a synthetic stimulant that can adversely affect the central nervous system and the immune system. Through various mechanisms, methamphetamine is toxic to neurons, endothelial cells, lymphocytes, granulocytes, and macrophages resulting in systemic damage. Reported is the sudden demise of an otherwise healthy 31‐year‐old woman with a history of stimulant abuse. At autopsy, acute bacterial meningitis was identified. Microbiology cultures grew a single isolate of Streptococcus pneumoniae. Toxicology was positive for amphetamine (0.13 mg/L) and methamphetamine (0.8 mg/L). The cause of death was classified as acute bacterial meningitis with methamphetamine use. Either the acute bacterial meningitis or the methamphetamine toxicity would have been sufficient to result in death; however, the concurrent pathophysiology of the two entities must be understood. A review of the current literature assesses the mechanisms of injury attributed to acute and chronic methamphetamine use, bacterial meningitis, and the synergy between the two.     

Methadone‐Related Deaths – Epidemiological,Pathohistological, and Toxicological Traits in 10‐year Retrospective Study in Vojvodina,Serbia

The number of methadone‐related deaths (MRDs) during a 10‐year period (2002–2011) in the region of Vojvodina, Serbia, was increased. The cases were evaluated according to epidemiological parameters, pathohistological findings, and toxicological screening. The majority of victims were men, aged from 20 to 38. Pathohistologically, the signs of acute focal myocardial damage were present in the heart of victims with drug abuse history shorter than 2 years, while both signs of recent and chronic focal myocardial damage were developed among victims with longer drug abuse history (2–5 years). In postmortem blood samples of 54.84% of victims, methadone was detected in combination with diazepam, both in therapeutic range. Alcohol was absent in most cases. Other detected drugs were antipsychotics and antidepressants in therapeutic concentrations. These findings raise the attention to the concomitant use of methadone and benzodiazepines with the need for further studies to clarify the mechanism of death in such cases.     

Post-mortem cases involving amphetamine-based drugs in the Netherlands: Comparison with driving under the influence cases

In this study we reviewed the post-mortem cases in the years 1999–2004 that were presented at the Netherlands Forensic Institute. The concentrations of amphetamine-based drugs in femoral blood from cases of suspected unnatural death were compared with concentrations in whole blood from non-fatal cases of driving under the influence (DUI cases) and with literature. Furthermore, the combinations with other drugs and/or alcohol were investigated. Amphetamine-based drugs were present in 70 post-mortem cases and 467 DUI cases. The most detected amphetamine-based drug was MDMA, followed by amphetamine. The presence of MDA could usually be explained by metabolism of MDMA. Methamphetamine and MDEA were rarely present. Frequently, the amphetamine-based drugs were taken in combination with alcohol and/or other non-amphetamine-based drugs such as cocaine or cannabinoids. The 70 post-mortem cases were divided into 38 amphetamine-based drug caused (i.e. the amphetamine-based drug directly caused or contributed to the death) and 32 amphetamine-based drug related deaths (i.e. death was not directly caused by the amphetamine-based drug). In the latter category, other (poly)drug intoxications and death by violence or drowning were the most frequent causes of death.In 30 cases, MDMA caused death directly. The range in blood concentrations of MDMA in these cases was substantial, i.e. 0.41–84 mg/L with a median concentration of 3.7 mg/L (n = 30). MDMA blood concentrations in the MDMA related deaths (n = 20) and in the DUI cases (n = 360) varied up to 3.7 and 4.0 mg/L, respectively. Seven victims died from the direct effects of amphetamine; the blood concentration of amphetamine ranged from 0.24 to 11.3 mg/L, with a median concentration of 1.7 mg/L (n = 7). The median concentrations of amphetamine in the amphetamine related deaths (n = 13) and the DUI cases (n = 208) were much lower, i.e. 0.28 and 0.22 mg/L, respectively. Amphetamine blood concentrations up to 6.0 and 2.3 mg/L were seen in the drug related deaths and DUI cases, respectively. The most frequently encountered amphetamine-based drugs in the investigated deaths were MDMA and amphetamine. The majority of MDMA- and amphetamine-caused deaths, i.e. 90% of these deaths, occurred with blood concentrations above 1.5 and 0.80 mg/L, respectively. MDMA and amphetamine blood concentrations in drug related deaths and DUI cases, however, overlap the range of fatal concentrations. Therefore, MDMA or amphetamine concentrations should never be used alone to establish the cause of death.     

