Cocaine‐Induced Intracerebral Hemorrhage in a Patient with Cerebral Amyloid Angiopathy*

Abstract: Intracerebral hemorrhage (ICH) is a well‐recognized complication of recreational cocaine use. The precise mechanism of the cocaine‐induced hemorrhagic event is unclear, although multiple factors have been implicated. We report a case of a 62‐year‐old woman who suffered left parieto‐occipital ICH with herniation and death, following a cocaine binge. Microscopic examination also revealed extensive cerebral amyloid angiopathy (CAA) in the vicinity of the hemorrhage. We additionally studied brain tissue in eight subjects between ages of 60 and 80 who were positive for cocaine metabolites at autopsy; of these, none had vascular amyloid‐β deposits by immunohistochemistry. Whereas we found no evidence that chronic cocaine use is a risk factor for CAA, given the age‐associated nature of CAA and the aging population using cocaine, CAA‐induced hemorrhage in the setting of cocaine use may be more common than recognized. This is the first reported case of CAA‐associated ICH precipitated by cocaine.     

Rare Death Via Histamine Poisoning Following Crab Consumption: A Case Report

Histamine poisoning (scombroid food poisoning) is a toxicity syndrome that results from eating spoiled fish. To date, however, few poisoning (or mortality) cases have been reported in relation to crab consumption. Here, we describe a very uncommon case in which a 37‐year‐old woman and her 14‐year‐old son ate cooked crabs (Scylla serrata), resulting in the death of the female. Samples of vomitus, food residue, liver tissue, gastric content, intestinal content, and cardiac blood were analyzed by high‐performance liquid chromatography. Toxicological analysis revealed that histamine concentrations were very high in the cooked crab (47.08 mg/100 g) and intestinal content (22.54 mg/100 g). Comparing our toxicological results, police investigations, and family member statements, it can be assumed that the decedent ingested spoiled crabs, and by excluding other causes of death, lethal intoxication with histamine poisoning was confirmed.     

Monitoring of Levamisole Concentration in Serum of Traffic Participants after Cocaine Consumption

This study highlights the problem of levamisole‐adulterated cocaine in context of active traffic participation. For the purposes of levamisole concentration monitoring in human serum, an analytical method based on LC‐MS/MS and solid‐phase extraction was applied. A Luna 5 μm C18 (2) 100 A, 150 mm × 2 mm column and a mobile phase consisting of A (H₂O/methanol = 95/5, v/v) and B (H₂O/methanol = 3/97, v/v), both with 10 mM ammonium acetate and with 0.1% acetic acid (pH = 3.2), were used. The validation experiments demonstrated that the method applied was appropriate for levamisole quantification in human serum. For 23% of levamisole‐positive samples, the concentrations exceeded 20 ng/mL. Therefore, the interaction of this drug with cocaine has to be considered as important for active traffic participation. As a consequence, monitoring of levamisole concentration in human serum is recommended, as long as it is used as cocaine adulterant.     

Cocaine-induced psychosis and sudden death in recreational cocaine users

Fatal cocaine intoxication presenting as an excited delirium is described in seven recreational cocaine users. Symptoms began with the acute onset of an intense paranoia, followed by bizarre and violent behavior necessitating forcible restraint. The symptoms were frequently accompanied by unexpected strength and hyperthermia. Fatal respiratory collapse occurred suddenly and without warning, generally within a few minutes to an hour after the victim was restrained. Five of the seven died while in police custody. Blood concentration of cocaine averaged 0.6 mg/L, about ten times lower than that seen in fatal cocaine overdoses. Police, rescue personnel, and emergency room physicians should be aware that excited delirium may be the result of a potentially fatal cocaine intoxication; its appearance should prompt immediate transport of the victim to a medical facility. Continuous monitoring, administration of appropriate cocaine antagonists, and respiratory support will hopefully avert a fatal outcome.     

Cocaine poisoning

Lethal cocaine intoxications in the Federal republic of Germany are still rather unusual. The present article describes chemical findings in a suicide case after oral/nasal intake. Our experience as well as the results of literature leads to the conclusion that if a cocaine intoxication is suspected, examinations are required which should include parts of the brain, the kidneys and the spleen. The application of RIA or rather the EMIT-Procedure only are not sufficient to clear up an intoxication.     

