Fatal complications of intramuscular and intra-articular injections

Four fatalities related to intramuscular and intra-articular injections are reported. In two of these cases a Staphylococcus aureus sepsis developed, as a consequence of injections into the left hip joint in one and in the lateral upper quadrant of the gluteal region in the other. The intra-articular injection of triamcinolone produced severe pain, but no marked signs of purulent arthritis were seen at autopsy, probably because of the anti-inflammatory effect of the corticosteroid. A cutaneous infection was seen in the gluteal region of the other patient, but no apparent abscess formation. In another case of intra-articular injection, purulent knee joint arthritis developed after an injection of glucosaminoglycan. The patient died of renal insufficiency, which was probably connected with the treatment of the arthritis with tobramycin and cefuroxim. The fourth case was that of a mentally ill patient who suffered sudden cardiac arrest after an intramuscular injection of chlorpromazine, but with no apparent signs of an anaphylactic reaction. It is suggested that vasodilatation and drop in blood pressure caused by the chlorpromazine could have had some effect, while cardiotoxicity of other psychotropic drugs with which he had been treated cannot be ruled out.     

Coincidence of Nicolau Syndrome and Rhabdomyolysis: Report of a Forensic Autopsy Case and Review of the Literature

Nicolau syndrome (NS) is a dermatological adverse reaction of intramuscular injections and is caused by several mechanisms. The etiopathogenesis remains unclear, and several hypotheses have suggested a vascular origin. Rhabdomyolysis (RM) is the destruction of striated muscle, with the subsequent release of muscle cell contents into circulation. NS and RM diagnoses may overlap. Herein, we present the autopsy findings of a 40‐year‐old female with NS complicated with RM. On clinical follow‐up, creatine kinase (CK) was 7146 IU/L, and urea and creatinine levels were elevated on the third day after intramuscular diclofenac injection. Possible ischemic process triggered the RM and subsequent acute renal failure. The opportunity for an early diagnosis was missed because the patient delayed seeking medical aid. The prognosis worsened, and the patient died due to secondary sepsis. Early diagnosis of NS before the occurrence of complications is the most important issue in patient education and can be life‐saving.     

Retropharyngeal Hematoma Secondary to Cervical Spine Surgery: Report of One Fatal Case

A 53‐year‐old woman suffering from radicular pain due to cervical herniation underwent a spinal surgery consisting of anterior cervical discectomy and fusion with an implantable titanium cage. Five hours after the procedure, the patient developed cervical swelling and dyspnea. An emergency surgery permitted evacuation of a deep cervical hematoma and intubation of the patient, who died some minutes later. The family of the deceased lodged a complaint with the public prosecutor because of unclear circumstances of death. After analysis of the medical records by two forensic pathologists, a medicolegal autopsy was ordered. Massive retropharyngeal and mediastinal hematomas were diagnosed. Pathological study confirmed acute cervical hemorrhage, but failed to detect the source of bleeding. The forensic pathologists concluded that death was due to mechanical asphyxia secondary to pharyngeal compression by the cervical hematoma. To the best of our knowledge, death secondary to retropharyngeal hematoma in this neurosurgical context is rarely encountered.     

A death due to perirenal hematoma complicating extracorporeal shockwave lithotripsy

Perirenal hematoma is an occasional complication of extracorporeal shockwave lithotripsy (ESWL) which does not usually require treatment. A 79-year-old woman died 23 h after ESWL. Forensic autopsy was performed to determine whether medical treatment contributed to her death. The cause of death was hemorrhagic shock due to massive hematoma from a ruptured small vein in the perirenal adipose capsule. No injury to other organs was found and the patient had neither coagulation abnormality nor venous disease. Perirenal hematoma can easily be diagnosed with abdominal sonography, if pain or symptoms of anemia develop. Doctors must be aware of the possibilities of severe renal hematomas after ESWL.     

Spontaneous fatal perforation of aorta and vena cava by Mobin-Uddin umbrella

A 60-year-old Caucasian woman died suddenly and unexpectedly after 4 days of dyspnea, lower back pain, and numbness of the legs. Autopsy revealed that death was due to perforation of both the aorta and the vena cava by the spikes of a Mobin-Uddin umbrella (an inferior vena cava filter designed to prevent recurrent pulmonary embolism) which was implanted 8 years prior to the patient's death. To prevent this type of lethal complication, it is suggested that the sharp spikes of the Mobin-Uddin umbrella be modified into curved, hook-like ends.     