Contributory and Incidental Blood Concentrations in Deaths Involving Citalopram

All cases presenting to the New South Wales Department of Forensic Medicine between January 1, 2001 and December 31, 2010 in which citalopram was detected were retrieved. A total of 348 cases were identified. Citalopram contributed to death in 21.0%, and was incidental in 79.0%. Cases in which citalopram was contributory to death had significantly higher blood citalopram concentrations than incidental cases (0.50 mg/L vs. 0.30 mg/L). Citalopram concentrations varied significantly by contributory status: sole citalopram toxicity (median = 1.30 mg/L), citalopram/other drug toxicity (0.50 mg/L), and incidental cases (0.30 mg/L). Citalopram concentrations also varied by suicide status, with the highest concentration found in suicides where citalopram contributed to death (0.70 mg/L) compared with 0.50 mg/L for nonsuicide cases where citalopram contributed to death. In almost all contributory cases (69/73), other psychoactive substances were also detected, most commonly benzodiazepines (47.9%), alcohol (45.2%), and opioids (40.1%).     

An Unusually High Cocaine Blood Concentration in an Impaired Driving Investigation

Cocaine is an illicit drug frequently encountered by forensic practitioners in driving under the influence of drugs (DUID) casework. Whole blood collected from a suspected drugged driver was found to contain 3.000 mg/L cocaine, 1.600 mg/L benzoylecgonine, and 0.260 mg/L methamphetamine. The high concentration of cocaine, while common in overdose death investigations, is unusual for an impaired driving case. Information from the officer revealed that the motorist swallowed cocaine during the traffic stop. Although a cocaine DUID charge could not be pursued, the blood methamphetamine concentration exceeded the State of Nevada “per se” limit for operating a motor vehicle. The motorist was successfully prosecuted for DUID based on his admission of using methamphetamine prior to driving and the blood methamphetamine result. This case highlights the importance of considering case history when interpreting laboratory results and the application of jurisdictional statutes as an approach to prosecuting suspected drug‐impaired drivers.     

Possible role of pseudoephedrine and other over-the-counter cold medications in the deaths of very young children

The Philadelphia Medical Examiners Office has reported a series of 15 deaths between February 1999 and June 2005 of infants and toddlers 16 months and younger in which drugs commonly found in over-the-counter (OTC) cold medications were present. A total of 10 different drugs were detected: pseudoephedrine, dextromethorphan, acetaminophen, brompheniramine, carbinoxamine, chlorpheniramine, ethanol, doxylamine and the anticonvulsants, phenobarbital, and phenytoin. The drugs were confirmed and quantified by gas chromatography (GC)-mass spectrometry, with the exception of ethanol, which was analyzed by headspace GC and of phenobarbital and phenytoin that were quantified by GC with a nitrogen phosphorus detector. The most predominant drug was pseudoephedrine, which was found in all of the cases (blood concentration, n=14, range=0.10-17.0 mg/L, mean=3.34 mg/L) and was the sole drug detected in three cases. Acetaminophen was detected in blood from each of the five cases with sufficient sample. Other drugs (with frequency of detection) were dextromethorphan (five cases), carbinoxamine (four cases), chlorpheniramine (two cases) and brompheniramine, doxylamine, and ethanol (one case each). In the majority of the cases, toxicity from drugs found in easily available OTC medications was listed either as the direct cause of death or as a contributory factor. The manner of death was determined to be natural in only two of the cases. This postmortem study supports previous evidence that the administration of OTC cold medications to infants may, under some circumstances, be an unsafe practice and in some cases may even be fatal. The treating physicians and the general public need to be made more aware of the dangers of using OTC cold medications to treat very young children so that these types of tragedies might be avoided.     

