Sudden death due to forced ingestion of vinegar.

Vinegar is a clear colorless liquid that commercially consists of 5% acetic acid. It has numerous benefits in everyday use, including culinary, medical, and cleaning. The ingestion of concentrated acetic acid is strongly discouraged and may have detrimental consequences, such as acute pancreatitis, disseminated intravascular coagulopathy, gastric and hepatic complications, upper airway obstruction, or death. We report the first case in the literature of a 5-year-old boy who experienced a sudden death due to ingestion of distilled white vinegar. The manner was homicide. There was evidence of nonfatal blunt force impacts of the head, trunk, and extremities. A pungent aromatic odor of the viscera, gastric/small bowel contents, and cranial cavity was noted at autopsy. A dusky gray discoloration of the gastric mucosa, small bowel, and pancreas was observed. Forensic pathologists should consider ingestion of vinegar when confronted with a compelling history as well as an aromatic odor suggesting vinegar and dusky gray discoloration of the gastric mucosa and small bowel. While vinegar is a common household item and has several advantages, it may prove fatal if ingested in large quantities.

Sudden Death Due To Acute Cocaine Toxicity-Excited Delirium in a Body Packer.

Excited delirium denotes a life-threatening medical condition characterized by the acute onset of agitated and violent behavior that often results in a sudden and unexplained death. Cocaine-induced excited delirium refers to fatal cocaine intoxication with the following symptoms occurring sequentially: hyperthermia, delirium with agitation, respiratory arrest, and death. We present a case of cocaine-induced excited delirium in a cocaine "body packer" or a "mule", specifically an individual who attempts to smuggle cocaine within the body. Investigators at the scene initially suspected homicide due to the victim's sharp and blunt force injuries. Three rubber packets containing cocaine were removed from the victim's rectum. Blood toxicological analysis revealed an alcohol concentration of 0.016 g/100 and cocaine >1 mg/L. The forensic pathologist should consider cocaine-induced excited delirium when an individual exhibits aggressive behavior, unexpected strength, and resistance to pain who dies suddenly. Further analysis should be performed during the scene investigation and autopsy for evidence of body packing.

Filicide-Suicide: Case Series and Review of the Literature.

Homicide-suicides or "dyadic deaths" refer to a homicide followed by the suicide of the perpetrator within 1 week of the homicide. A unique subset is filicide-suicide: a parent kills his/her child before committing suicide. Shooting is the preferred method for both the homicide and suicide. The perpetrator has depression in most cases.We present 3 cases of filicide-suicide. In case 1, a divorced mother with schizophrenia and bipolar disorder shot her son and herself. In case 2, a father shot his son and himself while involved in a child-custody dispute. In case 3, a father, experiencing a divorce and financial difficulties, and his daughter with Angelman syndrome succumbed to carbon monoxide poisoning.The forensic pathologist should be aware of the psychosocial dynamics that interplay in filicide-suicide. Diligent attention to a parent's life stressors may aid in determining risk factors for filicide-suicide.

Early age-related progression of AD-like neuropathology in Down's syndrome.

We have previously reported that increased numbers of Alz-50-reactive (apoptotic) neurons occurred in young DS subjects compared to controls, but increased in density with increasing age, and in advance of identifiable senile plaques (SP) in DS. The purpose of the study was to determine if there are further differences in Alzheimer's disease (AD)-like neuropathology with increasing age among individuals with Down's syndrome (DS) compared to cognitively normal age-matched controls. The two populations compared were age-matched normal controls (N = 14) between 11 months and 61 years of age and individuals with DS (N = 8) between 1 and 54 years of age. There were 7 cognitively intact DS and 10 control subjects under 35 years of age. The single demented 54 year old DS subject was compared to 4 non-demented controls between 48 and 61 years of age. 50 µm Vibratome sections of formalin fixed hippocampal formations were immunohistochemically stained for amyloid-ß (6E10), APP (22C11) and phosphorylated tau (AT8) using standard methods. AT8 immunoreactive features were found only in the oldest DS subject. In contrast, the number and intensity of amyloid-ß-immunoreactive neurons were maximal in the youngest DS subjects (1-24 years), reduced in the young adults (25-35 years) synchronous with the appearance of only diffuse-form SP, and were further reduced in the 54 year-old DS subject exhibiting abundant multiform SP. Distribution of APP immunoreactivity (22C11) was distinct from amyloid-ß (6E10) in appearance and by location and age in both DS and normal controls. The data indicates that the earliest observable neuropathologic feature in DS may be neuronal accumulation of amyloid-ß. Such accumulation of amyloid-ß occurs decades in advance of deposition as SP, which in turn occurs decades before cognitive decline.