Complications following cell therapy

So far, the law in the Federal Republic of Germany still allows the injection of fresh-cell preparations from animals as a roborant to increase the vitality of the organism and to strengthen the body's immune defense system. The use of "sicca-cell" preparations was provisionally forbidden in 1987 by the Federal Health Organization (Bundesgesundheitsamt; BGA). Prohibition of fresh-cell injections would have exceeded the authority of this office, although the same serious reservations also applied in the case of this treatment method. Several publications that have appeared since 1955 have reported serious complications of this therapy, some life-threatening and some even lethal. Two further cases are now added: (1) A woman aged 69 had been receiving treatment with cell injections for 9 years. Immediately after an injection of sicca cells she collapsed and was hospitalized; 7 days thereafter she developed an ascending paralysis with increasing inability to swallow or breathe. She died 25 days after the injection as a consequence of central and peripheral respiratory failure. Autopsy revealed the alterations typical for acute Landry-Guillain-Barré-Strohl syndrome. (2) A 76-year-old healthy woman had been receiving treatment with fresh-cell preparations for several years. After an injection of cell suspensions a painful local swelling was observed. The symptoms were interpreted as the consequence of an iatrogenic local hematoma, and repeated punctures were performed to obtain blood. The patient was transferred to a surgical department for further therapy. Two days after the injection she suddenly died with signs of acute cardiovascular failure. Autopsy revealed the signs of a fulminating clostridial infection and also the characteristic signs of Landry-Guillain-Barré syndrome with involvement of the autonomic nervous system. In both cases the development of an inflammatory process in the peripheral nervous system could be interpreted as an immune-mediated allergic disease, related to the repeated injection of heterologous antigenic material containing nervous tissues. This hypothesis would also explain the two other cases already published and would be consistent with the observed perivenous leukoencephalopathy of the central nervous system. The human disease pictures correspond to the well-established animal models of EAEM (experimental allergic encephalomyelitis) and EAN (experimental allergic neuritis). The pathogenesis is discussed; the major role of the central and peripheral nervous system is stressed, with special reference to the risk of acute autonomic failure. The need for specific autopsy techniques for the investigation of the entire nervous system, including spinal cord, roots, spinal ganglia and peripheral nerves with sympathetic chains, is raised.     

Sudden death due to unsuspected coronary vasculitis.

Coronary artery vasculitis is a well-recognized complication of polyarteritis nodosa and is occasionally seen in other forms of systemic vasculitis. However, involvement of the major epicardial coronary arteries leading to myocardial infarction and death is uncommon. Isolated coronary arteritis is even more rare. We report three cases of sudden death due to myocardial ischemia associated with arteritis of the major coronary arteries. All three decedents were previously healthy young to middle-aged men who had died suddenly after complaints of chest pain and shortness of breath. The autopsy findings and differential diagnoses are presented. Such cases are of particular interest to the medical examiner because of the sudden, unexpected nature of the deaths. An approach to the correct diagnosis is discussed.     

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.     

Three unusual neuropathologic-related causes of sudden death

We discuss the autopsy findings of three medico-legal cases of sudden death associated with uncommon neuropathologic findings of which the general forensic pathologist may not be familiar. Case 1 was a 43-year-old man who died of a seizure due to malignant melanoma of the temporal lobe associated with neurocutaneous melanosis (NCM). Case 2 was a 57-year-old woman with a history of mental retardation and incoordination because of chronic lead poisoning, who died of a pulmonary thromboembolism due to deep venous thrombosis status post left leg fracture after a fall down a staircase. Autopsy revealed atrophy and gliosis of her cerebellum as a result of childhood lead poisoning. The third patient was a 75-year-old woman who died as a result of acute bacterial leptomeningitis at the cervico-medullary junction with acute inflammation of the connective tissue of her upper cervical spinal column associated with subluxation of her atlantoaxial (AA) joint, also known as Grisel's syndrome.     