Exogenous Lipoid Pneumonia as a Contributory Factor in a Drug‐related Death

Postmortem investigation often reveals various conditions, which may or may not have played a part in the death of the individual. The case of a 32‐year‐old woman is reported, with a long history of drug addiction. She was found dead in her bed. The autopsy revealed diffuse pulmonary edema with congestion of the lungs, brain, liver, and spleen. Microscopic examination of the lungs showed multiple intra‐alveolar and interstitial foamy macrophages and extracellular fat droplets surrounded by polynuclear giant cells. Death was attributed to acute polydrug intoxication. As microscopic examination had revealed severe pulmonary lesions, lipoid pneumonia was considered as a contributing factor to death. Lipoid pneumonia is an uncommon entity with the characteristic radiograph features and histologic findings of alveoli filled with vacuolated, lipid‐laden histiocytes. It can be either exogenous or endogenous in cause, based on the source of the lipid. Exogenous lipoid pneumonia usually results from aspiration or inhalation of fat‐like material, such as mineral oil or petroleum‐based lubricants and decongestants, resulting in pulmonary inflammatory reactions.     

Morbidity Involving the Hallucinogenic Designer Amines MDA and 2C‐I*

Abstract: A case is presented of a 39‐year‐old woman who suffered severe debilitation because of a hemorrhagic stroke in the context of substance abuse. The patient presented to the emergency room with rapidly diminishing mental status, hypertension, and vasoconstriction; her friends provided a history of ingestion of cocaine, 3,4‐methylenedioxymethamphetamine (MDMA), and 2C‐I, a novel designer amine. A multi‐targeted LC‐MS/MS method for sympathomimetic amines and related drugs in urine detected and quantified 2C‐I and MDA, while ruling out MDMA. The cause of the stroke was determined to be an underlying cerebrovascular abnormality called Moyamoya, secondary to substance abuse. In clinical laboratories, gas chromatography–mass spectrometry or liquid chromatography–tandem mass spectrometry (LC‐MS/MS) confirmation of a positive amphetamine immunoassay is usually directed only towards amphetamine, methamphetamine, MDMA and MDA. This report demonstrates the utility of testing for a wider menu of compounds using LC‐MS/MS in order to better characterize the prevalence and toxicities of novel amines such as 2C‐I.     

Maybe a new killer in illicit cocaine

This is the study of the author that refers about a case of a 46 years old man found dead inside his house, the death was related to cocaine intake. The police found the corpse laying in his bed with a sheet of newspaper rolled up and a few plastic coverings containing trace of cocaine on the desk. Toxicological analysis was performed and drug levels measured by means of gas chromatography/mass spectrometry technology. Based on the autopsy findings and toxicological results the cause of death was related to an acute intoxication due to cocaine "overdose". In addition to the presence of cocaine and smaller alkaloids, in the sheet made of newspaper rolled up and eluted of the nasal mucosas has been highlighted the presence of 2,6-disopropylnaphtalene (2,6-DIPN), a fungicidal pesticide very health hazard for human. A very easy, simple and selective gas chromatography mass spectrometry method was employed for the detection of 2,6-DIPN in the cocaine powder.     

“Bath Salts” the New York City Medical Examiner Experience: A 3‐Year Retrospective Review

“Bath salts” are synthetic derivatives of cathinones, compounds found in the leaves of Catha edulis, which possesses amphetamine‐like properties. At the New York City Office of Chief Medical Examiner, we conducted a 3‐year retrospective analysis of deaths in which cathinones were detected. Two categories emerged; those in which cathinones were a contributory cause of death (15 cases) and those in which they were an incidental finding (15 cases). Of the former group, 13 were associated with additional intoxicants; two deaths were attributed solely to cathinone intoxication, both survived 10 h: a man whose postmortem blood methylone concentration was 0.71 mg/L and a woman whose postmortem blood ethylone concentration was 1.7 mg/L. In the latter category, there were several individuals who had higher concentrations of cathinones than the above two, the highest being a blood methylone of 4.8 mg/L. Based upon our data and the literature presented, lethal concentrations of cathinones cannot be established.     

A Fatality Following Ingestion of the Designer Drug Meta‐Chlorophenylpiperazine (mCPP) in an Asthmatic—HPLC‐MS/MS Detection in Biofluids and Hair

