Fatal capnocytophaga infection associated with splenectomy

A case of fatal sepsis due to Capnocytophaga species is described. Capnatophaga canimorsus and C. cynodegmi can cause localized wound infections and/or systemic infections in people who have been bitten, licked, scratched, or merely exposed to cats or dogs, especially splenectomized individuals. A thorough social, medical, and surgical history, the clinical presentation, and cultures are important in making the diagnosis of Capnocytophaga infections. It is important that the forensic pathologist be aware of this zoonotic disease.     

Fatal seizures associated with trimipramine poisoning

The present report describes a witnessed, fatal attack of seizures. Very high levels of trimipramine were found in the blood collected at autopsy. The cause of death would most likely have been misinterpreted as a suicidal intoxication if the attack had not been witnessed. Conversely, if toxicologic examination had not been undertaken, the fatality would probably have been registered as epilepsia.     

Fatal hydrothorax associated with subclavian vein catheterization for hemodialysis.

A rare iatrogenic complication of subclavian vein catheterization for hemodialysis is massive hydrothorax. A case is presented that illustrates the need for adherence to a standard procedure of prompt roentgenologic examination in conjunction with catheterization, and emphasizes the importance of the autopsy as a means of quality assurance.     

Fatal dog maulings associated with infant swings

We present three cases of fatal dog maulings of infants placed in mobile infant swings, a phenomenon not previously described in the literature. In each case, the victim was left in a mobile swing, unsupervised by an adult, and the attacking dog was a family pet. Case 1 involved an 18-day-old male infant attacked by a pit bull; Case 2 involved a 3-month-old male infant attacked by a Chow Chow and/or a Dachshund, and Case 3 involved an 18-day-old female infant attacked by a Labrador-pit bull mix. These cases not only underscore the importance of not leaving young children unattended in the presence of pet dogs, but also raise the possibility that mobile swings may trigger a predatory response in dogs and thus may represent an additional risk factor for dog attack.     

Fatal positional asphyxia associated with rollover crashes

Motor vehicle rollover crashes result in complex occupant kinematics with the potential for severe injury. Five cases of fatal asphyxia in occupants suspended from their safety belt upside down after a rollover crash are presented. These fatalities accounted for 13.5% of all motor vehicle related asphyxia deaths in San Diego County over a 10-year period. This study supports previous research noting that incapacitation due to other injuries, alcohol, or obesity may be associated with fatal positional asphyxia due to inversion during rollovers. Safety belts are proven to prevent serious injury in motor vehicle crashes and should always be worn. However, redesign of the buckle could be considered to permit easier release by an occupant. We also suggest that pre-existing heart disease may contribute to the possibility of a fatal asphyxia outcome. Although this is a rare cause of motor vehicle related death, our results suggest that these are potentially preventable deaths.     

Fatal childhood vascular injuries associated with seat belt use

The deaths of two children who were passengers in motor vehicles involved in accidents were directly attributable to vascular injuries derived from seat belts. In the first case, a 10-year-old boy died as a result of abdominal aortic transection by a lap seat belt, and in the second case a 15-year-old boy died as a result of transection of his common carotid artery by a lap-shoulder seat belt. Although these cases demonstrate rare fatalities associated with seat belt use, there is no doubt that seat belts have significantly reduced mortality and morbidity from traffic accidents. Although it is possible that a fatal outcome might have occurred in each of these cases from other injuries that might have been sustained had seat belts not been worn, appropriate positioning and size of seat belt harnesses might have avoided the lethal injuries.     

Fatal splenic arterial aneurysmal rupture associated with chronic pancreatitis

Splenic arterial aneurysms (SAA) are rare and are usually atherosclerotic and/or related to pregnancy. Because pregnancy is the most important predisposing factor, the strong predilection of SAA for women is not surprising. The authors report a case of SAA rupture in a man with chronic pancreatitis as the predisposing factor. A 56-year-old man with abdominal pain and hematemesis was resuscitated and underwent endoscopy, but he died 18 hours later of massive hematemesis before definitive surgery could be carried out. At autopsy, there was chronic pancreatitis with fibrous adhesions tethering the tail of the pancreas, spleen, and posterior wall of the stomach together. The SAA was indented into the posterior wall of the stomach, into which it had ruptured from without. He also had alcoholic cirrhosis but no esophageal varices or conventional gastric ulcers. Other important predisposing factors such as abdominal trauma, infective endocarditis, polyarteritis nodosa, and segmental medial arteriopathy were absent. Histologic examination confirmed the rupture of the SAA. The SAA had Monckeberg medial calcinosis but little evidence of atherosclerosis. The well-documented complications of acute and chronic pancreatitis include shock, abscess, pseudocyst formation, and duodenal obstruction. This report describes the rare complication of SAA rupture, which may be fatal.     

