Immune responses in fatalities involving opioids.

In some cases of fatalities involving opioid use, the concentrations of detected opioids are not in the toxic range. Immune reactions can be triggered by opioid use, suggesting that immune response may be a factor in these cases. Autopsy cases from 2002-2012 were reviewed. Persons with physical, microscopic or serum evidence of allergic reactions and opioid use at autopsy were compared to persons who used opioids but had no such signs. Overall, 49 persons were identified who had used opioids, of which five had evidence of immune response. A medical history of asthma was significantly more common in persons with signs of immune response (P = 0.0244) and fatality (P = 0.0085) compared to normals. A history of asthma is suggestive of susceptibility to immunologic reactions to opioids, and correlates strongly with the cause of death.

Anatomical changes correlated with chronic pain in forensic medicine.

This study was performed to determine the relationships between chronic pain and anatomic changes that may occur in the body. Autopsies were performed on fatalities that required death investigation in Linn County, IA, or adjacent and nearby areas. Persons with chronic pain were older than the control population at the time of death. Diabetes, hypertension and depression were more common in persons with chronic pain. Certain causes of death may also have been related to chronic pain. The heart, lungs, liver, spleen and kidneys were significantly heavier in persons with chronic pain; emphysema and pleural and abdominal adhesions were more common in persons with chronic pain. There appear to have been diffuse changes in the body related to chronic pain. These changes may have been mediated by a number of systemic mechanisms that are involved with chronic pain, including cardiovascular activity, the immune system, the neuroendocrine system and others.

The medium, not the message. How tattoos correlate with early mortality.

OBJECTIVES: At autopsy, tattoos are recorded as part of the external examination. An investigation was undertaken to determine whether negative messages that are tattooed on a decedent may indicate a predisposition to certain fatal outcomes. METHODS: Tattooed and nontattooed persons were classified by demography and forensics. Tattoos with negative or ominous messages were reviewed. Statistical comparisons were made. RESULTS: The mean age of death for tattooed persons was 39 years, compared with 53 years for nontattooed persons (P = .0001). There was a significant contribution of negative messages in tattoos associated with nonnatural death (P = .0088) but not with natural death. However, the presence of any tattoo was more significant than the content of the tattoo. CONCLUSIONS: Persons with tattoos appear to die earlier than those without. There may be an epiphenomenon between having tattoos and risk-taking behavior such as drug or alcohol use. A negative tattoo may suggest a predisposition to violent death but is eclipsed by the presence of any tattoo.

Psychosocial complications of Crohn's disease and cause of death.

Patients who suffer from Crohn's disease are prone not only to the complications of a relapsing, unpredictable disease, but also to feelings of stigmatization; depression; and increased risk of suicidal ideation, suicide, or drug and alcohol abuse. Cases performed at the Jackson County Medical Examiner's Office from 2008 to 2010 were reviewed. Autopsy findings, investigator reports, toxicology results, medical records, and interviews with survivors were analyzed. Twelve cases of Crohn's disease were recovered. In 10 of these cases, inflammatory bowel disease was not the cause of death. Instead, psychosocial consequences of the disease had significant implications in the deaths. The mean age of decedents was 45 years, with a female predominance. In eight cases, the decedents lived alone. Five patients had issues of acute or chronic drug or alcohol use. Five patients committed suicide. These cases underscore the role of psychosocial factors that can contribute significantly to the cause of death in patients with Crohn's disease.

Patterns of ecchymoses caused by manner of death and collateral injuries sustained in bruising incidents: decedent injuries, profiles, comparisons, and clinicopathologic significance.

We investigated how ecchymoses could be used to predict other injuries, or help establish the cause of death. Ecchymoses, fractures, lacerations, abrasions, and other data were recorded. Eleven percent of decedents had ecchymoses. Motor vehicle accident by car (MVA-C) was the most common cause of ecchymoses and showed the most collateral injuries. Decedents of natural causes were more likely to have ecchymoses without collateral injuries. There appeared to be two groups of decedents with ecchymoses: one group is younger, comprised of victims of MVA-C and homicides, with more injuries related to ecchymoses than others; another is an older group of victims of other accidents, natural causes, and suicide. There were no indeterminate causes of death among decedents with ecchymoses. Therefore, ecchymoses may be a surrogate marker to direct the pathologist to continue to seek a cause of death should be seen, even if the case, otherwise, appears to be indeterminate.

Optic nerve trauma with unilateral edema as a result of head injury.