A sudden death with lung embolism after inadvertent infusion of zinc oxide shake lotion

A 74-year old woman in postoperative treatment after a colonic surgery died immediately after perfusion of about 1.5 mL of a white emulsion which was believed to contain 1% propofol via cardiac catheter into the right atrium. It was strongly suspected that a syringe with a zinc oxide shake lotion (consisting of 20% ZnO, 20% talc, 25% glycerol and 35% water) which was intended for external treatment had been mistaken for the propofol syringe. During autopsy, an anatomic cause of death could not be found. In order to exclude an intoxication and to determine the significance of the perfusion fluid in this context, toxicological and histological investigations were performed. Propofol and other drugs applied to the patient were found in therapeutic or sub-therapeutic range. However, in comparison to a control case, the zinc concentrations determined by AAS were about 200 times higher in lung tissue, 10 times higher in heart blood and 3–4 times higher in kidney and liver tissue. No increase was seen in venous blood. Histology showed a strong embolism of the lung tissue with birefingent sharp-edged crystals, which were identified as the talcum, and an amorphous component (ZnO). The same embolism was seen to a medium extent also in the brain sections and to a low extent in heart, liver, pancreas and kidney. Pulmonary embolism by talcum and zinc oxide was established as the cause of death which occurred by syringe swap due to insufficient security precautions in the drug administration. The results are discussed in context of pulmonary microembolism cases frequently described for drug addicts after injection of crashed talcum containing tablets.     

A throttled hemophilic who died due to choking

It is the first reported case, in which death occurred due to asphyxia by choking in a victim of throttling. When an alcoholic hemophilic patient was throttled, he became unconscious. On regaining consciousness he died after approximately 16 h due to sub-mucosal collection of extravasated blood which blocked his upper respiratory tract. This paper stresses this unique danger of trauma to neck in hemophilic patients.     

Pulmonary arterial fibromuscular dysplasia: a rare cause of fulminant lung hemorrhage

Arterial fibromuscular dysplasia (FMD) represents a collection of noninflammatory and nonatherosclerotic vascular diseases with a poorly understood etiology. Classically occurring in renal and cerebral arteries, this entity has also been reported in coronary, carotid, and other medium and small arteries. One case occurring in the pulmonary vasculature has been reported. Fatal hemothorax and lung hemorrhage have multiple causes, including other vascular malformations and connective tissue disorders; however, cases of pulmonary FMD are exceedingly rare. We report what appears to be the second such association, occurring in a 69-year-old man. The patient presented with a 3-week history of increasing dyspnea, fatigue, and productive cough; 3 days of increasing back and chest pain; and syncope. Chest radiograph showed a "white-out" of the left lung. The patient died shortly after admission from a fulminant respiratory disease of undetermined etiology. At autopsy he was found to have a massive left hemothorax resulting from an unsuspected pulmonary arterial fibromuscular dysplasia.     

Death during transforaminal epidural steroid nerve root block (C7) due to perforation of the left vertebral artery

Treatment for individuals suffering from migraines and pain due to an inflammation or impingement of a nerve range from noninvasive methods such as massage, physical therapy, and medications to invasive methods such as epidural steroid injections and surgery. Each method of treatment has an associated level of risk. While minor to moderate complications from such procedures do occur, deaths are very rare. We report the first cited case of a death associated with the pain management procedure called nerve root block, also referred to as a transforaminal epidural steroid injection. We present the medical history and autopsy findings of a 44-year-old white female who died of massive cerebral edema secondary to the dissection of the left vertebral artery and subsequent thrombosis due to the perforation of that artery by a 25-gauge spinal needle during a C-7 nerve root block.     

Fat Transfer and Fatal Macroembolization

Fat embolism is usually associated with long bone fractures or other trauma. The diagnosis is usually clinical, and in most cases, emboli are not fatal and not usually seen on gross examination. At the Los Angeles County Coroner's Office, we autopsied the victim of fatal macroscopic fat embolization to the lungs. The patient died during buttock enhancement surgery when fat from liposuction was injected into her buttocks. Fat embolism from liposuction and fat injection is reportedly rare, and macroscopic embolization is rarer still. Varicose veins can occur in the area of the sciatic notch and are known to cause painful sciatica symptoms. We suggest them as a potential conduit for macroscopic fat to reach the lungs. Simple pre‐operative questioning for sciatica symptoms and possible radiologic study to rule out sciatic varices seem prudent before undertaking buttock‐enhancing surgery. Careful fat injection with pre‐aspiration is always advised.     

