Toxicological analysis after asphyxial suicide with helium and a plastic bag

A 23-year-old man was found on a raised hide in lying position, the head wrapped in a plastic bag connected with a helium gas cylinder by a polypropylene tube. The autopsy did not show any specific findings nor did the routine toxicological analysis reveal significant information regarding the cause of death (BAC 0.9 mg/g, diphenhydramine 0.81 μg/ml in heart serum). For the detection of helium in the lungs, gas samples from both lungs were collected by a method ensuring minimal dilution. Gas analyses were performed using a GC–MS with a split–splitless injector and a headspace syringe. As carrier gas the commonly used helium was replaced by nitrogen. Helium was found in clearly elevated concentrations in gas samples from both lungs. Therefore, suffocation by breathing helium enriched, and thus oxygen deficient atmosphere, can strongly be assumed as the cause of death.     

Death related to nasal surgery: case report with review of therapy-related deaths

The investigation of deaths that are suspected to be related to medical therapy present several challenges for the forensic pathologist. In all such cases, it is important for the pathologist to understand the therapy/procedure that may have played a role in death. As such, review of medical records and possible consultation with various medical specialists before autopsy can provide valuable information to ensure proper evaluation in any given case.Herein, we describe a rare death occurring as a complication of septoplasty, nasal polypectomy, and intranasal endoscopic ethmoidectomy, which are common surgical procedures performed by otolaryngology/head and neck surgeons. An otherwise healthy 58-year-old woman underwent the elective surgical procedures for a deviated nasal septum, multiple nasal polyps, and chronic ethmoid sinusitis. Following surgery, the patient never awoke from general anesthesia, and further evaluation before death revealed a basilar subarachnoid hemorrhage. Autopsy disclosed basilar subarachnoid hemorrhage, a traumatic defect of the right cribiform plate, and associated anterior cerebral artery injury with frontal lobe damage. No vascular anomalies were present. The cause of death was attributed to complications related to nasal surgery, and the manner of death was ruled "accident."Following the presentation of this case, the authors discuss these common nasal surgical procedures, including a summary of their known complications. In addition, the authors address and review the topic of deaths related to medical therapy.     

Fatal intoxication involving 2-methyl AP-237

Novel synthetic opioids contribute considerably to the opioid epidemic, especially with the frequent emergence of structurally similar compounds. This case report describes a fatal intoxication involving 2-methyl AP-237. A 54-year-old Caucasian male was found deceased from an apparent drug overdose. A plastic container labeled “2MAP” and a cut straw were found in the decedent's backpack at the scene. A white substance found in the container tested positive for fentanyl by field testing. According to his medical history, the decedent was treated for a drug overdose 3 years prior to his death. With no diagnostic findings at autopsy, the case was submitted for toxicological analysis. An unknown substance was detected in peripheral blood and urine using gas chromatography with nitrogen phosphorous detection (GC-NPD). Further testing was conducted using gas chromatography–mass spectrometry (GC–MS) and liquid chromatography-quadrupole-time-of-flight mass spectrometry (LC-QTOF-MS) which confirmed the presence of 2-methyl AP-237 and potential metabolites in blood and urine. Quantitation by GC-NPD revealed concentrations of 2-methyl AP-237 in blood and urine at 480 ng/mL and 4200 ng/mL, respectively. The toxicological analysis also identified and quantitated alprazolam in the blood at 55 ng/mL. Additionally, the metabolism of 2-methyl AP-237 was investigated and three hydroxylated metabolites were identified in peripheral blood and urine. Limited literature is available for the detection and quantitation of 2-methyl AP-237 in postmortem specimens. Given the toxicological findings with unremarkable autopsy findings, this case is an example of a fatal intoxication involving 2-methyl AP-237.     