We encountered a patient who suffered a head injury that translated to the optic nerves, leading to dramatic unilateral right optic nerve edema. The decedent was a 20-year-old unsecured passenger in a convertible. The car collided with a pickup truck. The patient survived for 8 h. At autopsy, a comminuted skull fracture involving the right frontal bone including the right orbital plate was found. The right optic nerve measured 1.2 cm in diameter, compared to only 0.4 cm for the left optic nerve. Microscopically, the right optic nerve was markedly edematous, but the nerve fibers and nuclei were viable and intact. The dramatic difference in size between the right and left optic nerves can be attributed to several mechanisms. The survival interval was essential for the asymmetrical swelling to take place. Optic nerve trauma is relatively rare in head injuries, reported to be present in 0.5% of automobile accidents and assaults. Other causes of optic nerve trauma and edema include tumors, osteopetrosis, or reaction to a peripheral hemodialysis shunt.

A fatality involving an unusual route of fentanyl delivery: Chewing and aspirating the transdermal patch.

We recently encountered a subject who died from an uncommon misuse of a fentanyl transdermal patch, chewing, followed by complications of aspiration of the patch. We report this case to alert medical examiners to the troubling trend of increased fentanyl patch abuse and its expanding range of misuses and associated morbidities. The decedent was a 28-year-old white male with a past medical history of prescription drug abuse who was pronounced dead in the emergency department shortly after arrival. An autopsy was completed and a tough but stretchy beige foreign body was identified lodged in a mainstem bronchus. Toxicological analysis of femoral blood showed methamphetamine, fentanyl and norfentanyl concentrations of 1456, 8.6 and 1.4 ng/mL, respectively. Individuals who abuse prescription medications often modify the route of administration of the drug from the intended method. As this case demonstrates, this choice can be fatal. The novel findings include a chewed patch, aspiration of a drug patch, and combination with an illicit drug at potentially lethal blood levels for both methamphetamine and fentanyl in a novice user.

Unexpected death following single blow to the orbit.

Severe brain injury is rare after assault to the head with a fist. Our patient was a 39-year-old white male who was punched in a parking lot. The subject fell on his right head. He did not lose consciousness. The subject was taken to the hospital. On admission, his blood alcohol concentration was 229 mg/dL. A CT scan of the head showed no injury. He was admitted to the detoxification unit. He became sober, and was seen ambulating at 3:30 am. By 5:20 am, he was unresponsive. A CT scan of the head showed that an epidural hematoma had developed over the right temporal lobe. The hematoma was drained. The patient did not recover. EEG confirmed no cerebral activity. At autopsy, the brain was removed, showing that the central brain was liquefied. The skull demonstrated a hairline fracture of the right temporal bone, corresponding to the impact with the sidewalk. Our patient differs from the typical victim of head trauma from assault in that severe brain injury or death is typically rare in assault. Alcohol is reported sometimes to have a neuroprotective effect in head injury. The present case illustrates an extreme conclusion of an otherwise-routine head trauma.

Dyads of father and son suicide separated by time and circumstances.

We encountered 2 dyadic suicides among fathers and sons. In the first dyad, the father was a 64-year-old man with complications of heart surgery. He committed suicide with a shotgun. The decedent's son was a 38-year-old man. Five years after his father's death, the son had an argument with his wife. That morning, he drove to the house where his father had lived and inflicted a handgun wound to his head. In the second dyad, the son was a 22-year-old man whose girlfriend left him. He inflicted a shotgun injury to the head. His blood alcohol level was 294 mg/dL. The father of this decedent was a 43-year-old man who 1 year later was despondent after a fight with his girlfriend. He was found dead at home with a single handgun wound to the chest. His blood alcohol level was 173 mg/dL. All 4 suicides appear to have been premeditated and all 4 men used guns. Suicide in a family tends to cause depression and complicate bereavement in survivors more than other types of death. Copycat suicide is well-documented in high-profile cases. The effect of father-son relationships is likely closer and more influential than celebrity suicides.

Identification at autopsy of pulverized pills in lungs of a first-time methadone user.

We recently encountered a 25-year-old white man who died of substance abuse including methadone. The route of administration of the drug(s) appears to have been insufflation. He was found dead at home. There were bottles of prescribed medications and an empty bottle of non-prescribed methadone. There was a grinding device nearby. At autopsy, no needle tracts were identified. Microscopically, the bronchi had desquamated ciliated respiratory epithelium admixed with red-brown pigment, which was found under plane-polarized light to be comprised of birefringent finely-granular material consistent with pulverized pills. Blood toxicology was positive for tetrahydrocannabinol, sertraline, nicotine, and methadone. The cause of death was ruled drug interactions with cerebral and pulmonary edema, the manner of death accidental. The decedent fit a profile of a victim of prescription drug abuse, for whom the mode of administration of drugs may be altered from intended use in as many as 80% of cases.

