High blood mirtazapine concentration in a newborn - A case of suspected postpartum infanticide.

We report a sudden death of an infant due to mirtazapine poisoning. A 15-day-old newborn boy was found dead when he was sleeping beside his mother who had suffered from panic disorder for approximately 1 year. After giving birth, she complained of palpitations and shaky hands, and was prescribed mirtazapine. The deceased newborn weighed 3,282 g and his height was 55 cm. There were no autopsy findings related to the death. The mirtazapine concentration as quantitated by liquid chromatography-tandem mass spectrometry analysis was 620 ng/mL in right heart blood, and was approximately 10 times higher than the therapeutic level in adults. Because transfer of mirtazapine into breast milk is low, mirtazapine was likely administered intentionally to the newborn. Based on the newborn's immature renal, liver, and blood-brain barrier function, the cause of death was attributed to mirtazapine poisoning. Poison-related homicide in the infant is rare. We report the first case of intentional mirtazapine poisoning case in a newborn.

Postmortem computed tomography findings in cases of bath-related death: Applicability and limitation in forensic practice.

PURPOSE: Bath-related deaths occur frequently in Japan, and many of these deaths are diagnosed as death from disease without autopsy in the current Japanese death-investigation system. Therefore, we aimed to examine the postmortem computed tomography (PMCT) findings of bath-related deaths to determine if PMCT can differentiate between real cases of drowning and sudden deaths not related to drowning. METHODS: Bath-related deaths were sampled from all autopsies conducted at the Tokyo Medical Examiner's Office from September 2015 to August 2016. A total of 90 bath-related deaths (77 drowning cases and 13 non-drowning cases) and 50 controls (sudden cardiac deaths non-related to bathing) were included in this study. We investigated factors contributing to drowning and measured PMCT parameters (presence/density of fluid in the maxillary sinus/trachea, distance between the lungs, lung patterns [ground glass opacities, consolidation], position of the right diaphragmatic dome, density in the right atrium, stomach volume, and density of the gastric/duodenal contents). RESULTS: The analysis of the factors contributing to drowning showed that alcohol intoxication was the most frequent (n=25), followed by cardiac pathology (n=22), and psychotropic drug intoxication (n=6). Radiological evaluation showed that measurements of all parameters differed significantly between the drowning group and the controls. In addition, significant differences were observed between drowning and non-drowning cases in three radiological parameters (i.e., distance between lungs, stomach volume, and density of gastric contents). CONCLUSIONS: Majority of bath-related deaths in this study showed signs of drowning at autopsy, and we observed a range of factors that contributed to drowning. By using several radiological parameters (e.g., the distance between the lungs, stomach volume, and the density of the gastric contents), PMCT for the investigation of bath-related deaths might indicate that drowning as opposed to other factors unrelated to drowning (e.g., sudden cardiac death) was the cause of death. This might allow for calculation of accurate mortality statistics on bath-related deaths.

A fatal poisoning case by intravenous injection of "bath salts" containing acetyl fentanyl and 4-methoxy PV8.

A man in his 30's was found at home, not breathing. He was admitted to an emergency hospital and the doctor confirmed his death. He had a history of methamphetamine abuse spanning several years, and while fresh needle marks were visible on his arm, the only other autopsy findings indicated an acute death. A small plastic bag containing a pale brown white powder, and a small amount of liquid in a syringe were found at the scene. The police forensic laboratory detected acetyl fentanyl and 4-methoxy PV8 (4-methoxy PHPP) in both the powder and the liquid. Scan analysis by gas chromatography-mass spectrometry (GC-MS) and liquid chromatography-mass spectrometry (LC-MS) identified acetyl fentanyl and 4-methoxy PV8 in the urine sample. Both drugs were quantitated simultaneously by liquid chromatography-tandem mass spectrometry (LC-MS/MS), using the selected reaction monitoring method. The concentration of acetyl fentanyl in the femoral vein blood, urine, and gastric contents were 153, 240, and 880ng/mL respectively, and the concentration of 4-methoxy PV8 in the femoral vein blood, urine, and gastric contents were 389, 245, and 500ng/mL respectively. Cause of death was attributed to acute poisoning by "bath salts" containing acetyl fentanyl and 4-methoxy PV8. Evidence indicated that self-administered intravenous injection was the most likely scenario, and that the deceased had been a habitual user of the "bath salt" drug for some time. Drugs detected in the gastric contents could be explained by the gastric secretion of basic drugs, or drug-containing bile entering the gastric contents.

Quantitative determination of n-butane metabolites in three cases of butane sniffing death.

Butane is an addictive volatile substance like toluene. We report three forensic autopsy cases of sudden death that occurred while sniffing n-butane and isobutane from portable gas cartridges. n-Butane and isobutane were detected in all three cases. In cases 1-3, n-butane concentrations in heart blood were 54.3, 25.5, and 30.7µg/mL, respectively. These concentrations were considered fatal according to the previous reports. In addition, n-butane metabolites (2-butanol and 2-butanone) were detected in cases 1 and 3 but not in case 2. Blood levels of 2-butanol and 2-butanone were 6.5 and 1.8µg/mL, respectively, in case 1, and 6.3 and 5.6µg/mL, respectively, in case 3. According to the police investigation, the decedent in case 1 had misused butane gas for more than 6 months in the period leading up to death. The decedent in case 3 also had a history of chronic misuse of butane gas. There was no history of chronic misuse of butane gas by the decedent in case 2. It was suspected that he attempted suicide via inhalation of butane gas using a plastic bag, leading to a rapid death. The presence or absence of n-butane metabolites might reflect the way of butane inhalation, such as the frequency and duration. Although additional experimental and case studies are necessary to establish the forensic applications of n-butane metabolite detection, it may be a useful method to understand the decedents' pattern of butane sniffing before death.

Small bowel perforation caused by Epstein-Barr virus-associated B cell lymphoma in a patient with angioimmunoblastic T-cell lymphoma.

On rare occasions, secondary Epstein-Barr virus (EBV)-associated B cell lymphoma can develop in a patient with angioimmunoblastic T-cell lymphoma (AITL). We report a case of a 66-year-old Japanese woman who developed diffuse large B-cell lymphoma (DLBCL) in her small intestine after chemotherapy for AITL. She was found to have panperitonitis due to perforation of the small intestine. Partial ileectomy specimen showed DLBCL cells infiltrating into the intestinal wall. In situ hybridization for EBV-encoded RNA revealed positivity in the lymphoma cells. The lymph nodes diagnosed as AITL were negative for EBV infection and there was no coexistence of B cell neoplasms in them. We thought small bowel perforation in this case was caused by EBV-associated B cell lymphoma secondary to AITL. Our case showed a remarkable deficiency of cellular immunity after chemotherapy, which we postulate was related to the cause of occurrence of B-cell lymphoma.