Culture-negative primary sternal osteomyelitis in a patient with uncontrolled type 2 diabetes mellitus.

Primary sternal osteomyelitis (PSO) is a rare condition defined as an infection of the sternal bone marrow with no contiguous source of infection. The overlap in symptoms of PSO with other cutaneous and malignant pathologies often leads to misdiagnosis and delay of appropriate care. In this case report, we outline the presentation of PSO in a 30 year-old male patient who was newly diagnosed with type 2 diabetes mellitus. The patient was successfully treated with antibiotic therapy alone, without need for surgical intervention. Interestingly, the patient's workup returned with negative microbial cultures. To our knowledge, this patient represents the first reported case of a spontaneously presenting, culture-negative PSO.

Thirteen Cases of Valeryl Fentanyl in Michigan: A Call for Expanding Opioid Testing.

ABSTRACT: In this report, we describe 13 cases of drug overdose in Michigan in which valeryl fentanyl was found in postmortem blood. Valeryl fentanyl is a schedule I opioid that is rarely found in drug overdoses in the United States. Although little data exist on the mortality and morbidity associated with valeryl fentanyl, its molecular structure indicates that it would be less potent than fentanyl.When analyzing blood samples for valeryl fentanyl, samples from peripheral sites were sometimes negative for quantitative levels; however, samples from central sites in the same decedent were positive. This could indicate unique pharmacokinetics for valeryl fentanyl, which could have implications for other fentanyl analogs. Given the paucity of pharmacodynamic information, the prohibition of its use, the potential to buttress law enforcement efforts in monitoring drug trafficking trends, and to determine the efficacy of current regulations, laboratories should test for valeryl fentanyl. When testing for valeryl fentanyl, and likely other fentanyl analogs, the site of sample collection is important: central sources of blood are preferred to peripheral sources.

Longitudinal Opioid Surveillance Project Involving Toxicologic Analysis of Postmortem Specimens from 9 Counties in Michigan Suggests the Discovery of New High-Intensity Drug Trafficking Areas.

ABSTRACT: Acetyl fentanyl (AF) is a Schedule I fentanyl analog that has been increasingly seen in heroin and fentanyl polydrug toxicity overdoses in Michigan (MI). Drug users are often unaware of the presence of AF in their drugs because it is often sold mixed into or disguised as heroin. High levels of AF in heroin drug products can cause increased incidence of overdose. This article describes data from a longitudinal opioid surveillance program and details 102 decedents in MI who were found to have evidence of heroin in their postmortem blood. A large portion of these decedents were also found to have evidence of fentanyl and AF. Our data further show significant overlap in incidence rates of AF and heroin-related overdose deaths in several MI counties, suggesting that AF is becoming enmeshed in heroin trafficking. Furthermore, we report unprecedented high incidence rates of AF and heroin-related overdose deaths in Calhoun county, and we propose that it is a high-intensity drug trafficking area. Highways US-131 and US-31 are likely used to transport these drugs. More study is needed into the drug trafficking trends in MI to ascertain drug sources and monitor the ever developing and dangerous polydrug heroin combinations.

A complicated case of bowel obstruction with sepsis and methamphetamine toxicity in a child with pica.

In this report, a pediatric case of bowel obstruction with sepsis complicated by methamphetamine toxicity is described. The decedent, an eleven-year-old female with a clinical history of pica, was found unresponsive in her home and pronounced dead following unsuccessful resuscitative efforts. Radiologic imaging showed multiple radio-opaque foreign objects in the stomach and bowel. Autopsy revealed a green leafy substance, coins and other metallic items, folded paper, and plastic in her stomach and bowels. Postmortem iliac blood and urine tested positive for amphetamine and methamphetamine. While the decedent's medical history and autopsy findings provided evidence consistent with bowel obstruction with sepsis due to the ingestion of foreign materials, the high methamphetamine concentration was suggestive of concurrent methamphetamine toxicity. Unique complications associated with this case include the phenomenon that methamphetamine toxicity and bowel obstruction can present similarly in children and the reported opinion that accidental drug ingestion is uncommon in children over the age of five. This case emphasizes that the age range for suspected accidental drug ingestion should be expanded for those with pica, as these patients, despite being older, may not be able to differentiate between what they should and should not ingest. Furthermore, when treating a pediatric patient with pica that appears to present with bowel obstruction, unintentional drug ingestion should also be considered, particularly if there is a suspicion that the child lives in a household where drugs are abused, given the prospect that drug toxicity can present similarly.