Overdose and death with olanzapine: two case reports

Olanzapine is an antipsychotic drug that has been on the market since 1996. Olanzapine-related deaths are very rare; the literature reports only one. However, in a recent 5-month period one medical examiner's office found two such cases that are reported in this paper. One is a suicide and the other is not. The toxicologic and anatomic findings for each are described. Blood olanzapine concentrations ranged from 0.237 microg/ml for one to 0.675 microg/ml for the other. Gastric content concentrations also exhibited a wide range, varying from 0.197 microg/ml to 17.400 microg/ml for the other. Distribution studies of the liver, kidney, and brain produced nondetectable concentrations for the drug. There were no consistent pathologic anatomic findings for cause of death except for moderate coronary atherosclerosis in the nonsuicide case. Both deaths were attributed to olanzapine toxicity.     

Persian leopard (Panthera pardus) attack in Oklahoma: case report

The authors report a fatal case of a Persian leopard (Panthera pardus) attack in an animal sanctuary in Oklahoma. The victim was a 53-year-old Costa Rican woman who was attempting to feed the animal when she was attacked and killed. Autopsy, radiography, fingerprint analysis, microbiologic cultures, and dental impressions were used to evaluate the case. These simple techniques can be applied to similar cases involving wild and domestic animal attacks.     

A baby, a virus, and a rat

The authors present a case initially thought to be a child abuse homicide that, after complete autopsy and thorough investigation, was determined to be caused by a viral infection and complicated by postmortem animal activity. Neonatal herpes simplex infection and postmortem skin defects are discussed.     

Correlation of the incidence of cocaine and cocaethylene in hair and postmortem biologic samples

Hair samples are useful as a matrix for drug testing because drugs can be detected in hair for longer periods than in blood or urine. The authors report a prospective comparison of the detection of cocaine and cocaethylene in routine postmortem biologic specimens to the detection of cocaine and cocaethylene in hair. The authors collected hair samples from various areas of the head in 53 autopsy cases, prepared them, and analyzed them by gas chromatography/mass spectrometry (GC/MS) for cocaine and cocaethylene. The authors compared the results of hair analysis with the results of toxicologic analysis performed on routine postmortem samples by enzyme multiplied immunoassay technique and GC/MS. Cocaine was found in either biologic fluids or in hair in 16 of 53 samples tested. Nine samples were positive for cocaine in both biologic fluids and hair. Five samples contained cocaine only in biologic fluids, and two contained cocaine only in hair. Cocaethylene was present in two cases. Drug screening of hair provides additional information in some autopsy cases, but the authors have not made hair analysis a routine practice. It may prove useful to save hair samples in all cases for later analysis if warranted by additional history or autopsy findings.     

Restraint-related fatalities in mental health facilities: report of two cases

Mental health facilities are occasionally confronted with patients who display destructive or disruptive behaviors requiring physical restraint. Under these circumstances, restraint can be associated with death. This case report describes two fatalities associated with physical restraint applied by staff members at mental health facilities.     

Discrepancy between CYP2D6 phenotype and genotype derived from post-mortem dextromethorphan blood level

OBJECTIVE: To describe the death of a toddler after a therapeutic dose of dextromethorphan and its investigation. STUDY DESIGN: Case report, cytochrome P450 phenotype and genotype determination in the victim and post-mortem drug redistribution study performed in rats. RESULTS: A 20-month Asian male who received 3 mg of dextromethorphan once at 09:00 h and again at 22:00 h was found dead at 04:35 h. Post-mortem examination showed signs of early bronchopneumonia (bacterial cultures were negative); dextromethorphan and dextrorphan blood concentrations taken from the heart cavity were 500 ng/ml (1. 84 micromol/l) and 200 ng/ml (0.78 micromol/l), respectively. Despite the dextromethorphan level being almost 100-fold higher than expected after therapeutic doses, intentional or unintentional overdose was extremely unlikely; other potential causes were investigated. Post-mortem drug redistribution study performed in rats showed that dextromethorphan does not undergo extensive redistribution after death (6+/-5-fold increase) and could not explain the observed dextromethorphan level. The dextromethorphan/dextrorphan concentration ratio of 2.5 found in this toddler was compatible with a slow CYP2D6 metabolizer phenotype. However, the toddler exhibited a fast metabolizer genotype. Potential reasons for this discrepancy are discussed. CONCLUSION: CYP450 phenotypes derived from post-mortem blood levels should be interpreted with caution and preferably confirmed by a genotype analysis.