Extracorporeal membrane oxygenation in the forensic setting: A series of 19 forensic cases

Extracorporeal membrane oxygenation (ECMO) employs vascular cannulation and a gas exchange circuit to provide support to patients with severely compromised cardiopulmonary function. ECMO is often the last intervention taken before death and thus presents a unique challenge to medical examiners. This study describes the characteristics of decedents on ECMO at the time of death, including clinical indications, types of circuit configurations, causes and manners of death, gross findings at autopsy, and therapeutic complications. Files of a regional medical examiner office within an academic medical center were searched for the period between 2013 and 2019. Nineteen cases were identified with a median age of 36 years. The circumstances surrounding the initial presentation included: sudden death, trauma, substance abuse, homicide, therapeutic complication, work-related injury, drowning, and hypothermia. The underlying causes of death included injury-related, as well as respiratory and cardiac-related natural diseases. The time spent on ECMO varied from less than 1 h to 10 months. Complications encountered due to ECMO included cannulation site bleeding, pneumohemopericardium, retroperitoneal hematoma, limb ischemia, clotting, and cannula dislodgement. The patient population likely to receive ECMO has significant overlap with death circumstances likely to be reported to the medical examiner. As ECMO therapy has become increasingly available, it is of importance for medical examiners and death investigators to be familiar with the procedure as well as its limitations. Familiarity with ECMO and its sequelae allows for the proper documentation of postmortem findings and fosters an informed determination of the cause and manner of death.     

Suicidal transurethral perforation of bladder

This case report describes a highly unusual way of committing suicide: the insertion of a cylindrical foreign body through the penile urethra, resulting in perforation of the urinary bladder and abdominal hemorrhage. The manner of death was determined by a psychological autopsy that successfully ruled out an autoerotic (accidental) death. The case is presented in order to alert medical examiners and psychiatrists that such a unique and painful method of taking one's life exists.     

Fatal Intoxication with Toluene Due to Inhalation of Glue

Two cases of fatal intoxications with toluene due to glue sniffing are described. In case 1, the autopsy did not indicate cause of death, while in case 2, the cause of death was determined to possibly be due to mechanical asphyxia by drowning. As the decedents had a history of glue sniffing, toxicological analyses were performed. Using gas chromatography with flame ionization detector and gas chromatography/mass spectrometry (GC/MS) with headspace method, toluene was detected in biological samples. Toluene ranged from 3.81 to 20.97 μg/g, with the highest concentrations observed in liver and brain (13.82–20.97 μg/g) in both cases. Based upon this data, the cause of death in both cases was determined to be toluene poisoning. Toxicological investigations are extremely important and should be considered mandatory in all deaths thought to be due to volatile substance abuse, as well as all deaths that are thought to be due to poisoning in young people.     

Medical negligence in drug associated deaths

According to epidemiological studies adverse drug events are one of the most frequently encountered complications during medical treatment, a leading cause of hospitalisation and frequent cause of death. However, medical malpractice claims due to medication errors seem to be relatively rare. Based on a retrospective multicentre study on medical malpractice cases with lethal outcome (n = 4450), drug related cases (n = 575) were further evaluated. In 50% of cases a causal connection between drug therapy and death could be ruled out already after autopsy. In 232 cases a causal connection between drug therapy and death could be approved (drug allergies, relative overdose, wrong application, mix-up of drugs and sepsis after injection abscess). However, within the legal context only in 70 cases a medication error was approved which was in 42 cases causal for death, in 28 not. Administration of contraindicated drugs, incorrect application and relative overdose in renal insufficiency are the prevalent mistakes. Concerning the frequency of ADE in epidemiological studies medication errors are underreported in all data sources on medical malpractice; this seems to be due to the fact that even doctors and attending physicians rarely recognize an ADE; furthermore approving the connection between drug effect and death is extremely difficult for the expert witness.     

Fatal Disseminated Cryptococcus as the Initial Presentation of HIV Infection in the Era of Highly Active Antiretroviral Therapy

Abstract:  Despite the availability of highly active antiretroviral treatment, many HIV-positive patients still present for the first time with a low CD4 count or an acquired immune deficiency syndrome (AIDS) defining illness. This may be due to patients' refusal to be tested for HIV, delay in seeking medical treatment, or the misdiagnosis of an AIDS-associated condition. We present a 39-year-old African American male with undiagnosed HIV, who died shortly after arrival to the emergency room. An autopsy was performed at the Dallas County Medical Examiners' Office, and the cause of death was determined to be disseminated cryptococcosis. Further investigation at autopsy revealed HIV 1/2 antibody positivity and HIV western blot positivity. This case demonstrates the importance of considering complications of HIV as a cause of death, even when the patient has no prior history.     

