An Autopsy Case of Sudden Death in Neurofibromatosis Type 1 With Pheochromocytoma and Myocarditis.

An autopsy case of sudden death in a 33-year-old man with neurofibromatosis type 1 (von Recklinghausen disease), pheochromocytoma, and myocarditis is reported. The decedent was found in his bedroom in cardiopulmonary arrest. Polypoid, elastic dermal papules on the neck, chest, abdomen, and back, and flat dark-brown macules on the chest and abdomen were observed. Flat, ovoid, dark-brown freckles were present in both axillae. Examination of the right adrenal gland revealed a tumor measuring 5 cm × 5 cm × 3 cm. Microscopic examination of the myocardium revealed moderate neutrophilic and lymphocytic infiltrates. In the right adrenal gland, tumor cells contained abundant granular eosinophilic cytoplasm and exhibited cell-nesting with an alveolar pattern (Zellballen). Polygonal cells were seen together with rich vascular networks. Immunohistochemical analyses showed cells diffusely positive for chromogranin A and dopamine ß-hydroxylase. Furthermore, blood from the right heart and the right common iliac vein contained high concentrations of serum epinephrine, norepinephrine, and dopamine. Death was attributed to adrenal crisis: circulatory failure caused by excessive catecholamines produced by the pheochromocytoma. In addition, myocarditis, which had been induced chronically by catecholamines, would have also contributed adversely to the clinical course. Pheochromocytoma and myocarditis should be considered when sudden death occurs in the setting of neurofibromatosis type 1.

Pediatric autopsy case of asphyxia due to salmon egg (ikura) aspiration.

Here we report an autopsy case of asphyxia due to aspiration of a salmon egg (ikura) into the airway. The patient was a 19-month-old girl. During breakfast, she put salmon eggs into her mouth, and began to walk. She slipped, fell down, and collapsed. She was pronounced dead following 2 h of resuscitation. The body was autopsied 28 h after death. The gastric contents consisted of rice, orange sections, and white salmon eggs. The lungs were deeply congested and over-inflated. In the right lung, areas of atelectasis in the upper and middle lobes were seen. A yellow salmon egg (8 mm in diameter) was found in the trachea. Although fish eggs are consumed throughout the world, reports of this sort are limited. The aspiration of fish eggs is under-acknowledged and underreported. The importance of preventive measures needs to be emphasized to parents and caregivers.

Relationship between the matrix effect and the physicochemical properties of analytes in gas chromatography.

The phenomenon "matrix-induced chromatographic response enhancement" (matrix effect) causes quantitative errors in gas chromatography (GC) analyses. This effect varies according to the analyte nature, matrix type and concentration, and GC-system parameters. By focusing on the physicochemical properties of analytes, a predictive model was developed for the matrix effect using quantitative structure-property relationships. Experimental values of the matrix effect were determined for 58 compounds in a serum extract obtained from solid-phase extraction as the matrix. Eight molecular descriptors were selected, and the matrix-effect model was developed by multiple linear regression. The developed model predicted values for the matrix effect without any further experimental measurements. It also indicated that the molecular polarity (particularly H-bond donors) and volume of the analyte increase the matrix effect, while hydrophobicity and increasing number of nonpolar carbon atoms in the analyte decrease the matrix effect. The model was applied to the analysis of barbiturates. The predicted values indicated that N-methylation decreases the matrix effect, and the relative predicted values were effective for the selection of an internal standard. The obtained insight into the matrix effect and the prediction data will be helpful for developing quantitative analysis strategies.

A case of Takayasu arteritis complicated by right atrium perforation and injuries of the right common iliac artery and vein caused by cannulation for percutaneous cardiopulmonary support.