Fatal malignant hyperthermia associated with recreational cocaine and ethanol abuse

Malignant hyperthermia is an often lethal hypermetabolic crisis state precipitated by a variety of pharmacological and environmental triggers in genetically susceptible persons. The present report documents, by medical history and necropsy, a fatal malignant hyperthermic crisis in a 20-year-old man after an evening of recreational cocaine and ethanol abuse.     

Fatal intoxications with chloral hydrate.

An alcoholic man, treated with chloral hydrate (CH) syrup to which he was dependent, was discovered comatose and in respiratory arrest. Death occurred on the ninth day of hospitalization following cerebral oedema. A woman, alcohol addicted, depressed, and epileptic was admitted in the Intensive Care Unit with heart and respiratory failure following CH absorption. She died three days later after a deep coma. In these two cases, CH intoxication was confirmed by toxicological analysis: CH and its major metabolite, trichloroethanol (TCE), were identified and determined in serum and urine using headspace-capillary gas chromatography-mass spectrometry. The concentrations measured were compared with those found in previously published fatalities. The analytical method used can be proposed for both clinical and forensic cases.     

Fatal poisonings with propoxur

The insecticide propoxur (2-isopropoxyphenyl-N-methylcarbamate) acts by blocking cholinesterase. This inhibition is fast and, unlike that brought about by organophosphorus compounds, reversible. The toxicity of propoxur to man is stated to be low compared with that of parathion. Only a small number of fatal intoxications have been published; at the Würzburg University Institute of Legal Medicine eight cases have been observed since 1978. In seven cases death occurred after deliberate oral ingestion of solutions of propoxur with suicidal intent, while in the other, intoxication was accidental, following inhalation of an aerosol containing propoxur. Organs and body fluids were investigated toxicologically and histologically. The results are presented and discussed. Special attention is paid to the combination of propoxur and alcohol.     

Fatal intoxication with melperone

Melperone is judged to be a safe neuroleptic drug. Until now there has been no report of a melperone fatality, though it has been used in suicide attempts. We report on a case of a 36-year-old woman where no cause of death could be established at autopsy. Criminological investigation pointed to a homicide by poisoning but also the possibility of a suicide had to be taken in account. The toxicological analysis of blood, cerebral spinal fluid and urine revealed extremely high concentrations of melperone which had never been reported before. Furthermore, diazepam, nordazepam and carbamazepine were detected. To our knowledge, this case is the first melperone fatality. Possible interactions with diazepam and carbamazepine are discussed.     

Fatal poisoning with blue vitriol

Cases of fatal poisoning with cupric compounds are relatively rare in everyday life and are not covered much in forensic literature. A case was encountered of fatal poisoning with a blue vitriol solution introduced into the uterine cavity in order to interrupt a pregnancy. A 39-year-old woman brought to the hospital by ambulance complained of pain in the lumbar region and profuse bloody genital discharge, which had appeared 3 days earlier. She believed she was 2 months pregnant and denied artificial interruption of the pregnancy. Upon examination, her condition was grave: a weak pulse of 80; blood pressure 100/60. The abdomen was soft, the liver and spleen not enlarged. Pasternak symptom was negative. The uterus was soft, painless and enlarged to 9 weeks of pregnancy. The uterine cervix was clean, the orifice closed. Discharge was profuse and bloody. The diagnosis was that she was 9 weeks pregnant and had a missed criminal abortion. Scraping out the uterus and corresponding therapy to control bleeding were ineffective. An operation was performed--extirpation of the uterus. However, despite the steps taken, the bleeding did not stop, and the patient's condition continued to worsen. 10 hours after being admitted to the hospital, she died. During forensic investigation, diffused, violet-colored cadaverous spots were discovered. Extensive subcutaneous hemorrhage was detected around the areas of injection. The skin covering was edematous; when pressed with a finger, areas of depression remained. There was about 250 ml of watery blood in the abdominal cavity. Internal organs were anemic. There were multiple subpleural, subepicardial, subcapsular, intraorgan and intramuscular micro- and macro-punctate hemorrhages; bleeding into the mucosa of the gastrointestinal tract and urinary tracts; and cerebral and pulmonary edema. Forensic histological examination showed acute circulatory disturbance with perivascular and peridiapedetic hemorrhage; concentrations of aggregated and hemolyzed erythrocytes in the small vessels and capillaries; cerebral, pulmonary and stromatic edema. In the kidneys there was coaugmentation of renal glomeruli; epithelial necrosis of part of the coiled ducts; lower epithelium in places had pigment grains; primarily in openings of straight ducts there were pigment cylinders; extreme plethora of the surrounding area, and infiltration from annular cells and polynuclears. Forensic chemical analysis showed 12.8 mg of copper; 6.6 mg in the uterus and 5.6 mg in the kidneys. From data obtained it can be concluded that the patient died from cupric compound poisoning, complicated by interruption of the pregnancy and uterine hemolytic hemorrhage. It was later established that during the month before being admitted to the hospital the patient introduced a solution of blue vitriol into the uterine cavity to interrupt the pregnancy.     

