Report on a methemoglobin-associated fatality

An autoerotic fatality due to mechanical compression of the neck by a sophisticated construction used for breath control games is reported. The presence of signs of methemoglobinemia as well as an empty "poppers" flask found beside the passed indicated the use of volatile nitrites to enhance sexual pleasure. It was assumed that vasodilatation had caused a sudden unconsciousness with consecutive hanging.     

An unusual fatality in a child due to oxycodone

An unusual fatality secondary to oxycodone in a child is reported. A 2-year-old female child was conveyed to a local hospital after exhibiting signs of rubbing of the mouth and staggering. A hospital toxicological immunoassay screen for drugs of abuse and tricyclic antidepressants was performed on a urine sample and reported as negative. She was discharged and found unresponsive the next morning. She was conveyed to a second hospital in full cardiopulmonary arrest and despite resuscitative efforts, was pronounced dead upon arrival. An autopsy was performed and postmortem specimens were submitted and screened for drugs using mainly chromatographic techniques. Quantitation was achieved by gas chromatography with nitrogen phosphorus detection. Confirmation was performed by gas chromatography/mass spectrometry. Oxycodone was the only drug detected in the following concentrations: heart blood, 1.36 mg/L; gastric contents, 7.33 mg in 33 mL (222.34 mg/L); liver, 0.2 mg/kg; and urine, 47.23 mg/L (47,230 ng/mL). In addition, immunoassay testing of the urine was positive for the opiate class of drugs. This case report demonstrates an unusual cause of death in a young child with emphasis on potential limitation in hospital urine screening tests and the importance of complete forensic toxicological testing in all child deaths.     

Heroin fatality due to penile injection

Death due to heroin overdose and/or rapid injection of heroin is a frequent occurrence among opioid addicts. We present an unusual case of heroin fatality due to the injection of the drug in the penis. Blood, urine, bile, and vitreous humor concentrations of morphine were 0.68, 0.49, 0.32 and 0.062 microg/ml, respectively. Ethanol was detected at concentrations of 104, 124, 106, and 94 mg/dl in the blood, urine, bile, and vitreous humor, respectively. The cause of death was determined to be due to heroin and ethanol intoxication.     

A fatality due to propofol poisoning.

This report describes a suicide by self-administration of propofol in a 29-year-old female radiographer. This is the first published report of death by overdosage with propofol. Propofol was detected in tissues using high performance liquid chromatography. Post mortem femoral blood and liver concentrations of propofol were 0.22 mg/L and 1.4 mg/kg, respectively. The scene suggested that a dose of 400 mg was used.     

LC-MS/MS analysis of fentanyl and norfentanyl in a fatality due to application of multiple Durogesic transdermal therapeutic systems

Fentanyl is a potent synthetic narcotic analgesic administered in the form of a transdermal patch for the management of chronic pain. A 78-year-old woman with a history of cancer was found dead in bed. She was lying on her back. The external examination revealed 10 Durogesic transdermal therapeutic systems (100 microg/h fentanyl) on the body. Liquid-liquid extraction and liquid chromatography tandem mass spectrometry with electrospray source in positive ionization mode was applied for the quantitation of fentanyl and its major metabolite norfentanyl in the post-mortem samples. Fentanyl-d5 and norfentanyl-d5 were used as internal standards. Multiple reaction monitoring was used for specific detection. Calibration was performed by addition of standard solutions to drug-free matrix (blood, urine and liver) prior to extraction. The method showed good linearity for fentanyl and norfentanyl over a concentration range of 5-150 microg/L in reconstituted extracts with coefficients of determination equal or greater than 0.998. Percent mean within-day precision and accuracy of 0.9-1.0% and 99.4-101.1% for fentanyl and 2.0-4.5% and 93.1-101.0% for norfentanyl were obtained. Mean extraction recoveries varied between 95.5% and 100.3% for fentanyl and 39.2-57.4% for norfentanyl. The following fentanyl (norfentanyl) concentration in the post-mortem samples were measured; 28.6 microg/L (3.0 microg/L) in right and 28.2 microg/L (3.5 microg/L) in left subclavian blood, 21.3 microg/L (<2 microg/L) in right and 20.9 microg/L (<2 microg/L) in left femoral blood, 37.6 microg/L (4.2 microg/L) in right and 33.9 microg/L (4.4 microg/L) in left ventricular blood, 282.9 microg/L (121.2 microg/L) in urine, 688.2 microg/L in stomach contents, 122.5 microg/L (25.4 microg/L) in bile, 19.5 microg/L (< 2 microg/L) in vitreous humour, 203.0 microg/kg (26.6 microg/kg) in liver and 78.6 microg/kg (46.3 microg/kg) in kidney. We concluded that the woman's death was caused by acute intoxication with fentanyl. The manner of death was presumed to be suicide due to excessive administered Durogesic transdermal therapeutic systems.     