Quantification of Methamphetamine in Mouse Thighbones Buried in Soil

Bone samples are used for analysis of drugs in decomposed or skeletonized bodies. Toxicological analyses of buried bones are important for determining the causes and circumstances of death. In this study, methamphetamine and amphetamine concentrations in heart blood, thigh muscles, and thighbones were analyzed using solid‐phase extraction with liquid chromatography–tandem mass spectrometry. Methamphetamine concentrations in heart blood, thigh muscle, and thighbone ranged from 0.041 to 0.873 μg/mL, 0.649 to 2.623 μg/g, and 56.543 to 643.371 μg/g, respectively. Thighbone concentrations were significantly higher than those in heart blood or thigh muscles were. Methamphetamine concentrations in buried thighbone (4.010–45.785 μg/g) were significantly lower than those of unburied thighbones were (56.543–643.371 μg/g). Methamphetamine and amphetamine were detected in thighbones buried for 7–180 days. These findings indicate that the methamphetamine concentrations in bone are higher and decrease after burial in soil.     

Sudden or Unnatural Deaths Involving Anabolic‐androgenic Steroids

Anabolic‐androgenic steroids (AASs) are frequently misused. To determine causes of death, characteristics, toxicology, and pathology of AAS positive cases, all cases (n = 24) presenting to the New South Wales Department of Forensic Medicine (1995–2012) were retrieved. All were male, and the mean age was 31.7 years. Deaths were mainly due to accidental drug toxicity (62.5%), then suicide (16.7%) and homicide (12.5%). Abnormal testosterone/epitestosterone ratios were reported in 62.5%, followed by metabolites of nandrolone (58.3%), stanozolol (33.3%), and methandienone (20.8%). In 23 of 24 cases, substances other than steroids were detected, most commonly psychostimulants (66.7%). In nearly half, testicular atrophy was noted, as was testicular fibrosis and arrested spermatogenesis. Left ventricular hypertrophy was noted in 30.4%, and moderate to severe narrowing of the coronary arteries in 26.1%. To summarize, the typical case was a male polydrug user aged in their thirties, with death due to drug toxicity. Extensive cardiovascular disease was particularly notable.     

Child Fatalities in Dammam: A Call for Child Fatality Reviews in Arab Countries

Identifying children's risk exposure is the first step toward mortality prevention. This retrospective study determined the causes of child fatalities in Dammam, Saudi Arabia. Death reports of children and adolescents from 1999 to 2015 (N = 157) were analyzed. Boys represented most cases (69%) and there were two age peaks (1–5 years and 16–18 years). Accidents (typically immersion) defined the main death circumstance (51%) followed by homicide (25%). Only 33% of cases underwent autopsy, and the most common cause of death was head injury (27%) followed by firearm injury. Only one immersion death underwent autopsy. This study revealed important data about the risk exposure of children in Dammam and emphasizes deficient investigative procedures. Child fatality reviews comprise systematic data collection by multidisciplinary teams to determine the true risks toward children in a community. Such teams do not exist in Arab countries; therefore, strategies should be implemented to initiate them.     

Detection of methamphetamine in mouse femurs exposed to high temperature

Bone samples are valuable for examining the cause of death and circumstance leading up to death when body fluids are not available for forensic toxicological analysis. Examined were heat-induced changes in methamphetamine and amphetamine concentrations in femurs removed from methamphetamine-injected mice to determine if the burned bones could be used for toxicology testing. The femurs were heated at 100°C, 300°C, or 500°C for 10 or 30 min. The tissue structure of the heated femurs was preserved at 100°C for 30 min but was destructed at higher temperatures. Methamphetamine and amphetamine were detected in femurs heated at 100°C for 10 min, 100°C for 30 min, and 300°C for 10 min (with methamphetamine and amphetamine concentrations ranging from 0.36 to 35 μg/g and 0.54 to 47 μg/g, respectively). Methamphetamine and amphetamine were detectable when heated above their decomposition temperature as a result of limited heat transfer do to protection provide by the femoral muscle. Thus, the bone could be a useful analytical sample in cases of burn-related deaths, where it is difficult to collect body fluids.     