Fatal poisoning with sodium chloride

This is an account of accidental fatal poisoning of a psychiatric patient following the use of a saline emetic for suspected chlorpromazine poisoning.     

Fatal accident with a special automobile

The authors report on a traffic accident in which the passenger of a Light Four-wheeled Vehicle (Microcar) approved for use by a disabled person was killed after a rear collision with a compact car. The severity of the accident trauma was critically determined by the vehicle's light construction. Consideration is also given to the legal situation regarding registration and driver's license issues.     

Fatal cyclobenzaprine overdose with postmortem values

There are only two published cases of overdose with postmortem blood cyclobenzaprine concentrations, both with confounding factors. We report two additional cases of fatal cyclobenzaprine overdose with postmortem values. Case 1: a 56-year-old female was found in full cardiopulmonary arrest after a verbal suicide threat to a friend. Postmortem blood concentrations were cyclobenzaprine 0.96 mg/L and diazepam 0.3 mg/L. Case 2: a 37-year-old male was found in full arrest by a family member after an intentional ingestion of cyclobenzaprine. Postmortem blood concentrations were cyclobenzaprine 0.8 mg/L and ethanol 0.174 gm/dL. The concentrations of diazepam and ethanol reported in these two patients were not found in quantities usually associated with a fatal outcome, suggesting that the cyclobenzaprine was the primary cause of the fatality. Additionally, the blood was drawn from a femoral site, so that postmortem redistribution is not a likely factor. Blood concentration of > or = 0.8 mg/L cyclobenzaprine may be associated with a fatal outcome.     

Fatal acetaminophen poisoning with evidence of subendocardial necrosis of the heart.

The authors describe a case of fatal acetaminophen overdose which occurred in a 16-year-old female. Her serum acetaminophen concentration 11.5 h postingestion was 154 mg/L. Antidotal therapy was unsuccessful, and after 9 days she died. Autopsy findings included centrilobular zonal liver necrosis, acute proximal renal tubular necrosis, and diffuse alveolar pulmonary damage. Her heart was transplanted into a young woman with congenital heart disease. The recipient expired 14 days after the transplant as a result of sepsis complicating bowel ischemia. The transplanted heart showed extensive subendocardial myocyte necrosis related to acetaminophen toxicity and not rejection.     

Fatal respiration of liquefied petroleum gas.

We have found that an efficient method of providing evidence of lethal solvent abuse is to sample headspace above lung tissue and then perform cryogenically focused gas-liquid chromatography. In the case presented, the level of lethal agent in lung tissue was low, but the solvent was present in abundance in the pleural cavity. We conclude that the pleural cavity acts as an efficient trap for aspirated substances.     

Fatal MDMA-intoxication with postmortem diagnosis of hyperthermia

Hyperthermia is one of the main symptoms of the toxic MDMA effect. In a fatal intoxication, the premortal increase in body temperature may lead to a false assessment of the time of death. The problems of drug-induced hyperthermia faced by forensic pathologists and criminal investigators are discussed on the basis of a death from the autopsy material of the Berlin Institute of Legal Medicine (CCM).     

Fatal salmonella aortitis with mycotic aneurysm rupture

Salmonellae most commonly cause uncomplicated cases of gastroenteritis but have a predilection for damaged blood vessels, especially those damaged by atherosclerosis. The abdominal aorta is most frequently affected. The most serious complication of aortitis is mycotic aneurysm formation with subsequent rupture. The authors present the case of a 61-year-old man who was found unresponsive at home 3 days after discharge from the hospital for treatment of gastroenteritis with bacteremia. Postmortem examination revealed a ruptured mycotic aneurysm with a large retroperitoneal hematoma. Numerous gram-negative rods were embedded in the wall of the aorta and surrounding inflammatory infiltrate, compatible with the patient's previously isolated. Whereas abdominal aortic aneurysm rupture is most commonly associated with atherosclerosis, the isolation of from blood cultures, coupled with radiographic evidence of gas surrounding the aorta, should raise the suspicion of infectious aortitis. Whereas fatal rupture of an aortic aneurysm secondary to atherosclerosis alone or in conjunction with aortitis will not have an impact on the manner of death, infections are reportable and thus have public health implications.     

Fatal bronchial asthma with bilateral lung collapse

Fatal bronchial asthma is classically characterized in pathology textbooks and journal articles as associated with lung hyperinflation at autopsy. The following is a report of a case of fatal bronchial asthma associated instead with bilateral lung collapse. This manifestation of asthma at autopsy has not been previously reported, to my knowledge. A 31-year-old man with a history of recurrent asthma was found in an unresponsive state in his automobile after a low-speed collision. Medical personnel during the resuscitation noted a decrease in breath sounds bilaterally and some wheezing. There was no escaping air with needle thoracostomies at the outset. Cardiac monitoring demonstrated pulseless electrical activity during most of the 30-minute resuscitation attempt. An autopsy disclosed collapsed lungs bilaterally. Microscopic examination of the lungs disclosed the characteristic histopathologic features of bronchial asthma.