Oxycodone intoxication in an infant: accidental or intentional exposure?

A case is presented of a 10 month old male who went into cardiac arrest at a local store. The infant subsequently expired and was autopsied at the Office of the Chief Medical Examiner, State of Maryland. The only remarkable finding was the detection of oxycodone in the postmortem specimens; the blood and liver oxycodone concentrations were 0.6 mg/L and 1.6 mg/kg, respectively. Oxycodone was identified and quantitated by gas chromatography-nitrogen-phosphorus detection and confirmed by full scan electron ionization gas chromatography-mass spectrometry. The medical examiner ruled that the cause of death was oxycodone intoxication, and the manner of death was homicide. The key toxicologic question in this case was whether or not it was reasonable for the infant to be exposed to oxycodone exclusively through breast milk or through an alternate source. It was concluded that, at best, there were serious concerns about the likelihood of drug exposure through consumption of breast milk.     

Fatal virus-associated hemophagocytic syndrome in a young adult producing nontraumatic splenic rupture.

A 24-year-old man with no previous medical history was admitted to a local hospital with pancytopenia after a recent "viral illness." During his hospitalization, he developed sudden abdominal distension and hypotension. Surgical exploration of his abdomen revealed a ruptured spleen. The spleen was removed, but the patient did not survive the operation. We investigated this unexpected and unexplained hospital death for any traumatic or iatrogenic injury. The cause of death after review of the clinical history, autopsy, and microscopic sections was virus-associated hemophagocytic syndrome (VAHS). VAHS consists of a generalized histiocytic proliferation and marked hemophagocytosis associated with a systemic viral infection. Clinically it presents as pancytopenia and organomegaly. This recently described entity is often confused with malignant histiocytosis. This is the first case report of VAHS producing nontraumatic splenic rupture, thus adding to the differential diagnosis of spontaneous splenic rupture and sudden natural death.     

Fatal case of BOTOX-related anaphylaxis?

Anaphylactic drug reactions are rare and often serious events. The Botulinum toxin A, marketed as BOTOX, was recently approved by the Food and Drug Administration for cervical dystonia and glabellar wrinkles, after its approved use and success with blepharospasm, strabismus, and disorders of the 7th cranial nerve. It has been well received due to its efficacy in improving facial lines. This case report documents the first death associated with a Botox-lidocaine mixture given to a woman for chronic neck and back pain. Based on the medical records, autopsy, and laboratory findings, the cause of death was determined to be anaphylaxis to the Botox-lidocaine mixture. The history, indications, off-label uses and possible future applications of Botox are reviewed as well as the uses and complications of lidocaine. Although the anaphylaxis cannot be definitively proven to be due to Botox alone, this case warns of an adverse reaction related to Botox, a drug that is rapidly expanding in range of use as well as increased usage.     

An unusual drug death involving maggots

Toxicologic analysis of decomposed specimens provides greater analytical challenges than those encountered with fresh postmortem specimens. Despite the difficulties involved, in cases in which the cause of death is not determined at autopsy or when there is a strong indication of drug intoxication, all reasonable steps must be undertaken to perform as comprehensive a drug screen as possible. An unidentified white male was found in a field near a river. The body was decomposed and skeletonized, and 3- to 4-mm maggots were present on the body. Near the body was an empty bottle of secobarbital that had been prescribed to a female. There was no evidence of injury. Calf muscle and maggots were sent for toxicologic analysis. No volatile substances or drugs were detected in the calf muscle. Because intoxication due to secobarbital was strongly suggested from the scene investigation, the only other specimen available, the maggots, were tested for acid-neutral drugs. Secobarbital was identified by retention time and was confirmed by full-scan electron ionization gas chromatography/mass spectrometry. Based on the available information, the medical examiner ruled that the cause of death was secobarbital intoxication and the manner of death was suicide.     

