Dispensing error causing fatal chlorpropamide intoxication in a nondiabetic

A 38-year-old nondiabetic female developed fatal hypoglycemia when chlorpropamide (Diabinese) was accidentally substituted for acetaminophen (Tylenol) with codeine no. 3 in a pharmacy dispensing error. When found, the patient's serum glucose was less than 20 mg/dL. The serum chlorpropamide level on hospital admission was 124 micrograms/mL. The possibility of dispensing error should be considered whenever unexpected drug effects are encountered. In cases of suspected drug overdose, labels and contents of medicine vials found at the scene should be checked for discrepancy.     

Postmortem differential diagnostics of diabetic and alcoholic ketoacidosis

It was shown that ketoacidosis may be an immediate cause of death in subjects suffering chronic alcoholic intoxication. The authors present a list of biochemical studies and parameters that can be used for differential diagnosis between diabetic and alcoholic ketoacidosis.     

A caliber-persistent artery of the gastric wall resulting in fatal haemorrhage

A 12-year-old girl was admitted to hospital with haematemesis. Her family suffered from histidinaemia. Due to her numerous injuries the police suspected a crime. After a short period of clinical treatment she died. Autopsy showed the left ureter to be narrowed and a consecutive abscedens pyelonephritis. Pyloric ulcer caused erosion of a caliber-persistent artery which led to death with haemorrhage. The death had nothing to do with violence. Adequate surgical treatment could have saved the patient's life.     

Estimation of caloric deficit in a fatal case of starvation resulting from child neglect

We report the case of a 3-year-20-day-old girl who died of starvation as a result of severe neglect. Her body weight had been 12 kg 70 days before her death, but was only 5 kg at the time of autopsy. From information supplied by her parents to police, we calculated her daily caloric intake and estimated the factors for physical activity. The daily recommended dietary allowance for the victim was calculated from 700 kcal/ day x the appropriate factor for physical activity. In the absence of enough food, body fat (7.2 kcal/g body fat) and protein (4 kcal/g protein) would have been used to compensate until death. The calculated body weight at the time of death was around 5 kg. The statements of the parents therefore appear to be true.     

Necrotizing fasciitis: reports of three fatal cases simulating and resulting from assaults

Necrotizing fasciitis is a progressive, potentially fatal, rapid, necrotizing infection of the subcutaneous tissues and fascia often caused by a mixture of organisms or by infection with group A Streptococcus pyogenes with or without Staphylococcus aureus. Three cases are presented that have been encountered in forensic pathologic practice. Two cases presented after assaults, and the third simulated an assault and burglary. The history, scene, and pathologic findings are presented with a brief review of the literature.     

Investigation of markers to indicate and distinguish death due to alcoholic ketoacidosis, diabetic ketoacidosis and hyperosmolar hyperglycemic state using post-mortem samples

Data from 191 post-mortem cases where post-mortem blood beta-hydroxybutyrate (βHB) and acetone concentrations and vitreous humor glucose concentrations (where available) had been measured were retrospectively investigated to determine the markers required to identify and distinguish between Alcoholic Ketoacidosis (AKA), Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic State (HHS). Blood βHB concentrations above 250 μg/mL were considered significant and it was shown to be the preferred marker of ketoacidosis. All cases with significant βHB detected also had acetone present (greater than 2mg/dL) demonstrating that acetone can be used as a marker to identify ketoacidosis and can be used to indicate when βHB measurement is necessary. Vitreous humor glucose concentrations above 6.9 mmol/L were considered high and indicative of hyperglycemia prior to death. Vitreous humor glucose concentrations can be used to distinguish between DKA and ketoacidosis from other causes and to identify deaths due to HHS. The data showed that ketoacidosis can occur without a history of alcoholism or diabetes. Many diabetics are undiagnosed for many years. Therefore, DKA or HHS should be considered in sudden or unexplained deaths and glucose should be routinely measured especially in cases with risk factors for diabetes including obesity, old age, a history of mental health problems or treatment with atypical antipsychotic drugs including clozapine, olanzapine, quetiapine and risperidone.     