Methamphetamine and alcohol detection in vehicle-driver fatalities in South Australia: A 10-year survey (2008–2018)

Motor vehicle driver fatalities (≥18 years) from the files at Forensic Science South Australia were reviewed from January 2008 to December 2018 for cases in which either positive blood sample for methamphetamine (MA) or an illegal blood alcohol concentration (BAC) >0.05g/100 ml were found. Three hundred driver deaths were found with MA detected in 28 cases (age range 21–62 years; ave. 37.8 years; M:F 23:5). Hundred and fifteen cases with a BAC > 0.05 g/100 ml were identified (age range 18–67 years; ave 35.7 years; M:F 95:20). No change was found in numbers of MA cases, although alcohol cases showed a significant decline (p < 0.001). Drunk driving-related fatal crashes tended to occur in the evening (5 p.m. to 11 p.m.), while MA-related fatal crashes had a longer peak extending from late evening until late morning (11 p.m. to 8 a.m.). This study has demonstrated that while roadside breath testing, legislative changes, and increased monitoring have resulted in reduced levels of drunk driving, similar safety countermeasures have had negligible effects on MA use in drivers. Continued monitoring of MA use by drivers will, therefore, be necessary to assess the possible effects, or not, of new countermeasures.     

A study of drug detection in a postmortem pediatric population

At The Office of the Cuyahoga County Coroner (CCCO), Cleveland, Ohio, it is customary to perform an autopsy and conduct toxicological testing on decedents less than 19 years of age. This study provides a retrospective evaluation of drugs detected in a pediatric postmortem population between the years 1998 and 2002 (n = 730). Demographic information, cause and manner of death, and toxicological results were examined. Blacks comprised 54% of cases, males 59%, and 48% were less than one year of age or stillborn. Forty-two percent of deaths were ruled natural, 27% accident, 13% undetermined, 5% suicide, and 2% homicide. Of the 640 cases subjected to comprehensive testing, 38% of the cases were positive for at least one compound. Resuscitative/treatment drugs were detected most frequently (56% of positive results), followed by illicit drugs (26%), ethanol (11%), carbon monoxide (8%), and antihistamines (6%). Eighty-seven cases contained more than one drug. The deaths of 47 individuals were drug related (6%). In this population, it is recommended that illicit drugs and ethanol are targeted for testing, especially when limited specimens are available for analysis.     

Involvement of Amphetamines in Sudden and Unexpected Death

Abstract:  In the present study, the effects of amphetamine-class drugs were examined in cases reported to the Victorian coroner from 2001 to 2005 to determine if death can occur from the use of amphetamine-class drugs alone. A total of 169 cases were reviewed where a forensic autopsy detected amphetamine(s) in the blood. Pathology, toxicology, and police reports were analyzed in all cases to ascertain the involvement of amphetamine-class drugs in these deaths. In Victoria, methamphetamine (MA) is the principal abused amphetamine-class followed by methylenedioxymethamphetamine (MDMA). There were six cases in which a cerebral hemorrhage caused death and three cases in which serotonin syndrome was established as being caused by the interaction of MDMA and moclobemide. There were 19 cases in which long-term use of amphetamines was associated with heart disease. There were three cases where amphetamine-class drugs alone were regarded as the cause of death, of which two cases exhibited high levels of MDMA and lesser amounts of MA and/or amphetamine. There were no cases in which significant natural disease was absent and death was regarded as caused by the use of MA. There was no correlation between blood concentration of drug and outcome.     