Fatal biliary peritonitis due to postinsertion migration of a Robinson drain tip, with erosion into the liver parenchyma

Iatrogenic injury due to incorrectly sited drains and tubes is a rare but recognized complication and can occur at many different sites. Migration of correctly sited drains and tubes is rarer still. A handful of rare cases involving longstanding ventriculoperitoneal and lumboperitoneal shunts migrating and causing perforation of the bowel exist, often complicated by central nervous system sepsis. We present a previously unreported complication of a Robinson drain, one of 2 abdominal drains inserted under direct vision during a subtotal gastrectomy for carcinoma, in a frail 78-year-old woman. Twenty-four days postoperatively, after a period of predictably slow but steady recovery, bile-stained fluid was noted in the drain. Unfortunately, the patient rapidly deteriorated and died. Autopsy revealed multiorgan failure due to peritonitis. Both drains were noted to be correctly and firmly sutured to the skin. The tip of the right-sided Robinson drain was found to have migrated, eroding into the liver parenchyma, resulting in biliary peritonitis. The left-sided Robinson drain was correctly sited in the peritoneal cavity. We present the postmortem findings and a review of the literature.     

Left paraduodenal hernia: an autopsy case

We present a case of a left paraduodenal hernia diagnosed at autopsy. A left paraduodenal hernia is an internal hernia of congenital origin due to the abnormal rotation of the midgut during embryonic development. Internal hernias are a rare cause of intestinal obstruction, with the paraduodenal being the most frequent. The clinical course can be asymptomatic, cause chronic or intermittent abdominal pain, or present with acute abdomen. The clinical entity is a diagnostic challenge, which is illustrated in the present case where there patient died during hospital admission. The case also emphasizes the difficulty in diagnosing the disease by plain abdominal radiography.     

Argemone mexicana poisoning: autopsy findings of two cases

Epidemic dropsy, a disease due to Argemone mexicana poisoning, is characterized by pathological accumulation of diluted lymph in body tissues and cavities. Recently, the largest epidemic of the disease in India affected Delhi and its neighboring states during the months of August-September 1998. Over 3000 persons fell ill, and more than 65 died in the state of Delhi alone. Two cases belonging to the same family died, out of the large number of cases admitted in this tertiary care teaching hospital situated in eastern part of Delhi. Autopsy findings of these two cases are presented and discussed here along with the review of toxicity due to this poisoning.     

Philemon and Baucis Death? Two cases of double deaths of married couples

When two human corpses are found in temporal and locational context the assumption of a non-natural cause of death is close at hand. Suicide, extended suicide, homicide or accident (particularly with carbon monoxide) come to mind. When, however, a natural cause of death emerges for both after autopsy and further examinations, this provokes the question whether this incidence is coincidental. In our two presented cases, a married couple each was found dead together. In both cases, the wife needed nursing and was being cared for by a husband who died of cardiac disease shortly before the wife died. In one case, the wife died of acute uncompensated chronic congestive heart failure. In the other case, the cause of death of the wife was hypovolemic shock due to acute gastrointestinal bleeding from recurrent gastric mucosal erosion. It is to be discussed for both cases whether, given the pre-existing illness, the acute stress of the situation in view to the husbands' death may at least have favored the occurrence of death and may, thus, have led to the criminologically conspicuous situation of finding.     

Necrotizing fasciitis: manifestations, microbiology and connection with black tar heroin

A 10-year review of records of the King County Medical Examiner's Office found 87 deaths due to necrotizing fasciitis and related necrotizing soft tissue infections. In 64 of these cases there were sufficient details to provide an analysis of the manifestations, microbiology, and source of infection. One half (32) of the cases were due to injection of black tar heroin, the nearly exclusive form of heroin in the Northwest United States. Of those due to black tar injection, 24 were clostridial infections with various species represented, eight of which were Clostridium sordellii. Of the 32 cases not associated with drug injection, streptococcal species predominated, with Streptococcus pyogenes isolated in 14 cases. Only three of 32 cases not associated with injection drug use were clostridial infections. These differences were statistically significant. Staphylococcus aureus was isolated from 14 cases; two were methicillin-resistant strains. Overall, 28 of the 64 cases were polymicrobial infections, 15 due to black tar injection and 13 not associated with drug injection. This study supports the conclusion that necrotizing fasciitis due to black tar heroin injection is predominantly a clostridial disease, and in this way differs significantly from necrotizing fasciitis due to other causes.     

Klebsiella meningitis mimicking clinical deterioration from hemorrhage of a complex posterior fossa arteriovenous malformation

We report a case of a 33-year-old male with a history of complex posterior fossa arteriovenous malformation (AVM) with partial resection done in China; at follow-up in our unit, he presented with a 1-day history of acute deterioration of consciousness level after minor head injury. The clinical and radiologic features were compatible with spontaneous hemorrhage from the AVM, and the patient died 1 day after admission. However, postmortem examination revealed the direct cause of death was due to Klebsiella meningitis. The clinical catch is highlighted, and the importance of early and prompt detection of this condition is emphasized.