A 20‐year‐old man, a cocaine addict and regular ecstasy user, with a medical history of allergic asthma died after ingesting half a tablet earlier the same day. The white tablet, stamped with a “smiling sun” logo looked very much like an ecstasy tablet and was sold as such. He experienced a severe asthma attack just after ingesting the half tablet and it evolved over the next few hours into fatal cardiorespiratory arrest. Biological samples, taken after embalming, were analyzed by high‐performance liquid chromatography tandem mass spectrometry (HPLC‐MS/MS). Analysis revealed meta‐chlorophenylpiperazine (mCPP) in concentrations of 45.8 mg in a similar tablet obtained later from the drug dealer, 5.1 ng/mL in the bile, 0.3 ng/g in the liver, 15.0 ng/mL in the urine, and its absence in a hair sample (<0.02 ng/mg), which indicated he was not a regular user (whereas strong concentrations of MDMA and cocaine were found in the hair). Interrogated by the police after his arrest, the dealer said that he had sold the victim and for the very first time two tablets with the same “smiling sun” logo. The tablet used for analysis was from the same brand as the one ingested by the victim. The autopsy excluded other causes of death, while the histological analyses showed a large number of polynuclear eosinophils in the bronchial walls, confirming the asthmatic pathology. None of the other organs examined (larynx, liver, heart, adrenal glands, and kidneys) showed any distinctive signs, and in particular no inflammatory infiltrate. The death was the result of an asthma attack in an asthmatic person, violently decompensated following ingestion of approximately 20 mg of mCPP.     

Multiple Self‐Inflicted Stab Wounds to Neck,Chest and Abdomen as a Unique Manner of Suicide

Abstract: This is a case report of a 30‐year‐old man found dead in his flat lying on the floor with multiple stab wounds over the body, surrounded by an extensive volume of blood. Examination of the scene of death showed a secure flat, locked from inside. A blood‐stained knife was present close to the body and two unstained notes left on the sofa at the locus. A small plastic bag containing white powder (which following toxicological examinations appeared to be cocaine) and an almost full bottle of beer were present on a table. Autopsy revealed more than 40 stab wounds to neck, chest, and abdomen arranged in isolated groups within which the wounds showed similar directions and had a transverse orientation. Together with hesitation marks located on the neck and wrists these characteristics allowed to interpret this case as a suicide.     

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.     

Pregnancy,Cesarean, and Pheochromocytoma: A Case Report and Literature Review

A 43‐year‐old full‐term pregnant woman (gravida 2, para 1, medical history of gestational diabetes mellitus) developed a sudden and malignant hypertension with hemoptysis, sweat, and tachycardia during a scheduled C‐section. A dead newborn was delivered and was successfully resuscitated. The mother died after resistant cardiac arrest. Autopsy and pathological analyses revealed an acute pulmonary edema and a necrotic and hemorrhagic voluminous tumor of the left adrenal gland, which was a pheochromocytoma. Pheochromocytoma is a rare tumor of the adrenal glands which secretes catecholamines. In pregnant women, its symptoms can mimic gestational hypertension, preeclampsia or eclampsia, and gestational diabetes mellitus. The gestational diabetes mellitus was presumed to be a symptom of the pheochromocytoma, and cardiopulmonary failure the result from the necrosis of the tumor provoked by gravid uterus compression. From a medico‐legal point of view, the tumor could not have been suspected during the pregnancy.     

Lethal Bentazone Intoxication – A Report of Two Cases

This study presents two cases of lethal bentazone poisonings, their clinical presentation, the course of the disease and the autopsy findings. The first is a 50‐year‐old male who had sprayed corn with a solution of bentazone and was admitted to the hospital with sweating, fever, nausea, vomiting of aqueous and hemorrhagic content, and bloody, watery stools. He was treated according to the symptoms including extracorporeal hemodialysis, but eventually suffered from multiorgan failure (acute respiratory failure, acute liver failure, coagulopathy, acute renal failure, metabolic acidosis, and gastrointestinal bleeding) and died 11.35 h after admittance. The cause of death was probable bentazone intoxication. The second case, also a male, aged 49 who committed suicide by ingesting a bentazone solution. He was transferred to the hospital prostrated and cyanotic and died 14.15 h after admittance despite all efforts by the hospital staff. The cause of death was acute bentazone intoxication.     

Fatal Ingestion of Chlumsky Disinfectant Solution

A 32‐year‐old pregnant woman in the 25th week of pregnancy underwent oral glucose tolerance screening at the diabetologist's. Later that day, she was found dead in her apartment possibly poisoned with Chlumsky disinfectant solution (solutio phenoli camphorata). An autopsy revealed chemical burns in the digestive system. The lungs and the brain showed signs of severe edema. The blood of the woman and fetus was analyzed using gas chromatography with mass spectrometry and revealed phenol, its metabolites (phenyl glucuronide and phenyl sulfate) and camphor. No ethanol was found in the blood samples. Both phenol and camphor are contained in Chlumsky disinfectant solution, which is used for disinfecting surgical equipment in healthcare facilities. Further investigation revealed that the deceased woman had been accidentally administered a disinfectant instead of a glucose solution by the nurse, which resulted in acute intoxication followed by the death of the pregnant woman and the fetus.     