Sudden death due to polyarteritis nodosa.

Classical polyarteritis nodosa (cPAN) refers to a rare, potentially fatal systemic transmural necrotizing vasculitis that usually affects medium-sized, and occasionally small, muscular arteries, primarily involves the kidneys, gastrointestinal tract, skin, nervous system, joints, and muscles, and is rarely, if ever, expressed in the lungs. The incidence of mortality has significantly decreased with recently developed treatment modalities, in particular antiviral medications. Sudden death due to previously undiagnosed cPAN is rarely encountered. We report a case of a young man who had been evaluated on three occasions by medical personnel in the 3 weeks prior to his death. He had complained of nonspecific symptoms of abdominal and perineal/suprapubic pain, nausea, vomiting, sensation of chilling, and constipation. The spectrum of diagnoses included "gastroenteritis," enteric infection, and prostatitis. Found agonal at home and dying despite immediate cardiopulmonary resuscitation (CPR), he underwent a medicolegal autopsy, which revealed vasculitis of various organs, including heart (myocardium and epicardium) and extramural coronary arteries, liver, spleen, kidneys, adrenal glands, stomach and bowel, omentum, gallbladder, and pancreas. His sudden death was cardiac in nature due to PAN associated clinically with hepatitis B surface antigen positivity (hepatitis B virus-associated PAN [HBV-PAN]). A complete autopsy with thorough histopathological examination is necessary to diagnose this uncommon yet potentially fatal vasculitis.

Sudden and unexpected death from pituitary tumor apoplexy.

Pituitary tumor apoplexy refers to a clinical syndrome precipitated by the expansion of a pituitary adenoma by hemorrhage or infarction. Individuals may present with myriad signs, including sudden onset of severe headache, visual changes, altered mental status, cranial nerve palsies, and hormonal dysfunction. This disorder constitutes a medical emergency and warrants an expedited evaluation, diagnosis, and treatment to prevent the potential sequelae of permanent visual loss, endocrine abnormalities, or death. We report a case of sudden death from undiagnosed pituitary tumor apoplexy. The decedent was evaluated by medical personnel on three occasions in the week prior to her death for severe headache, nausea, vomiting, and photophobia. Postmortem examination demonstrated a hemorrhagic infarction of a pituitary adenoma with necrosis and expansion out of the sella turcica. The recognition of and treatment for a patient with pituitary tumor apoplexy requires a rapid multidisciplinary effort. Failure of prompt diagnosis may be fatal and require a medico-legal death investigation for sudden and unexpected death.

Sudden and unexpected death in three cases of Ehlers-Danlos syndrome type IV.

Ehlers-Danlos syndrome (EDS) type IV is a connective tissue disorder characterized by the inability to produce sufficient amounts of collagen or a defect in the structure of collagen. The most serious complications include a rupture of a viscus or vascular rupture with or without mural dissection. Death may result from internal hemorrhage. This report describes three cases of sudden and unexpected death caused by EDS type IV. Two cases involved hemothorax as a result of dissection of the subclavian artery and aorta, respectively. The third case represented spontaneous pulmonary rupture and hemorrhage. A detailed family history should be sought, and additional specimens collected to confirm the diagnosis, including skin fibroblasts for collagen testing and blood for DNA testing. The forensic pathologist should consider the possibility of EDS type IV upon discovery of spontaneous visceral or arterial rupture and should alert the family members of this hereditary and potentially fatal condition.

