Intravenous amphetamine abuse, primary cerebral mucormycosis, and acquired immunodeficiency

Two intravenous amphetamine abusers had fatal, rapidly progressive cerebral mucormycosis with abscess formation in the presence of absolute lymphopenia. Postmortem examination confirmed the primary nature of the fungal cerebritis, documented by postmortem culture and histology. The clinical and pathologic features of these cases are compared to previously reported occurrences of primary fungal cerebritis (and abscess) among intravenous drug abusers, including cocaine users. Primary fungal cerebritis associated with intravenous abuse of stimulant drugs is discussed as a possible variant of the acquired immunodeficiency syndrome.     

Cocaine-associated rhabdomyolysis and excited delirium: different stages of the same syndrome.

Previous case reports indicate that cocaine-associated rhabdomyolysis and excited delirium share many similar features, suggesting that they may be different stages of the same syndrome. We tested this hypothesis by comparing data from 150 cases of cocaine-associated rhabdomyolysis reported in the medical literature with data from an autopsy registry for 58 victims of fatal excited delirium and 125 victims of fatal acute cocaine toxicity. Patients with rhabdomyolysis are similar to victims of fatal excited delirium with regard to age; gender; race; route of cocaine administration; the experiencing of excitement, delirium, and hyperthermia; and the absence of seizures. Compared with victims of fatal acute cocaine toxicity, patients with rhabdomyolysis are different with regard to each of these variables. Compared with victims of fatal acute cocaine toxicity, both victims of rhabdomyolysis and fatal excited delirium are more likely to be black, male, and younger; to have administered cocaine by smoking or injection; and to have experienced excitement, delirium, and hyperthermia; they are also less likely to have had seizures. Because cocaine-associated rhabdomyolysis and excited delirium have similar clinical features and risk factors, occur in similar populations of drug users, and can be explained by the same pathophysiologic processes, we conclude that they are different stages of the same syndrome. It appears that this syndrome is caused by changes in dopamine processing induced by chronic and intense use of cocaine rather than by the acute toxic effects of the drug.     

Cocaine and sudden "natural" death

The cardiovascular effects of cocaine may culminate in clinical episodes of angina pectoris, myocardial infarction, arrhythmias, and intracranial hemorrhage. To clarify whether or not cocaine causes fatalities by these mechanisms, we studied 24 cases of sudden, apparently natural deaths as a result of coronary arteriosclerosis (15 cases), hypertensive cardiovascular disease (4 cases), and intracranial hemorrhage (5 cases) associated with cocaine use. In 11 cases, cocaine was found in the blood (average concentration: 0.57 mg/L, range: 0.05 to 1.45 mg/L), whereas in the remainder, cocaine or its major metabolite was found in the urine or other tissues. In the majority of decedents, autopsy disclosed the existence of severe natural disease which could have been exacerbated by the administration of stimulant drugs, including cocaine. These data, and a review of the current medical literature, indicate that cocaine may precipitate the sudden death of an individual with undiagnosed cardiovascular disease. A contributory role of cocaine should be considered in any apparently natural death occurring in a population where cocaine abuse is prevalent.     

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.     

The forensic significance of conjunctival petechiae

Conjunctival petechiae were mentioned in 227 (4.5%) of 5,000 consecutive autopsy reports of the Dade County Medical Examiner Department. They were most frequently observed in those who had died natural deaths (particularly due to cardiovascular disease), followed by those who had died from asphyxia, head injury, and central nervous system disorders. The incidence of conjunctival petechiae in victims of homicidal asphyxiation was 78%. These data suggest that conjunctival petechiae most often are the result of hypoxia coupled with an acute increase in cephalic vascular pressure. The latter factor may be the consequence of mechanical vascular obstruction or acute right heart failure.     

The retina in forensic medicine: applications of ophthalmic endoscopy: the first 100 cases

The retina reflects a variety of diseases in the living patient. However, the retina is not routinely examined in deceased persons, and therefore it is unknown if routine retinal examination would be a useful adjunct to the forensic autopsy. To examine this issue, the retinae of routine medical examiner cases were examined utilizing an ophthalmic endoscope. The results of the first 100 examinations are reported. Specific attention was given to changes that reflected the postmortem interval, the development of petechiae as related to cardiopulmonary resuscitation, and the association of retinal hemorrhages to subconjunctival hemorrhages. The procedure was helpful in cases of suspected shaken baby syndrome, exsanguination, and carbon monoxide poisoning and in cases with sudden increased intracranial pressure (Terson syndrome). It appears that lividity patterns exist in the retina, and this may be potentially useful in determining body position after death. Some natural disease processes, such as hypertension, were also identified. Finally, the utility of the ophthalmic endoscope as a means of circumventing the problem of corneal clouding is discussed, and ideas for further research using this technology are presented.     

National Association of Medical Examiners position paper on the certification of cocaine-related deaths

The National Association of Medical Examiners Committee on Cocaine-related Deaths recommends that the following guidelines be applied in the process of documenting, interpreting, and certifying potential cocaine-related fatalities. The committee cautions that the investigation of any drug-related death requires a complete investigation of the circumstances of death, the death scene, and past medical history. It is also necessary to have the results of the forensic toxicological analysis and those of a complete forensic autopsy examination prior to formulating an opinion as to the cause and manner of death. Cocaine should be considered the underlying cause of the death when 1 or more of the following is true: (1). the circumstances surrounding the death can be associated with an acute cocaine exposure and there are no supervening causes of death; (2). the immediate cause of death is directly due to a readily identifiable mechanism or disease such as a gunshot wound or a stroke, yet the acute use of cocaine was the direct underlying cause of the trauma or the disease process; and (3). chronic cocaine use leads to a disease that results in an ultimately fatal pathologic process leading to organ injury and death. The committee further cautions that reported drug levels may not directly relate to the toxic or lethal effects of the drug upon the patient. These guidelines are intended for use by practicing medical examiners and physicians who certify drug deaths, as well as providing education tools for students.     

Accidental death from a black-powder rifle breech plug

Authentic black-powder muzzle-loader weapons and replicas are used today primarily for hunting game such as deer and hogs. The following is a case presentation of accidental death from cerebral trauma caused by a .45-caliber black-powder-rifle breech plug implanting in the victim's brain.     

National Association of Medical Examiners position paper on the medical examiner release of organs and tissues for transplantation

The medical examiner community plays a key role in the organ and tissue procurement process for transplantation. Since many, if not most, potential organ or tissue donors fall under medicolegal jurisdiction, the medical examiner bears responsibility to authorize or deny the procurement of organs or tissues on a case-by-case basis. This responsibility engenders a basic dichotomy for the medical examiner's decision-making process. In cases falling under his/her jurisdiction, the medical examiner must balance the medicolegal responsibility centered on the decedent with the societal responsibility to respect the wishes of the decedent and/or next of kin to help living patients. Much has been written on this complex issue in both the forensic pathology and the transplantation literature. Several studies and surveys of medical examiner practices, as well as suggested protocols for handling certain types of cases, are available for reference when concerns arise that procurement may potentially hinder medicolegal death investigation. It is the position of the National Association of Medical Examiners (NAME) that the procurement of organs and/or tissues for transplantation can be accomplished in virtually all cases, without detriment to evidence collection, postmortem examination, determination of cause and manner of death, or the conducting of criminal or civil legal proceedings. The purpose of this position paper is to review the available data, the arguments for and against medical examiner release, and to encourage the release of organs and tissues in all but the rarest of circumstances.