Fatal Diabetic Ketoacidosis—A Potential Complication of MDMA (Ecstasy) Use

A 19‐year‐old woman with insulin‐dependent diabetes mellitus was found dead in bed having allegedly recently taken ecstasy and consumed alcohol. At autopsy, there were microhemorrhages in the brain with subnuclear vacuolization and Armanni–Ebstein changes in renal tubules. Biochemical analyses confirmed diabetic ketoacidosis (vitreous glucose—46.5 mmol/L; β‐OH butyrate—13.86 mmol/L.). Toxicological analyses of blood showed a low level of 3,4‐methylenedioxy‐methamphetamine (MDMA) (0.01 mg/L), with acetone but no alcohol or other common drugs. Death was attributed to diabetic ketoacidosis most likely provoked by mixed MDMA/alcohol ingestion. Although the use of illicit drugs by young individuals with diabetes mellitus is being increasingly recognized, it has been noted that there is minimal information about the relationship between drug use and acute diabetic complications. Toxicological screening of cases of lethal diabetic ketoacidosis in the young may clarify lethal mechanisms in individual cases and also help to determine the extent of this problem.     

Methamphetamine-related deaths in San Francisco: demographic, pathologic, and toxicologic profiles

A study was undertaken to develop demographic, toxicologic, and pathological profiles of methamphetamine-related deaths. Anatomic and toxicologic findings in 413 deaths where methamphetamine was detected were compared with findings in a control group of 114 drug-free trauma victims. The number of cases per year did not change significantly over the course of the study. Mean age was 36.8 years, but 11% were over the age of 50. Decedents were overwhelmingly male (85.2%) and Caucasian (75%). Blood concentrations of methamphetamine and amphetamine were indistinguishable in cases where methamphetamine was related to the cause of death (MR) and cases where it was not (non-MR) (2.08 vs. 1.78 mg/L, p = 0.65, and 0.217 vs. 0.19 mg/L, p = 0.82). Coronary artery disease, ranging from minimal to severe multivessel, was identified in 79 of the 413 drug users, but in only six of the 114 drug-free controls (p = 0.0004), and MR decedents had enlarged hearts compared with controls. There were also ten cases of subarachnoid and intracranial hemorrhage in the MR group. Abnormalities of the liver (34%) and lungs (24.7%) were frequent. In 65% of these cases, death was due to accidental methamphetamine toxicity. In the remaining cases, methamphetamine was an incidental finding. We conclude that, in our jurisdiction, neither the rate of detection nor the number of methamphetamine deaths has increased significantly in the past 13 years. Decedents are almost all Caucasian males, and many were approaching middle-age. Methamphetamine use is strongly associated with coronary artery disease and with subarachnoid hemorrhage.     

Classical stimulants in Dallas County: A retrospective review of toxicological,seized drug,and demographical data from 2017 to 2022

Cocaine and methamphetamine remain highly abused drugs in the United States due to their euphoric effects. This study examines classical stimulant casework, defined as cases positive for methamphetamine and/or cocaine, received by the Toxicology Laboratory and the Drug Analysis Laboratory at the Dallas County Southwestern Institute of Forensic Sciences from local law enforcement agencies and/or the Office of the Medical Examiner (OME) between January 1, 2017, and December 31, 2022. Methamphetamine positivity increased from 10.4% to 20.3% in the Toxicology Laboratory over the 6 years, whereas cocaine positivity remained relatively stable at approximately 17%. Similarly, in the Drug Analysis Laboratory, the methamphetamine positivity rate changed from 24.8% to 33.2%, whereas cocaine identification remained stable at approximately 20%. Blood concentrations of methamphetamine in OME cases ranged from 10.1–42,740.0 ng/mL while they were lower in DWI casework ranging from 10.2–2385.0 ng/mL. The blood concentration trends of cocaine were similar to methamphetamine, with OME casework ranging higher (10.0–24,501.0 ng/mL) than DWI casework (10.2–371.6 ng/mL). Polydrug use was evident for both methamphetamine and cocaine in postmortem cases, and the top three most frequently co-occurring drug/drug class were opioids/opiates, cannabinoids, and ethanol. The results from this study aid in the understanding of historical usage trends of cocaine and methamphetamine in Dallas County and how those trends have changed over time as newer stimulant drugs have emerged.     