Death of a toddler due to ingestion of sulfuric acid at a clandestine home methamphetamine laboratory.

Exposure to strong acids such as sulfuric acid to either the skin or the gastrointestinal or respiratory mucosa will result respectively in significant-occasionally fatal-cutaneous chemical burns as well as devastating corrosive damage to the respiratory and gastrointestinal tracts. Most injuries are accidental, but there are reports of using acids as weapons or as a means of suicide. The primary mechanism of acid injury is coagulative necrosis of the tissues. Sulfuric acid is a chemical often used in industrial and chemical laboratories, and it is an ingredient in household products like drain cleaner. Easily accessible, over-the-counter, household drain cleaner is one of several common materials used to manufacture methamphetamine. With increasing clandestine methamphetamine laboratories in the United States, exposure to methamphetamine and the toxic chemicals used for its production is a growing problem. In many instances, children living in these laboratories qua homes are at risk for injury and death. We report the death of an unattended toddler, who ingested sulfuric acid drain cleaner in his home. The gross and histopathological autopsy findings in this case are similar to those of previously described cases of sulfuric acid injury.

Sudden death in a child with Carpenter Syndrome. Case report and literature review.

Carpenter syndrome (Acrocephalopolysyndactyly type II) is a rare disorder characterized by acrocephaly, mental retardation, congenital heart disease, syndactyly, preaxial polydactyly, obesity, cryptorchidism, hypogenitalism, bony abnormalities, and umbilical hernia. We present a case of unexpected death of a 7-year-old boy with Carpenter Syndrome complicated by twin and premature birth as well as repaired congenital heart disease.

Dog bite-related fatalities: a 15-year review of Kentucky medical examiner cases.

A human dog bite-related fatality generally refers to death proximately caused by trauma from a dog's teeth and jaws. According to The Humane Society of the United States, more than 300 individuals died of dog attacks in the United States between 1979 and 1996. Children <12 and elders >70 years represent the typical victims. Pit bull-type dogs, Rottweilers, and German Shepherds constitute the majority of canines implicated in these fatalities.This is a 15-year (1991-2005) retrospective review of dog bite-related fatalities undergoing medicolegal investigation in Kentucky. Of the 11 deaths, 10 consisted of multiple bite marks and blunt force injuries of the head and neck, trunk, and extremities. In 1 case, an asplenic victim's immediate cause of death was bacterial sepsis secondary to a dog bite. Individuals ranged between 14 months and 87 years; 7 (63.6%) were < or =6 years; 10 (90.9%) individuals were white, and 8 (72.7%) were male. Forensic odontological examinations were performed on the dogs in 4 cases. The requisite multidisciplinary investigation includes a detailed assessment of the scene, the victim, and dog or dogs suspected in the attack.

Angiotensin I-converting enzyme I/D polymorphism and suicidal behaviors.

Suicide is one of the ten most common causes of death in Western countries. It involves genetic vulnerability factors and is often associated with major depression. A Japanese team reported an association between the insertion allele of the angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism with completed suicide. The ACE I/D polymorphism was investigated in two independent case-control studies, one involving 64 suicide completers and 90 controls who all underwent forensic investigations, the second one consisting of 588 suicide attempters and 639 controls. In the two population samples studied a statistically significant risk of suicidal behavior was observed for subjects bearing the DD genotype. These results suggest a possible role of the renin-angiotensin system in suicidal behavior.

Russian roulette and risk-taking behavior: a medical examiner study.

Fatal Russian roulette refers to death following an act of extreme bravado in which the individual spins the cylinder of a revolver loaded with at least one cartridge, aims the muzzle at the head, and pulls the trigger. The majority of victims are men younger than 30 years who, in the presence of others, are under the influence of ethanol or other drugs. This is a 10-year (1993-2002) retrospective review of self-inflicted gunshot wounds of the head, among which we culled and paid special attention to cases of Russian roulette, at the Medical Examiners' Offices in Kentucky. Of the 24 incidents of Russian roulette, the majority of victims were white (79.2%), and all were men between 14 and 47 years with a mean age of 24.8 years. Compared with other cephalic firearm suicides, the subjects engaging in Russian roulette were significantly more likely to have elevated blood levels (> or = 0.1%) of ethanol along with various drugs detected in urine. Although the presumed intent of the risky act is to survive, Russian roulette is deemed to be suicide, which is based on a comprehensive understanding of the inherently deliberate, volitional actions of the decedent.