Rupture of liver cell adenoma with fatal massive hemoperitoneum resulting from minor road accident

Blunt abdominal trauma can cause rapid death resulting from serious injuries of internal organs. The liver is commonly involved and may show tearing, usually in its upper surface, resulting in hemoperitoneum eventually leading to death. Minor trauma implies serious liver damage only when previous pathologic changes causing enlargement of the organ are present. The case of a 25-year-old woman who died as a consequence of a minor road accident is reported. At autopsy, the body showed no external injuries, the only relevant finding being a massive hemoperitoneum from the rupture of an unusually large liver cell adenoma. Liver cell adenomas carry a serious risk of spontaneous rupture, which may result in the death of the patient. The occurrence of the rupture after a minor blunt abdominal trauma is highly unusual.     

Postmortem detection of isopropanol in ketoacidosis

Isopropanol (IPA) detected in deaths because of diabetic ketoacidosis (DKA) or alcoholic ketoacidosis (AKA) may cause concern for IPA poisoning. This study addressed this concern in a 15-year retrospective review of 260 deaths in which concentrations of acetone and IPA, as well as their ratios, were compared in DKA (175 cases), AKA (79 cases), and IPA intoxication (six cases). The results demonstrated the frequency of detecting IPA in ketoacidosis when there was no evidence of IPA ingestion. IPA was detectable in 77% of DKA cases with quantifiable concentrations averaging 15.1 ± 13.0 mg/dL; 52% of AKA cases with quantifiable concentrations averaging 18.5 ± 22.1 mg/dL; and in cases of IPA intoxication, averaging 326 ± 260 mg/dL. There was weak correlation of IPA production with postmortem interval in DKA only (r = -0.48). Although IPA concentrations were much higher with ingestion, potentially toxic concentrations were achievable in DKA without known ingestion.     

Fatigue in multiple-car fatal accidents

In a re-examination of 334 fatal multiple car accidents, without any reasonable explanation besides possible intoxication, 205 drivers were found responsible for the accident. Twenty-one of these accidents happened between midnight and 0600 h and 11 of the drivers were found to be intoxicated with a blood/alcohol content (BAC) of more than 0.080%. The remaining 184 accidents took place during the rest of the day and 55 drivers were intoxicated. By comparing this apparent over-representation of intoxicated drivers in night-time accidents with that of a control group of no less than 15,923 drivers, it was possible to convert this over-representation into an under-representation. This decline in accidents while under influence seems to indicate another human accident factor specific to night-time traffic. It is concluded that fatigue is an overlooked but most obvious cause of otherwise unexplainable accidents in the night-time traffic.     

Sudden and unexpected death resulting from splenic artery aneurysm rupture: two case reports of pregnancy-related fatal rupture of splenic artery aneurysm

Rupture of a splenic artery aneurysm is a rare and usually catastrophic event, most commonly associated with pregnancy. In spite of increasingly common reliance on abdominal angiography, magnetic resonance imaging, and computerized tomography during the past quarter century, clinicians uncommonly recognize any of the various splanchnic arterial aneurysms absent premonitory signs or symptoms. Accordingly, rupture of a visceral aneurysm, including splenic artery aneurysm, typically presents as sudden, unexpected obtundation or death. As a consequence, the initial recognition and diagnosis of splenic artery aneurysm rupture take place only at autopsy. This report presents two such cases of sudden death resulting from splenic artery aneurysm in a pregnant woman and a postpartum woman, respectively.     

Esophageal injury in fatal rear-impact collisions

Neck injuries resulting from motor vehicle collisions (MVC), often referred to as whiplash trauma and injury, often demonstrate little or no evidence of significant tissue damage. In rare instances, however, serious injury to the anterior neck organ injuries can result from such trauma. The present study describes esophageal injury associated with rear-impact collisions, based on a unique case report, review of the scientific literature and a query in the National Automotive Sampling System (NASS) database of the US National Highway Traffic Safety Administration. The Medline search and present case study totaled five cases of rear-impact collision-related serious esophageal injury (laceration or rupture). In the four published cases all patients survived, whereas in the presented case study, the patient died due to mediastinitis and sepsis. The NASS query revealed an additional three cases out of a total of 55,926 investigated crashes. All three cases were associated with fatalities. Although no anatomical or bioengineering studies have presented data on the behavior of the esophagus during rear-impact whiplash loading, sudden tensile and/or compressive forces is the likely explanation of injury, often in combination with a local fracture of a vertebral body. In these 8 cases significant esophageal injury carried a substantial (50%) risk of mortality. Clinicians should be aware of the potential for significant complications in the whiplash trauma-exposed patient who complains of chest pain, mid-thoracic pain, discomfort in the neck and throat, respiratory distress, or hoarseness. For those forensic specialists involved in whiplash cases these study results highlight the need to consider esophageal injuries as a rare but potential consequence of whiplash trauma.     