We describe an autopsy case of Takayasu arteritis with right atrium perforation and injuries of the right common iliac artery and vein caused by cannulation for percutaneous cardiopulmonary support (PCPS). The decedent was an 8-year-old girl admitted for examination in respect to chest pain and syncope. During catheter angiography, she suddenly went into cardiac arrest. PCPS was attempted, whereupon bleeding into the abdominal cavity and an injury to the common iliac vein were observed. She was pronounced dead 78 hours after the initiation of PCPS. Autopsy revealed thickening of the aortic wall from the ascending aorta to the abdominal aorta, with narrowing of the proximal branches. Hemopericardium induced by right atrium perforation, and an injury of the right common iliac artery, were also found. Microscopic examinations of the aorta disclosed thickening of each layer of the vessel wall and inflammatory cell infiltration, mainly into the outer layer of the media. It was speculated that manipulation of the catheter and the underlying Takayasu arteritis caused cardiac arrest. It is also considered that hypovolemia was induced by the injuries of the right common iliac artery and vein caused during the insertion of the PCPS venous cannula. In addition, the right atrium was injured by the edge of the PCPS cannula, leading to hemopericardium. In pediatric cases involving PCPS, or in cases where cannulation is difficult, regular examination of the pericardial and abdominal cavities by echocardiography would provide useful information to prevent such accidents.

Detection of levorotatory methamphetamine and levorotatory amphetamine in urine after ingestion of an overdose of selegiline.

In this study, we measured the urine concentrations of methamphetamine and amphetamine as metabolites of selegiline after ingestion of an overdose of selegiline. A patient who had developed Parkinson disease took selegiline in a suicide attempt. Analysis by gas chromatography-mass spectrometry (GC-MS) with trifluoroacetic acid-derivatization revealed the presence of methamphetamine and amphetamine in the patient's urine at concentrations of 0.62 microg/ml and 0.25 microg/ml, respectively. To determine the stereospecificity of the methamphetamine and amphetamine, a urine sample was analyzed by GC-MS after derivatization with N-(trifluoroacetyl)-l-prolyl chloride. The methamphetamine and amphetamine were levorotatory in form. The ratio of the methamphetamine to amphetamine concentration in the urine was 2.5. This value is consistent with other case reports of ingestion of selegiline, which suggests that the methamphetamine to amphetamine concentration ratio in urine is useful information for indicating use of selegiline.

A case of carbamazepine overdose with focal myocarditis.

An autopsy case of carbamazepine overdose with focal myocarditis is reported. The decedent was a 33-year-old female with a history of schizophrenia and bipolar disorder, who reportedly took 5-day dose of prescribed medications at around midnight. Although she stayed home following the direction of the physician, she was pronounced dead 8h after the intake. At autopsy she was obese, and her face was slightly swollen. The 420 g heart was free of coronary atherosclerosis, and the myocardium had no obvious scars. Both the left and right lungs were markedly congested and edematous. Strong congestion was also noted in the brain and visceral organs. Microscopic examination disclosed focal infiltration of inflammatory cells, most of which were lymphocytes, into the myocardium. In the toxicological analyses, carbamazepine concentration in the blood was 9.9 microg/ml, and other medications were below the toxic levels. It was considered that under the compromised cardiac function due to myocarditis presumably induced by some prescribed medications, and obesity, the carbamazepine overdose deteriorated her condition by triggering critical arrhythmia or congestive heart failure.

Clinical and toxicological findings of acute intoxication with synthetic cannabinoids and cathinones.

Aim: Reporting of the analytical and clinical findings of synthetic cannabinoids and cathinones is essential in carrying out a complete clinical assessment of new psychoactive substances. Methods: From 2012 to 2014, we examined synthetic cathinone and cannabinoid poisoning in six patients aged 22-42 years old. Analyses of these compounds were carried out using liquid chromatography-tandem mass spectrometry. Results: The observed clinical symptoms were similar to those reported for intoxication with synthetic cathinones and cannabinoids. In cases of intoxication with synthetic cathinones, the psychiatric and neurological symptoms were long-lasting, and these compounds were detected in serum for 15-48 h after use. Although the clinical symptoms induced by the synthetic cannabinoids disappeared within several hours after use, the range of serum concentrations of these compounds was ≤5 ng/mL for 1-3 h after use. In one fatal case, in which high serum concentrations of synthetic cathinones and cannabinoids were detected, the most plausible cause of death was heart failure due to overdose with these drugs. The long-lasting symptoms induced by synthetic cathinones correlated with the long detection window in serum, whereas the early disappearance of symptoms induced by synthetic cannabinoids corresponded to the short detection window in serum. Conclusions: This study shows that the profiles of synthetic cathinones and cannabinoids in serum are closely related to the duration of the toxic symptoms and that concomitant use of two psychoactive drugs with different pharmacological actions may have the potential for fatal cardiotoxicity.