Is SIDS on the rise??

OBJECTIVE: Sudden Infant Death Syndrome (SIDS) is defined as a diagnosis of exclusion, after an evaluation of the medical history, complete postmortem examination, and scene investigation. The diagnosis of SIDS in many sudden and unexplained infant deaths has not been consistently applied nationally or, prior to July 2003, in the state of Kentucky. In order to better standardize practices in formulating the diagnosis of SIDS in cases of sudden and unexpected infant deaths, all of the Kentucky medical examiners formed a working group to collectively standardize the classification of this enigmatic type of infant death. METHODS: We conducted a retrospective review (2000-2004) of infants < 1 year who underwent complete historical review, circumstantial investigation, postmortem examination, and toxicological analysis performed at the Medical Examiners' Offices in Kentucky encompassing all deaths certified as Sudden Infant Death Syndrome, positional asphyxia, overlay, and undetermined cause and manner of death. RESULTS: A total of 417 cases were deemed sudden unexplained infant deaths after postmortem examination at the Medical Examiners' Offices in Kentucky between 2000 and 2004. A total of 237 (56.8%) infants had been bedsharing with at least one other person when found. Prior to the SIDS classification policy change in July 2003, a significantly greater number of sudden unexpected infant death cases were deemed undetermined in both cause and manner in contrast to a smaller number classified as SIDS. After the policy change, the number of deaths classified as SIDS greatly surpassed the number classified as undetermined. CONCLUSIONS: The increase in the number of deaths consistent with SIDS and a reciprocal decline in cases reported as undetermined cause and manner of death in Kentucky is due to the uniformity and standardization of terminology, rather than an actual increase in the number of infant deaths. The Kentucky policy in July 2003 has been invaluable in ensuring uniform criteria in the diagnosis of SIDS and other categories of sudden unexpected death in infants < 1 year.

Schizophrenia and suicide: a 10-year review of Kentucky medical examiner cases.

The risk of suicide is significantly increased in schizophrenics; it is estimated that 10-13% of individuals suffering from schizophrenia commit suicide. Schizophrenia is marked by psychotic exacerbations and remissions, with persistent deterioration in baseline functioning with each relapse. We present a 10-year (1993-2002) retrospective review of Medical Examiners' cases of suicide of schizophrenic victims. Twenty-nine cases were between the ages of 20 and 75 (mean age of 41.6 years). The majority of victims were male (62.1%) and Caucasian (86.2%). The leading method of suicide for both males and females was firearm injury (48.3%) mostly of the head, followed by overdose (20.7%), and hanging (13.8%). A comprehensive investigation of the biopsychosocial factors is warranted in cases of schizophrenics who commit suicide. This study offers an insightful analysis pertaining to the determination of intent in formulating the manner of death in this unique population.

Hypothermia and hyperthermia medicolegal investigation of morbidity and mortality from exposure to environmental temperature extremes.

CONTEXT: The determination of the cause of death from exposure to extreme temperatures is a diagnosis of exclusion. Because both clinical and autopsy findings are nonspecific, a thorough investigation of the background and scene, evaluation of temporally relevant environmental conditions, and assessment of the victim's underlying state of health with appropriate laboratory studies, which frequently include autopsy, are essential to establish the cause of injury and/or death with reasonable medical probability. Individuals may encounter environmental extremes in many settings during any season. Both constitutional and external factors exacerbate the stress brought about by extreme temperature. OBJECTIVE: This article reviews guidelines for forensic investigation into environmental temperature extremes that contribute to an important seasonal grouping of morbidity and mortality in the United States. DATA SOURCES: Articles on clinical and pathologic aspects of hyperthermia and hypothermia were collected and reviewed. CONCLUSIONS: Recognition of multiple risk factors predisposing humans to both cold-related and heat-related morbidity and mortality enhances prevention. Awareness of the susceptibility of these exposed at-risk individuals is crucial to investigations by both clinicians and medicolegal death investigators.

