The "mini-packer" syndrome. Fatal ingestion of drug containers in Baltimore, Maryland

We report seven fatalities resulting from the ingestion of illicit drugs packaged in condoms, rubber balloons, or plastic bags which were observed in the last 4 years at the Office of the Chief Medical Examiner, State of Maryland. All the victims, with the exception of one, were men ranging in age from 19 to 37 years. There was no racial predominance. No drug paraphernalia was found at any scene. In two cases, seizure-like activity was documented. One victim had recently returned from Nigeria; therefore, Lassa fever was initially suspected. Two of the victims were "body packer" contrabanders who had just arrived from Africa. They used body cavities to hide large amounts of heroin to avoid U.S. Customs. The other five cases were "mini-packers," small-time illicit drug dealers who had swallowed a single bag of cocaine to avoid police detection. The possible mechanism of leaking or rupture of the latex container is discussed.     

Causes of death of patients in an institution for the developmentally disabled

The causes of death of 53 severely to profoundly developmentally disabled patients who died in an intermediate care facility were reviewed. Respiratory disease, predominantly pneumonia and aspiration, accounted for 72% of deaths. Seven patients died of nonrespiratory causes, and in 8 patients, no cause of death could be determined, even after a complete autopsy or investigation. The median age at death was 20 years. The weights of these patients' organs at autopsy were lower than those for normal individuals of the same age. The lifespan of these severely impaired individuals continues to be significantly shortened, even with improved methods of care.     

Schizophrenia and sudden death: a medical examiner case study.

This study reviews the causes of sudden death of 66 schizophrenic patients who presented to the Office of the Chief Medical Examiner (OCME) for the State of Maryland over a 3-year period from 1994 through 1996. We identified an increased incidence of suicide compared with the general population of OCME cases. This observation is consistent with reports by other investigators. The majority of the deaths were the result of natural diseases, mostly atherosclerotic cardiovascular disease. Accidents, suicides, and 1 homicide were also present in this group.     

Diagnosis of sudden death in infants due to acute dehydration

When infants die suddenly of acute dehydration, clinical signs and autopsy findings may be equivocal or absent, and microbiologic cultures often are not helpful. Vitreous humor electrolyte and urea nitrogen concentrations were measured in 53 infants dying of gastrointestinal infections, sudden infant death syndrome (SIDS), other infectious diseases, and miscellaneous causes to determine whether these parameters would assist in the recognition and confirmation of deaths resulting from dehydration. Significant differences were found when comparing the mean sodium and urea nitrogen levels of infants dying of gastrointestinal infections with those succumbing to SIDS or other causes. We recommend that these determinations be routinely performed whenever the gross autopsy findings are insufficient to explain the death.     

The investigation of alleged insecticide toxicity: a case involving chlordane exposure, multiple sclerosis, and peripheral neuropathy

A man with no previous medical problems had two documented exposures to an insecticide containing the organophosphorous compounds chlordane and heptachlor. Six months to one year later, he began to experience neurological symptoms which progressed until his death. At autopsy, his brain showed classic findings of multiple sclerosis, and he had a severe peripheral neuropathy. Review of the literature indicates that the findings are not compatible with chlordane toxicity. Some of the factors to be used in determining the casual relationship between toxic exposure and disease processes are discussed.     

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.     

Sudden death due to a paraganglioma of the organs of Zuckerkandl

A 20-year-old woman died suddenly in a hospital emergency room after presenting with nausea, vomiting, back pain, and hypertension. At autopsy, an extra-adrenal pheochromocytoma (paraganglioma) of the organs of Zuckerkandl was found, with microscopic focal myocardial necrosis similar to that described in death from adrenal pheochromocytomas. Tumors of the organs of Zuckerkandl are extremely rare; less than 100 such cases have been reported in the world's literature, and only six, including the present case, have presented as a sudden, unexpected death. The symptoms of catecholamine storm may mimic those of acute drug intoxications, leading to misdiagnosis by both clinical physicians and pathologists.     

Status of alcohol absorption in drinking drivers killed in traffic accidents

One issue which constantly confronts the forensic toxicologist in drinking driver cases is the relationship between the breath or blood alcohol concentration (AC) of the driver at the time of an event such as a traffic stop or an accident and the AC measured at a time subsequent to the event. In theory, the AC can be rising, on a plateau or declining at the time of the event. Several studies have indicated that the overwhelming majority of drinking drivers are on a plateau or are post-absorptive at the time of the event. In this study, driver fatality cases investigated by the Office of the Chief Medical Examiner, State of Maryland during a three-year period were reviewed. Included in this study were cases positive for alcohol in the blood at a cutoff of 0.01 g/dL and death occurring within 15 min of the accident. In fact, many of these deaths were instantaneous or near instantaneous based on the injuries documented by the medical examiner at autopsy. The blood and urine were analyzed for alcohol by head-space gas chromatography and urine AC to blood AC ratios were calculated. A total of 129 cases were included in this study. Eleven of the 129 cases (8.5%) had urine to blood AC ratio less than 1.0. It is likely that these individuals were in the absorptive phase at the time that the accident occurred. Thirty-two cases had a urine to blood AC ratio between 1.0 and 1.2 inclusive. In these cases, the subject could be viewed as in the plateau phase of the blood AC versus time curve. The remaining 86 cases had a urine to blood AC ratio greater than 1.2. This suggests that these individuals were in the post-absorptive state at the time of the accident. The information acquired from this study provides additional evidence to support the notion that the vast majority of individuals are not in the absorptive phase at the time of a traffic stop or an accident.     

Failure to detect elevated levels of carboxyhemoglobin in infants dying from SIDS

Carboxyhemoglobin (COHb) levels were determined in stored blood samples from 91 infants diagnosed to have died from the sudden infant death syndrome (SIDS) (0.59+/-0.41%, excluding one outlying value of 10.83%); 48 age-matched controls (0.53+/-0.38%); and three individuals who died from fire related causes (41+/-20%). No statistical differences in COHb levels were detected between blood from SIDS and control infants (p = 0.43).