Black Esophagus: Acute Esophageal Necrosis in Fatal Haloperidol Intoxication

Herein, we present a case of 53‐year‐old psychotic woman with acute esophageal necrosis (black esophagus), who was found lying on the floor in the living room of her flat. Pillboxes of antipsychotic drugs were located in the bin. External examination of the body was unremarkable. On internal examination, we found acute esophageal necrosis. Histologically, there was complete epithelial necrosis with focal involvement of muscularis mucosae, dense infiltrate of leukocytes, and ulcerations without any viable cells. There was no evidence of underlying organic diseases or trauma. Toxicological analysis revealed a fatal blood level of antipsychotics (haloperidol, zotepine, and chlorprothixene). Death of the deceased was attributed to fatal intoxication with three various types of antipsychotics. As far we know, this is the first described association between so‐called black esophagus and fatal blood level of neuroleptics.     

A Case of Nonfatal Intoxication Associated with the Recreational use of Diphenidine

Diphenidine is a dissociative drug that shows several psychotropic effects including euphoria, shifts in perception of reality, hallucinations, and transient anterograde amnesia. In this study, a case of acute intoxication occurring after diphenidine intake is reported. A 30‐year‐old Caucasian male was hospitalized after he was found in a confused and agitated state and unable to communicate. The physical examination displayed tachycardia, miotic pupils, and increased both body temperature and respiratory rate. After a liquid–liquid extraction procedure, GC/MS analysis revealed the presence of diphenidine in plasma and urine at concentrations of 308 and 631 ng/mL, respectively. Methylphenidate and diclazepam were also detected in the plasma. The clinical progress of the patient was favorable, and his symptoms were cured with a symptomatic treatment. The combined circumstantial elements and toxicological results of the case reported revealed the occurrence of an acute intoxication ascribable to the recreational abuse of diphenidine.     

An Unusual Case of Multiple‐Gunshot Suicide of an Alcohol‐Intoxicated Cancer Sufferer with Prolonged Physical Activity

Multishot firearm suicides are relatively rare and suggest the possibility of homicide. Physical activity following gunshots to the head, the neck, and the thorax does occur, and immediate incapacitation does not occur in every fatal gunshot wound that penetrates the head or perforates the heart. Cancer patients appear to be at increased suicide risk, but alcohol intoxication is less common in such cases. We present—to the best of our knowledge for the first time—a case of a 54‐year old, male, liver cancer sufferer, who under the influence of alcohol, discharged his revolver three times, suffered, among other wounds, a heart‐perforating wound, and died after c. 1.5 h, being able to talk until just before he died. Our case underlines the importance of keeping an open critical mind when dealing with multiple‐gunshot fatalities, especially when posttraumatic physical activity might be crucial in differentiating homicide from suicide.     

Drug Recognition Evaluation and Chemical Confirmation of a 25C‐NBOMe‐Impaired Driver

This case report details an individual arrested for drug‐impaired driving after leaving the scene of multiple motor vehicle collisions and evading police. The driver was examined by a drug recognition expert and failed the drug recognition evaluation. The driver admitted to using cocaine, marijuana, an antidepressant medication and “N‐bomb,” a novel psychoactive substance that possesses hallucinogenic properties. Toxicological analyses at the Centre of Forensic Sciences’ Toronto laboratory revealed only the substance 2‐[4‐chloro‐2,5‐dimethoxyphenyl]‐N‐[(2‐methoxyphenyl)methyl]ethanamine (25C‐NBOMe) in the accused's urine. This is the first report in which 25C‐NBOMe was identified through DRE and toxicological analyses in a drug‐impaired driver.     

Colchicine Extract Suicidal Lethal Poisoning Confirmation Using High‐Resolution Accurate Mass Spectrometry: A Case Study

A case of suspected acute and lethal intoxication caused by colchicine has been reported. The woman was hospitalized after her suspicion of suicidal poisoning by a rare autumn crocus (Colchicum autumnale). Suspected colchicine poisoning was confirmed using a novel UHPLC method with a modern reversed‐phase stationary phase with a sub 2‐micron superficial porous particle size combined with a QTOF mass spectrometer. Sample preparation procedure included the addition of propiverine as internal standard, protein precipitation using methanol and solid phase extraction. High‐resolution MS only and targeted MS/MS modes are reported for the qualitative analysis and screening of other potential drugs of abuse in blood samples. All Ion MS mode was used for quantitative determination of colchicine afterward. The concentration of colchicine in the blood sample was approximately 41 ng/mL, and more than 200 μg/mL of the plant extract used for the suicide.