Reporting a fatality during tumescent liposuction

Deaths of patients during elective surgery have drawn attention to the danger of anesthesia. Tumescent local anesthesia is subcutaneous infiltration of large volumes of dilute lidocaine with epinephrine to produce vasoconstriction while delivering anesthesia over large areas without lidocaine toxicity. This report documents the case of a 38-year-old woman who attended an outpatient clinic to undergo liposuction of the abdomen and bilateral hips and thighs. According to one witness, around 30 min after anesthesia administration, the victim suffered an episode of tonic–clonic convulsion. When the emergency medical services arrived the patient was in asystole. She died in spite of attempted cardiopulmonary resuscitation. The patient had no significant past medical history including no history of allergies or any known complications with anesthesia. A complete autopsy was performed and possible causes of death such as myocardial infarction, aspiration of food or foreign body, and pulmonary embolism were discarded. Anaphylactic shock was considered a possible but unlikely explanation for the fatality. Toxicological analyses revealed the presence of lidocaine and mepivacaine in heart blood, at concentrations of 4.9 and 16.2 mg/L, respectively. All drugs involved in the case were detected using gas chromatography with nitrogen–phosphorus detector and confirmed using gas chromatography–mass spectrometry full scan mode after solid-phase extraction using Chem-Elut columns. An additional high-performance liquid chromatography coupled to diode-array detection screening also obtained the same results. Based on the autopsy findings, case history, and toxicology results, the forensic pathologists ruled that the cause of death was an overdose of local anesthetic agents. The Court of Law ruled the death as an involuntary homicide due to gross negligence.     

Caffeine fatality: a case report

A case of fatal caffeine toxicity due to suicidal ingestion of a "look-alike" illicit drug is reported. Caffeine concentrations were determined by high pressure liquid chromatography (HPLC) with the brain having the highest level reported in the literature to date. Also, the blood concentration of caffeine was one of the highest among the cases reported. A literature review of caffeine fatalities is presented.     

Phenol: tissue distribution in a fatality

A case is reported where phenol, a disinfectant, was ingested and resulted in the death of a 40-year-old white female. Concentrations of phenol were determined in blood (130 mg/L), urine (47 mg/L), bile (187 mg/L), brain (486 mg/kg), kidney (331 mg/kg), muscle (204 mg/kg), liver (228 mg/kg), and stomach content (668 mg) and compared to other cases reported in the literature.     

Accidental dichloromethane fatality: a case report

A case of accidental dichloromethane poisoning by inhalation is presented. It is of interest that carboxyhemoglobin levels were within the normal range, suggesting that the narcosis and respiratory depression were due to the direct effect of DCM on the central nervous system. The accidental death was attributed to improper ventilation of vapors in the working area.     

Use of radiographic atlases in a mass fatality

In May and June of 1996, a forensic anthropology team from the C.A. Pound Human Identification Laboratory at the University of Florida identified 9 of 10 juveniles from the crash of ValuJet 592. The team relied primarily on a radiographic atlas developed and used by clinical practitioners to determine skeletal age. Postmortem radiographs of the juvenile victims were compared with radiographic standards to determine skeletal age. Skeletal age was then compared to a passenger list indicating the sex, weight, height, and chronological age of each individual. Tentative identifications based on the atlas method were organized into an exclusion matrix. Final identifications were based on this assessment in conjunction with other anthropological data such as appearance and fusion of ossification centers and estimation of stature.     

Sudden Death due to Brainstem Leukemic Hemorrhage: A Case Report

Introduction Leukemia is a hematologic neoplasm character- ized by potential infectious and hemorrhagic com- plications. In adult patients with acute leukemia, in- fection is the most common complication. Intracra- nial hemorrhage （ICH） is the second most common complication. However, ICH has been identified as the major cause of morbidity and mortality in pa- tients with leukemia[1-6].     

A diflunisal related fatality: a case report

A case is reported where the death of an individual resulted from the ingestion of diflunisal. Diflunisal was identified by a combination of liquid chromatography, UV spectrophotometry and colorimetry. Diflunisal was quantified in blood (260 mg/l), bile (71 mg/l), kidney (350 mg/kg), liver (400 mg/kg), stomach contents (34 mg) and urine (78 mg/l). No previous literature references discussing diflunisal related fatalities were available.     

Postmortem distribution of sertraline and desmethylsertraline in a fatality

Sertraline (CAS 79617-96-2) is a relatively safe medication for patients suffering from depression. Data reporting the postmortal distribution of sertraline and desmethylsertraline remain rare as well as reports of risks of side effects following ingestion of the drug. In a case of a young woman found dead in her flat sertraline and desmethylsertraline were identified and quantified in body fluids and tissues by gas chromatography/mass spectrometry and high performance liquid chromatography with diode array detection after alkaline extraction. Sertraline and its desmethyl metabolite were found in the peripheral blood in levels of 0.15 mg/l and 0.20 mg/l, concentrations in liver and bile were markedly higher. By exclusion of other reasons for death a lethal sertraline intoxication was decided. Sertraline is suggested to possess a low inherent toxicity, however, a risk of side-effects which may occur in single cases even under moderate dosages should be considered.     