Concentrations of toluene in the body killed by an injury to the head shortly after ingesting thinner.

An autopsy was conducted on a male showing leather-like skin damage, revealing the cause of death to be an injury to the head. Thinner was found scattered around the scene of death, and stomach and intestine contents smelled strongly of solvent. Toxicological analysis was conducted to determine whether or not the solvent was of a lethal level. Using gas chromatography, peaks of toluene, xylene, and ethylbenzene were detected in the blood and gastric contents. No toluene was detected in the urine, and therefore it was concluded that the decedent died of a severe head injury shortly after solvent ingestion. In the literature, toluene concentrations in blood and lung samples were determined as both fatal and non-fatal but clear differences in the fatality of toluene in solid organ samples, namely, the brain, liver and kidneys were shown. The brain is especially useful in postmortem analysis. In this case, the concentration of toluene in the brain was 20.0 microl/g, which was considered as a non-lethal level.

A case of acute gasoline intoxication at the scene of washing a petrol tank.

We encountered a case of acute gasoline intoxication at the scene of washing the inner wall of a petrol tank. The decedent was a 50-year-old male, who was the supervisor. Two young workers wearing mask respirators began to wash the inner wall of the gasoline tank under poor ventilation. About 1 h later, because one of the workers lost consciousness, the supervisor entered the tank, without a mask respirator, to rescue the worker. However, the supervisor immediately fainted, and died 26 h after the accident. In the autopsy, blisters were observed on the skin of the face, neck, anterior chest, upper extremities, and back. The heart contained hemolyzed blood. Histologically, hemorrhagic pulmonary edema, pneumonia, and proximal tubular necrosis were found. In the toxicological analyzes, toluene, xylene, and trimethylbenzene were detected in the blood, brain, and gastric contents. Toluene concentrations in the blood and brain were 0.3 mug/ml and 3.7 mug/g, respectively. Since pathological findings were consistent with the reported findings concerning gasoline intoxication, and constituents of gasoline were in the body, death was attributed to acute gasoline intoxication. It was considered that sufficient ventilation and proper use of a mask respirator were essential for this kind of work.

[A case of mixed poisoning by organophosphate and methanol].

We encountered a case of mixed poisoning by organophosphate and methanol. Each poisoning was comparatively frequent but we reviewed no cases of mixed poisoning of them. A 49-year-old woman was transferred to our hospital because of oral ingestion of organophosphorous compound (about 14 g of fenitrothion) and glass cleaner (about 40 g of methanol) for suicidal purpose. She underwent general antioverdose treatment including gastric lavage, activated charcoal and cathartics. For fenitrothion poisoning, she received atropine and pralidoxime. For methanol poisoning, she was treated with hemodialysis. Three days later, she moved to psychiatric ward from emergency ward without aftereffects and was given a diagnosis of depression.

Distribution of Aconitum alkaloids in autopsy cases of aconite poisoning.

Aconite is a well-known toxic-plant containing Aconitum alkaloids such as aconitines, benzoylaconines, and aconins. We describe here the distribution of Aconitum alkaloids detected by liquid chromatography-tandem mass spectrometry (LC/MS/MS) in three autopsy cases of suicide by aconite poisoning. Case 1: a male in his fifties had eaten aconite leaves. The concentrations of jesaconitine in cardiac blood, urine, and kidney were 12.1 ng/ml, 993.0 ng/ml, and 114.2 ng/g, respectively. Case 2: a female in her fifties had eaten aconite root. The aconite root in the stomach included a high level of mesaconitine. The concentrations of mesaconitine in cardiac blood, liver, and kidney were 69.1 ng/ml, 960.9 ng/g, and 776.9 ng/g, respectively. Case 3: a male in his sixties had drunk liquor in which aconite root had been soaked. The concentrations of mesaconitine and aconitine in cardiac blood were 259.5 and 228.5 ng/ml, respectively. The Aconitum alkaloid levels were very high in the liver. The absorption of ethanol and Aconitum alkaloids might have been increased because of his having undergone total gastrectomy. In all three cases, the Aconitum alkaloid levels were high in the liver and kidney and low in the heart and cerebrum. The level in the cerebrum was lower than that in blood. Data on the distribution of the Aconitum alkaloids in the body in cases of aconite poisoning is useful to elucidate various actions of aconite alkaloids.