Postmortem tissue distribution of olanzapine and citalopram in a drug intoxication

A 40-year-old white male was found dead in bed in a group home for mentally ill adults. The decedent had been diagnosed a paranoid schizophrenic. An autopsy was performed at the Office of the Cuyahoga County Coroner in Cleveland, Ohio. Toxicological testing detected olanzapine and citalopram in post mortem specimens. Multiple fluids and tissues were assayed by liquid-liquid extraction followed by gas chromatography with nitrogen phosphorus detection, and qualitative confirmation by electron impact gas chromatography/mass spectrometry. Drug concentrations [olanzapine: citalopram; mg/L or mg/Kg] determined in this case are the highest reported to date involving these drugs- 1.38:3.35 heart blood, 1.11:1.65 femoral blood, 60.24:32.43 urine, 6.47:10:71 liver, and 38.36:49.16 lung, respectively. Drug concentrations in tissues were found to be the highest in lung for both drugs and lowest in the heart. Citalopram but not olanzapine was detected in bone. The cause of death was ruled acute intoxication by the combined effects of olanzapine and citalopram and the manner, accident.     

Undiagnosed progressive supranuclear palsy in a patient with neuroleptic malignant syndrome due to use of neuroleptics: the utility of autopsy in deaths due to known drug reactions

Medical examiners must decide whether or not a complete autopsy is warranted in evaluation of deaths that have been referred to their office. This decision is influenced by many factors. In most cases, the choice to perform only an external examination occurs in deaths where the decedent had previously documented potentially lethal natural disease or well-documented trauma. We report a patient who apparently died of the sequelae of a well-known complication of pharmacotherapy (neuroleptic malignant syndrome following Haldol administration). The death was referred to the medical examiner's office, where, based upon the history, an external examination was performed. Subsequently, the family requested an autopsy by the treating hospital. The autopsy established the diagnosis of progressive supranuclear palsy (PSP). The patient's presenting signs and symptoms were not typical of the disease; however, PSP most likely played a role in the neuroleptic malignant syndrome-like manifestations the patient exhibited following the Haldol administration. The results of the complete autopsy highlight its importance in identifying and enhancing our understanding of the underlying conditions in natural disease-based causes of death involving known therapeutic complications.     

Fatal paradoxical air embolism diagnosed by postmortem imaging and autopsy

The recognition and visualization of an arterial gas embolism are difficult. We report a case of sudden death caused by paradoxical air embolism of coronary and cerebral arteries, diagnosed by the pre autopsy computed tomography (CT) scanning. A 54-year-old woman suddenly died after the self-removal of the jugular vein catheter. Postmortem imaging examination using CT scanning showed multiple gas embolisms in the cerebral arteries, pulmonary artery, right atrium and ventricle, left ventricle, aorta, and coronary arteries. These findings suggested that the occurrence of acute ischemia of the brain and heart caused by massive air inflow to the artery. Conventional autopsy revealed a patent foramen ovale of the heart. These results indicated that the patient died of paradoxical air embolization of the coronary and cerebral arteries through a patent foramen ovale because of right-to-left shunting. The use of postmortem imaging as an aid for conventional autopsy has proved to be of advantage in the case of gas embolism.     

Sudden Unexpected Death Due to Graves' Disease During Physical Altercation

We report a case of a 30‐year‐old woman who suddenly collapsed after having a physical altercation with her husband. Despite immediate resuscitation, she died on arrival at the hospital. The victim's parents requested an autopsy because they believed that their daughter was killed by her husband. Postmortem examination revealed that the victim had a diffusely enlarged thyroid gland and cardiomegaly with left ventricular hypertrophy. There was no evidence of significant trauma on the body. Further postmortem thyroid function tests and review of her medical history indicated that her death was due to Graves' disease. To the best of our knowledge, this is the first case reported of sudden death due to cardiac arrhythmia from Graves' disease induced by physical and emotional stress associated with the criminal activity of another person. The autopsy findings are described. In addition, the literature is reviewed and the significance of postmortem evaluation of thyroid hormones in the cases of sudden death is discussed.