Suicide by Self‐Administration of a Drug Mixture (Propofol,Midazolam, and Zolpidem) in an Anesthesiologist: The First Case Report in Italy

The authors report an unusual case of suicide of an anesthesiologist, in which the suicide manner and means depend upon the victim's occupation. This is the first case report published in Italy of a death involving propofol and other drugs. The anesthesiologist was found dead with an empty drip still inserted in the hand and another one near his body. Forensic and toxicological findings suggested that the cause of death was a respiratory depression due to a self‐administration of a rapidly infused lethal drug mixture. Analytical drug quantification was performed by gas chromatography‐mass spectrometry. Blood analysis revealed: zolpidem (0.86 μg/mL), propofol (0.30 μg/mL), midazolam (0.08 μg/mL), thiopental (0.03 μg/mL), and amitriptyline (0.07 μg/mL). Adipose tissue and hair analysis suggested a previous and repeated use of these drugs verifying the fact that in Italy recreational abuse of anesthetic and sedative agents in health care practitioners is becoming an increasing problem.     

Undetermined Manner of Death: An Autopsy Series

A manner of death may be ruled undetermined by the forensic pathologist when there is insufficient information about the circumstances surrounding the death to make a ruling. The aim of our study was to retrospectively analyze a series of autopsy cases that were classified as undetermined manner of death after complete investigations. In all, 48 cases were examined. In 23 cases (48%), the cause of death was determined. The most frequent cause of death was toxic death (n = 11). More than one manner of death was deemed conceivable for most cases (n = 39). The most frequent and the most probable manner of death was accident (n = 37). Homicide was not excluded in about 23% of the cases. Our study showed that the manner of death may remain undetermined despite an established cause of death, and even when two or more conceivable causes of death are considered. Our study pointed out that undetermined manner of death covers a wide range of situations and that homicide may be underestimated.     

The impact of fentanyl on DUIDs and traffic fatalities: Blood and oral fluid data

Fentanyl has emerged as the most prolific drug in the ongoing opioid epidemic and has greatly impacted traffic safety in recent years. This study aimed to evaluate fentanyl prevalence and concentrations in blood and oral fluid in driving under the influence of drugs (DUID) cases in three different regions (i.e., Alabama, Orange County, CA, and Houston, TX) from 2017 to 2022. Furthermore, traffic fatalities were evaluated for Alabama and Orange County, CA. Fentanyl positivity in DUID and traffic fatalities increased for most years in this study. In Alabama, the prevalence of fentanyl DUID cases increased 4-fold in 2022 compared to 2017. Orange County's increase from 2017 to 2022 was 14-fold. In Houston, the increase was approximately 2-fold from 2019 to 2022. The greatest increase for all laboratories coincided with the start of the COVID-19 pandemic. In 2022, the median fentanyl DUID blood concentrations were 4.7, 11, and 4.7 ng/mL in Alabama, Orange County, and Houston, respectively. Most fentanyl cases were polydrug cases (≥90%). Methamphetamine, THC, and alprazolam were the most frequently detected drugs in combination with fentanyl. Alabama has collected oral fluid and blood in DUID cases since 2018. The detection of fentanyl in oral fluid was comparable to blood. However, 59% and 8.7% of fentanyl-positive cases had concentrations of >20 ng/mL in oral fluid and blood, respectively. Therefore, oral fluid as an alternative or supplemental specimen to blood is an attractive approach for fentanyl in DUID cases. This study contributes to understanding recent fentanyl trends and their impact on traffic safety.