Demonstration of a chloroquine fatality after 10-month earth-grave

A 19-year-old woman suspect of a suicidal drug intoxication was exhumed after a 10-month earth-grave, because the police was accused of manslaughter and neglected help by the relatives of the deceased. Toxicologic analysis revealed as the cause of death an acute chloroquine intoxication. An expert opinion had to deal with the question if the woman would have been saved if the police had appeared earlier. Therefore the duration of agonal period after suicidal chloroquine ingestion was important. An estimation of the time since death was possible on the one hand ex-post from the development of cadaveric changes and supravital reactions and on the other hand, based on premortal changes detectable on the body together with the findings of the authorities. Taking into account all evidence the woman was probably already dead at or prior to the arrival of the police (110 min after ingestion), at least this could not be excluded. Chloroquine has to be considered to be useful for fatal poisoning, which is also recommended in some publications on methods to commit suicide.     

Sudden, unexpected death due to cardiac fibroma. Report of a case and review of the literature

A case of cardiac fibroma in a 58-year-old woman with a history of atrioventricular block is described. The patient died suddenly at home 6 days following the insertion of a pacemaker. Review of the pertinent literature is presented.     

Rolled up to death. An unusual autoerotic fatality

Recently, an unusual case of autoerotic death in which a man died of hypoxia after having enclosed himself in plastic was reported in this Journal (1). We present a second case showing many similarities to the one published previously.     

Bioinformatics and human identification in mass fatality incidents: the world trade center disaster

Victim identification initiatives undertaken in the wake of Mass Fatality Incidents (MFIs) where high-body fragmentation has been sustained are often dependent on DNA typing technologies to complete their mandate. The success of these endeavors is linked to the choice of DNA typing methods and the bioinformatic tools required to make the necessary associations. Several bioinformatic tools were developed to assist with the identification of the victims of the World Trade Center attacks, one of the most complex incidents to date. This report describes one of these tools, the Mass Disaster Kinship Analysis Program (MDKAP), a pair-wise comparison software designed to handle large numbers of complete or partial Short Tandem Repeats (STR) genotypes, and infer identity of, or biological relationships between tested samples. The software performs all functions required to take full advantage of the information content of processed genotypic data sets from large-scale MFIs, including the collapse of victims data sets, remains re-association, virtual genotype generation through gap-filling, parentage trio searching, and a consistency check of reported/inferred biological relationships within families. Although very few WTC victims were genetically related, the software can detect parentage trios from within a victim's genotype data set through a nontriangulated approach that screens all possible parentage trios. All software-inferred relationships from WTC data were confirmed by independent statistical analysis. With a 13 STR loci complement, a fortuitous parentage trio (FPT) involving nonrelated individuals was detected. Additional STR loci would be required to reduce the risk of an FPT going undetected in large-scale MFIs involving related individuals among the victims. Kinship analysis has proven successful in this incident but its continued success in larger scale MFIs is contingent on the use of a sufficient number of STR loci to reduce the risk of undetected FPTs, the use of mtDNA and Y-STRs to confirm parentage and of bioinformatics that can support large-scale comparative genotyping schemes capable of detecting parentage trios from within a group of related victims.     

Tissue distribution of ethosuximide and clobazam in a seizure related fatality

The case of a six-year-old male who died in a hospital while receiving several anticonvulsant drugs is described. Phenytoin, desmethyldiazepam, clobazam (an experimental 1,5 benzodiazepine), and desmethylclobazam were quantitated in serum, liver, and brain tissue by high performance liquid chromatography. Ethosuximide was quantitated by gas chromatography. To our knowledge, this is one of few reports describing tissue concentrations of ethosuximide collected at autopsy and the first report of clobazam/desmethylclobazam tissue distribution in man.     

A special case of bolus fatality

The case of a 58-year-old man is reported, who had been hospitalized for almost 30 years for paranoid-hallucinatory schizophrenia. He was found unconscious in the clinic with a scarcely perceptible pulse and irregular breathing. Attempts at resuscitation were not successful. Looking at the corpse, no findings of particular value were noted. At the court-ordered autopsy, a mouse was found in the oral cavity; the head of the mouse was stuck in the laryngeal inlet. The cause of death was ascribed to asphyxia by alimentary bolus; the cause of death was apparently the effect of choking combined with a reflex action. In the large colon (megacolon) many metal objects were found. On the basis of the evidence, it was assumed that the mouse was already dead when the patient choked on it. A disturbance in the ability to swallow as a result of alcohol or medication was ruled out, as were neurological diseases.     

Sudden unexpected death due to papillary fibroma of the aortic valve. Report of a case and review of the literature

The case of the sudden unexpected death of a 21-year-old man due to embolization of segments of an aortic valve papillary fibroma to the left main and anterior descending coronary artery is presented. The literature regarding cardiac papillary fibroma is reviewed with particular reference to those cases associated with sudden death.