Liver pathology in fatal drug addiction

Liver sections from 273 drug addicts submitted to medicolegal autopsy at the Institute of Forensic Medicine in Copenhagen in the period 1975 – 1979 were studied. In 65% of the cases non-specific portal inflammation only was found. Birefringent foreign material — identified as the mineral talc (magnesium silicate) was observed in 38% of the cases; in these cases non-specific portal inflammation was always present. Changes compatible with acute or chronic persistent hepatitis or hepatitis sequelae were observed in 8% of the cases; cirrhosis in 3%. HBs-antigen was detected in 4%. In 22% fatty infiltration was present; in 4% as the only abnormal finding. Finally no pathological changes were found in 6%. The results were related to anamnestic information of kind and duration of drug abuse and to the cause of death. Furthermore a comparison was performed between the groups with and without birefringent material. The data suggest that the birefringent material may be of importance to the pathogenesis of the non-specific portal inflammation.     

Injuries in fatal cases of falls downstairs

Downstairs falls frequently occur within domestic environments and are mainly associated with elderly and intoxicated individuals, often feature multiple injuries on various parts of the body. In most cases it is not possible to determine the cause of the fall and/or death solely by means of external examination. In this retrospective study, which covers a period of 11 years, all cases of death which included a fall downstairs in their case history, were collected from the Forensic Institutes of the Universities of Bonn and Greifswald, Germany. Falls downstairs made up to 2% (166 cases) of all postmortem examinations carried out within this period. Interestingly, almost double of the amount of such falls applied to males as to females. The primary cause of death was cranio-cerebral trauma and the vast majority of skull injuries associated with falls downstairs were found above 'the hat brim line'. Injuries were also often found on several other parts of the body at once. Nineteen of the 116 examined individuals exhibited agonal injuries. In these cases, postmortem examination revealed pre-existing disease or intoxication to be the cause of death and thus, cause of the fall. The injury pattern only allows a tendency towards vital or agonal incident as a conclusion.     

Vehicle-assisted suicide resulting in complete decapitation

A rare case of vehicle-assisted suicide in a 43-year-old man is presented. The man had tied a rope between a fence and his neck and, while seated on the driver's seat, accelerated the vehicle, which resulted in complete decapitation. Earlier that day, the man had tried to bleed himself to death by bottling his own blood in his flat, thus defining the case as secondary complex suicide.     

Toxicological findings in a fatal overdose of verapamil

Presented is a case where the death was attributed to the deliberate ingestion of an overdose of verapamil (V). Blood, urine, and gastric concentrations of the drug were determined by gas chromatography with nitrogen phosphorus detection (GC-NPD). Identification of norverapamil (NV) was made. A presumptive identification of o-demethylnorverapamil (DNV) was also made.     

Chemico-toxicologic findings in fatal suicidal poisoning by demeton-S-methyl

A case of lethal suicidal intoxication with demeton-S-methyl is reported. Capillary chromatography on wide-bore columns (CP-sil 5, 0.53 mm ID, 1 micron film thickness) was used for the quantitative determinations of this substance in the body fluids and tissues.     

Drug levels found in cases of fatal self-poisoning

A list of drug levels found in cases of fatal self-poisoning is presented here. These are all cases where only one drug was found and the cause of death in each case was attributed to an overdose of that particular drug. For each case a full drug screen was carried out. In general thin-layer chromatography (TLC) was used as the initial screening technique and any positive findings were then confirmed by gas liquid chromatography (GLC) and high performance liquid chromatography (HPLC). When the drug had been positively identified, the blood level was measured.     

A high endrin concentration in a fatal case.

Gas chromatography coupled to mass spectrometry was employed to quantify endrin in biological fluids in a death attributed to endrin overdose. The blood concentration of endrin was 544.9 mg/l. Results are discussed in the light of the existing literature.