A fatal case of acute hydrogen sulfide poisoning caused by hydrogen sulfide: hydroxocobalamin therapy for acute hydrogen sulfide poisoning.

A patient committed suicide with hydrogen sulfide (H(2)S) by combining two commercial products. The patient was given hydroxocobalamin as an antidote in addition to treatment with cardiopulmonary resuscitation, but died approximately 42 min after his arrival at the hospital. The patient's cause of death was attributed to acute hydrogen sulfide poisoning. Serum concentrations of sulfide before and after administration of hydroxocobalamin were 0.22 and 0.11 µg/mL, respectively; serum concentrations of thiosulfate before and after hydroxocobalamin administration were 0.34 and 0.04 µmol/mL, respectively. Hydroxocobalamin is believed to form a complex with H(2)S in detoxification pathways of H(2)S. Although H(2)S is rapidly metabolized and excreted, the decreased sulfide concentration may be also associated with this complex formation. The decreased sulfide concentration suggests that hydroxocobalamin therapy may be effective for acute H(2)S poisoning. The decreased thiosulfate concentration seems to be associated with formation of a thiosulfate/hydroxocobalamin complex, because hydroxocobalamin can form a complex with thiosulfate. The thiosulfate concentration decreased to a greater extent than did sulfide, suggesting that hydroxocobalamin has a higher affinity for thiosulfate than for H(2)S. Therefore, prompt administration of hydroxocobalamin after H(2)S exposure may be effective for H(2)S poisoning.

An autopsy case of aortitis resulting in sudden death due to a rupture of aneurysm of the aortic sinus.

An autopsy case of spontaneous rupture of a clinically undiagnosed inflammatory aneurysm of the aortic sinus is presented. A 34-year-old man consulted a physician complaining of anterior chest pain and heartburn persisting for 2 days. Diagnoses of common cold and gastritis were made, but 3h later his condition deteriorated, leading to death. Autopsy revealed hemopericardium due to rupture of a saccular aneurysm of the aortic sinus. Histological examination of the aortic sinus disclosed aortitis characterized by fragmentation and loss of elastic tissues with fibrous thickening of the intima. Lymphocytes along with polymorphonuclear leucocytes and plasma cells infiltrated the adventitia and media at severely affected areas. These changes were limited to the aortic sinus, and other portions of the aorta and its main branches were essentially intact. An eccentric intimal thickening with medial degeneration was found within the anterior descending branch of the left coronary artery, and occasional collection of lymphocytes was noted in the epicardium. This case would be a rare and illustrative case for differentiation of aortitis, although we could not pinpoint the etiology of the aortitis because of non-specific histological findings and negative serological results for exogenous pathogens.

An autopsy case related to a terrorist attack using a ball-bearing bomb.

We encountered an autopsy case related to a terrorist attack using a ball-bearing bomb. The decedent was a 51-year-old male without significant medical histories. During dinner in a restaurant, the perpetrator suddenly exploded a ball-bearing bomb, the blast from which blew the victim off his chair. The victim was found to be unresponsive, and pronounced dead. X-ray photographs taken before autopsy revealed six spherical shadows. Three penetrating wounds in the head, one in the neck and chest, and two in the left upper arm were observed in vivo. Six projectiles recovered from the body were identified as ball-bearings, one of which traveled through the midbrain, diencephalon, and left temporal lobe. Although blast injuries and penetrating wounds are often combined in bomb attack victims, penetrating brain injury would be the cause of death in this case. Lethal injuries to major organs can thus occur even though the destructive force of a ball-bearing bomb is weak. X-ray films were informative for detecting the ball-bearings in this case, suggesting that autopsy imaging is essential in cases of terrorism victims.