Adolescent and young adult suicide: a 10-year retrospective review of Kentucky Medical Examiner cases.

The compilation of all suicidal causes of death attained the third highest ranking of mortality between the ages of 15 and 24 following unintentional deaths and homicide in the United States, accounting for approximately 4000 deaths in 2002. A variety of biopsychosocial factors may contribute to adolescent suicidal behavior, including psychiatric disorders, risk-taking behaviors, and lack of a cohesive family unit. The authors conducted a 10-year (1993-2002) retrospective review of 108 Medical Examiner cases of suicide ages 11-17 and 358 cases ages 18-24 in Kentucky, which represents two thirds of the Coroner cases in the state. The majority of victims were male and Caucasian. The major causes of death were the same for the two age groups, specifically, firearm injury (72.2% and 70.7%), hanging (22.2% and 18.7%), and drug intoxication (2.8% and 5.3%). An integrated Coroner-Medical Examiner system profits in the public health arena by providing collaborative research data for policy decisions. The prevalence of youth suicide by firearm should prompt further discussion regarding ways to better identify high-risk adolescents and young adults and restrict pediatric access to unsecured household firearms.

Toxicologic findings in suicide: a 10-year retrospective review of Kentucky medical examiner cases.

Toxicologic analysis is an integral component in the investigation of suicide and requires correlation with a detailed scene inspection, with an extensive exploration into the decedent's medical and social background to uncover suicidal ideation or intent and a postmortem examination of the body. In this review, the authors analyzed 2864 cases classified as suicide upon autopsy and toxicologic examinations between 1993 and 2002 in the Kentucky Division of Medical Examiner's Services. Blood and urine were collected in 95.0% and 72.3% of cases, respectively. A total of 32.5% of the victims had negative blood toxicologic results, and 52.7% of urine toxicology screens yielded no drugs. Analysis of the data indicated that 3 times as many women had taken antidepressants and more than twice as many had consumed opioids. Drug toxicity ("overdose") ranked as the third (9.9%) leading cause of suicide after firearm injury (67.5%) and hanging (13.7%). Women succumbed to drug toxicity more than men (27.5% versus 5.9%). Of the overdose deaths, 66.5% had a negative blood alcohol concentration (BAC), while antidepressants, opioids, and benzodiazepines were detected in blood in 54.4%, 37.4%, and 29.2% of the subjects, respectively. The collection of these data serves the goals of public health and clinicians in devising strategies for suicide prevention.

The serotonin transporter promoter polymorphism and suicide.

Serotonergic dysfunction has been implicated in mood disorders and in the pathophysiology of suicidality. A functional polymorphism (a 44-base pair insertion (L)/deletion (S)) in the promoter of the gene encoding the serotonin transporter (5-HTTLPR), associated with mood disorders, has been inconsistently associated with suicidality. To add to this debate, we designed a case-control study involving 62 suicide victims and 72 controls matched for age, gender and ethnicity. All subjects underwent forensic investigation. No association could be detected between the 5-HTTLPR polymorphism and suicide. This result is consistent with the proposal that different genes are involved in hopelessness and suicidal behavior or in depressive illness.

Suicide in our elders : A 10-year review of kentucky medical examiner cases.

The suicide rate in the United States is consistently higher in the elderly (>-65 years) than among younger cohorts, reaching approx 5500 deaths in 2002. In this article, we present a 10-year (1993-2002) retrospective review of 348 Kentucky medical examiner cases ascribed to suicide between 65 and 96 years. Most victims were males (86.8%) and Caucasian (98.9%). The predominant cause of death was firearm injury (80.7%), followed by hanging (4.9%) and overdose (4.3%). The pervasiveness of elderly suicide by firearm requires a multidisciplinary approach to the recognition of indicators and the development of strategies for treatment and prevention of suicide in at-risk elders.