Fatal Ludwig's Angina: Cases of Lethal Spread of Odontogenic Infection.

We report two cases of deaths resulting from complications of odontogenic infections/submandibular space infections. In one case, the decedent had a history of toothache as well as facial and tongue swelling; autopsy revealed inflammation involving the tongue and larynx. In the second case, the decedent had a history of toothache, and at autopsy there was spread of infection to the mediastinum. Ludwig's angina is a form of submandibular space infection, which often is a result of odontogenic infection. The infection can spread into the deep spaces of the neck, producing complications including edema of the tongue and pharynx (causing airway obstruction), descending mediastinitis, pericarditis, necrotizing fasciitis, pleural empyema, and pneumonia. Gross findings at autopsy might reveal a dental abscess or other forms of infection of the head and neck, necrosis of the neck muscles and larynx, and infrequently, infection extending to the chest cavity. Microscopically, there is acute inflammation with necrosis and/or granulation tissue predominantly within the fascia. Without treatment, submandibular space infections can be life threatening and progression to death can be swift. These cases demonstrate the lethal effects of odontogenic infections. Without a clinical history of toothache or dental abscess, one can be alerted to a possible submandibular space infection by identifying isolated necrosis of the neck musculature.

Multiple Drug-Toxicity Involving Novel Psychoactive Substances, 3-Fluorophenmetrazine and U-47700.

3-Fluorophenmetrazine (3-FPM) is a stimulant-like novel psychoactive substance (NPS) and fluorinated analog of phenmetrazine that has recently appeared on the recreational drug market, with limited published information. Likewise, the synthetic opioid U-47700 has gained popularity among recreational drug users and is frequently detected in postmortem casework. We present the case history, autopsy and toxicological findings of a fatality involving the designer drugs 3-FPM and U-47700 for the first time in the literature. A sensitive and specific liquid chromatography-tandem mass spectrometry method was developed and validated for the quantification of 3-FPM in whole blood, with a 0.001-0.100 mg/L analytical range. The method met the requirements for acceptable linearity, bias and precision. 3-FPM was detected along with U-47700 and other drugs including amitriptyline, nortriptyline, methamphetamine, amphetamine, diazepam, nordiazepam, temazepam, and the designer benzodiazepines flubromazolam and delorazepam. 3-FPM was quantified in the decedent's peripheral (femoral) and central (aortic) blood at 2.4 and 2.6 mg/L, respectively. These concentrations are similar to reported concentrations in non-fatal intoxications. U-47700 was present in peripheral blood at a semi-quantitative concentration of 0.36 mg/L, consistent with reported U-47700 postmortem concentrations. The cause of death was considered multiple drug-toxicity (3-FPM, U-47700, amitriptyline, methamphetamine, diazepam, temazepam, flubromazolam and delorazepam) and the manner of death ruled an accident. This case illustrates the dangers of polysubstance use and discusses the potential overlap between recreational and fatal concentrations for some NPS.

Sexual assault documentation program.

Since 2001, the Los Angeles County Department of Coroner has collaborated with Los Angeles County-University of Southern California Medical Center Violence Intervention Program and their Sexual Assault Center. The partnership was established at the suggestion of the district attorney's office to enhance the clinical recognition of sexual assault in the medical examiner's office using the extensive experience of experts in the field of sexual assault. As of December 2008, over 5 dozen victims of sexual assault have been evaluated with this collaboration. The partnership relied on the expertise of 2 pediatricians who are established clinical experts in the field of sexual abuse and assault, in collaboration with the staff of the medical examiner's office. In cases of suspected sexual assault, a joint evaluation by the clinical experts and the medical examiner was made. The goal of the project was for the medical examiners to become more confident in their observations and documentation of crimes of sexual abuse. Even though they are still available upon request, consultations with the sexual assault experts have decreased as the skills of the medical examiner to evaluate sexual assault cases have increased.

A comparative immunohistochemical analysis of small round cell tumors of childhood: utility of peripherin and alpha-internexin as markers for neuroblastomas.

Immunohistochemical study of neuroblastomas, Ewing sarcomas, rhabdomyosarcomas, and Wilms tumors demonstrate specific expression of peripherin and alpha-internexin in 20/22 and 6/22 cases of neuroblastomas, respectively. Microtubule-associated protein 1B (MAP 1B) was strongly and diffusely expressed in all 22 cases of neuroblastomas, but was also focally or multifocally expressed in 9/12 rhabdomyosarcomas and also in the blastema and stroma of 8/11 Wilms tumors. All rhabdomyosarcomas strongly and diffusely express nestin, but this marker was also expressed, multifocally, in 15/22 neuroblastomas and also in the blastema and stroma of all 11 Wilms tumors. NeuN, a neuron-specific nuclear protein, was expressed focally in 1 case of neuroblastoma and diffusely in 2 other cases (3/22). Surprisingly, it was also focally expressed in 2/12 rhabdomyosarcomas. In contrast, all 7 cases of Ewing sarcoma were negative for peripherin, MAP 1B, alpha-internexin, NeuN, and nestin. Thirteen neuroblastomas were also immunostained for neurofilaments, tyrosinase, and anaplastic lymphoma kinase 1 (ALK 1), and were found to be negative for these markers. Our results confirm that peripherin and alpha-internexin are neuroblastoma markers useful for the differential diagnostic work-up of small round cell tumors of childhood. Strong diffuse immunoreactivity for MAP 1B favors a diagnosis of neuroblastoma, whereas strong diffuse immunoreactivity for nestin favors a diagnosis of rhabdomyosarcoma.

Primary cutaneous plasmacytoma (posttransplant lymphoproliferative disorder, plasmacytoma-like) in a heart transplant patient.

Extramedullary plasmacytomas in posttransplant patients are rarely encountered. We present the fifth case of a primary cutaneous plasmacytoma (posttransplant lymphoproliferative disorder, plasmacytoma-like) that developed in a heart transplant patient. The tumor presented as a solitary nodule of the skin 10 years after transplantation. It subsequently involved 2 other cutaneous sites and remained confined to the skin for 5 years. The neoplastic cells were Epstein-Barr virus small RNAs (EBER 1,2) positive and EBV-latent membrane protein 1 (LMP 1) negative, corresponding to type I EBV latency. The direct role of EBV in the development of the tumor remains uncertain.