Mast cell tryptase in a case of anaphylaxis due to repeat antibiotic exposure.

Mast cell tryptase can be an indicator of type I hypersensitivity reaction and thus may serve as a surrogate marker of anaphylaxis. A 34-year-old white male patient presented with a history of systemic lupus erythematosus. Shortly after administration of cefazolin for dialysis, he developed pruritus and shortness of breath. He expired an hour later. Autopsy excluded anatomic causes of death. There was an elevated postmortem mast cell tryptase level, 29.2 ng/mL. For mast cell tryptase level to be useful, the patient must survive long enough after exposure to an allergen for mast cells to release this enzyme. A credible allergen must be identified. In this case such, mast cell tryptase could establish anaphylaxis as the cause of death. The case suggests that in a patient with autoimmune disease, it may be prudent to test for immune reaction to a drug before administering it a second time via pinprick or other method.

Brain trauma in head injuries presenting with and without concurrent skull fractures.

Head injuries and skull fractures may be problematic in cause and manner of death. Over a 10-year period, 54 cases showing head injuries were studied. Of these, 34 had skull fractures and 20 had no skull fractures. Virtually all decedents with skull fractures had brain injuries. The most common injury in both groups was motor vehicle accidents (MVA), in which 50% had skull fractures. In cases of skull fracture, brain lacerations, hemorrhages, and cerebral edema were common. Of 20 decedents with head injury but no skull fracture, most were accidents, and all but 3 cases had brain injury, although often relatively minor, except for atlanto-occiptital dislocation. There were significant differences between the two groups. Decedents with skull fractures tended to by younger (mean 35 years) compared to those with head injury only (mean 52 years) (p=0.0021). The use of drugs or alcohol was more likely in decedents with skull fractures than in those with head trauma only (p=0.0431). Mean abbreviated injury scale scores were higher for the face and head/neck of decedents with skull fractures, while significantly lower for chest and extremities, compared to decedents without skull fractures. Brain injury of some kind occurred in 90% of cases of head trauma, so a high level of suspicion should be placed in seeking skull fractures or brain injury.

Death from undiagnosed glioblastoma multiforme and toxic self-medication presenting with concurrent dysfunctional behavior.

We encountered a decedent with an unexpected glioblastoma multiforme. A 61-year-old retired African-American woman was found dead in her home, fully clothed in her bathtub, with a pillow under her head. At autopsy, the brain showed a glioblastoma multiforme. Toxicology showed elevated hydrocodone, propoxyphene, acetaminophen, and positive paroxetine. The presence of a brain tumor likely caused a severe headache. The use of her medications could have indicated a reaction to the escalating pain of the brain trauma, and overuse could be consistent with escalating pain or loss of rational thought processes. The present case is interesting in that it had evidence of behavioral dysfunction that could be related to the brain tumor, and death arising from the glioblastoma multiforme (cerebral hemorrhage and edema) with concurrent multiple drug intoxication.

Massive internal injury in the absence of significant external injury after collisions of passenger vehicles with much larger vehicles.

We have encountered cases of motor vehicle collisions in which there was relatively little external trauma, but there were massive internal injuries that were much more extensive than might be expected from the external examination. Two cases were collisions between trains and pickup trucks, the third a collision between a semi trailer and a van. In all three cases, the external examination showed minor abrasions and lacerations. Internally, however, there were massive injuries which were fatal. While the significant injuries in our cases were not surprising given the force of the collisions involved, it is interesting that the external examination showed relatively little injury. We speculate that collisions between passenger vehicles and very large vehicles generate massive internal injuries by transmission of force through the victims.

Classes of drugs and their prevalence in multiple drug intoxication in suicides and accidents.

In autopsy cases of multiple drug intoxication (MDI), the drugs identified may seem inadequate to cause death, especially when no drug is present in a concentration that is considered lethal. We sought to describe the combinations of drugs in MDI and to discern trends that could aid in the investigation of these deaths. Medical examiner autopsy cases were surveyed. MDI was established by postmortem blood screening. Of 24 cases, 13 were determined to be suicides, 9 were accidents, and 2 were indeterminate. The mean age was 37 years. Men were more likely to die from MDI by accident while women were more likely to die from suicide. The mean number of drugs found in suicides was 4, compared to 2 in accidents (p=0.0274). Opiates, antidepressants, benzodiazepines, ethanol, and cocaine were equally likely to be present in either group. Other legal drugs were more likely to be found in the suicides (p=0.0115). Ethanol was considerably less common in fatal MDI than controlled prescription drugs such as opiates and benzodiazepines, and also less common than other prescription drugs. These data suggest profiles that may help elucidate manner of death in indeterminate cases of death from MDI.