Late-onset non-obstructive mesenteric ischemia (NOMI) resulting from delayed absorption of overdosed antihypertensive drugs: An autopsy case report.

Non-obstructive mesenteric ischemia (NOMI) is caused by reduced blood flow to the intestines without physical occlusion in the mesenteric artery. Previous reports show that drug overdose occasionally induces late-onset NOMI; however, in most cases, the reason for the delayed onset is unclear. Here, we present an autopsy case of late-onset NOMI that was induced by a drug overdose. An 80-year-old man was admitted to the intensive care unit because of severe hypotension after an overdose of antihypertensive drugs. He received vasopressor therapy and continuous hemodiafiltration dialysis; however, gastrointestinal decontamination was not performed. He began to recover but developed acute mesenteric ischemia on the evening of day 4 and died on day 5. Autopsy showed discontinuous submucosal bleeding from the duodenum to the colon; there was no thrombus in the mesenteric artery, which led to a diagnosis of NOMI. In the stomach, there was 250 mL of reddish-brown fluid with a muddy brown substance. Histologic examination revealed ischemic necrosis in the small intestine. Quantitative analysis of serum collected during hospitalization revealed that nifedipine and cilostazol levels had peaked on day 3 of hospitalization. The formulation of nifedipine was a controlled-release tablet, and the low water solubility of cilostazol may have caused the tablets to adhere and remain in the stomach. Therefore, the drugs had been released into the blood stream several days after hospitalization, leading to delayed-onset NOMI. In cases of overdose, it is crucial to consider the formulation and properties of the involved drugs when determining medical treatment.

Correlations between blood volatile hydrocarbon concentrations in different types of fire-related deaths.

Analysis of volatile hydrocarbons in blood from fire-related deaths provides useful information such as whether the victim inhaled smoke from the fire before death or whether an accelerant was used in the fire. In this study, we used headspace gas chromatography-mass spectrometry to quantify volatile hydrocarbons in post-mortem heart blood from 121 fire victims. The cases were classified into the following four groups according to the detected volatile hydrocarbons: construction fires without accelerants, kerosene fires, gasoline fires, and a group with no fire-related hydrocarbons detected (other fires). We investigated the relationships between blood concentrations of carboxyhemoglobin (COHb) and volatile hydrocarbons, and between various volatile hydrocarbons. The mean COHb concentrations were higher in the construction fire group than in the kerosene and gasoline fire groups. In the construction fire group, there was a high correlation coefficient between the concentrations of benzene and COHb and relatively high coefficient correlations between the concentrations of benzene and toluene, benzene and xylene, toluene and styrene, and ethylbenzene and styrene. Our results indicate that the relationships between benzene, xylene, and toluene concentrations could be used to distinguish between deaths in construction fires, kerosene fires, and gasoline fires.

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.

Effects of arterial hemorrhage speed on the blood coagulation/fibrinolysis system and hemodynamics in rats.

: The effects of rapid hemorrhage on coagulopathy have been reported. However, the effects of different hemorrhage speeds on the blood coagulation/fibrinolysis system have not been investigated. This study aimed to compare different hemorrhage speeds for clarifying their effects on the coagulation/fibrinolysis system and circulation disorders in rats. Male Sprague-Dawley rats (301-396 g) were randomly assigned to five groups depending on hemorrhage speed and length of procedure: first, rapid (1.4 ml/min, 30-min bleeding); second, rapid-L (1.4 ml/min, 30-min bleeding and observation until 6 h); third, slow (0.1 ml/min, intermittently, 6-h bleeding); fourth, control (30-min observation); and fifth, control-L (6-h observation). Hemorrhage was induced by withdrawing blood until 40% of the estimated blood volume from the femoral artery. We measured vital signs, hematology, general chemistry, blood gas status, coagulation parameters, fibrinolytic markers [tissue-type plasminogen activator and plasminogen activator inhibitor one (PAI-1)], vascular endothelial damage (syndecan-1), and liver PAI-1 mRNA expression. Rapid hemorrhage induced elevation of lactate and syndecan-1 levels and prolonged prothrombin time and activated partial thromboplastin time in the rapid group. In contrast, slow hemorrhage did not induce these changes. Hemorrhage speed had no effect on plasma tissue-type plasminogen activator and hematology. Plasma PAI-1 levels were significantly increased in the rapid-L group, while liver PAI-1 mRNA levels were increased in the slow group. This study shows changes in the circulatory and fibrinolysis systems, depending on the hemorrhage speed. Hemorrhage might promote production of PAI-1, while tissue hypoxia due to rapid hemorrhage might promote release of PAI-1.

Cerebrospinal fluid neurotransmitter levels and central nervous system depression in a rat drug overdose model.

A neuropsychiatric drug overdose impairs physiological function via central nervous system (CNS) depression. In drug-related deaths, only the drug concentration can currently provide information regarding CNS depression in victims. In this study, using a drug overdose model, we investigated the ability of neurotransmitters in the cerebrospinal fluid (CSF) to serve as biomarkers for CNS depression. Four groups of rats were orally administered diazepam (200 mg/kg) and/or phenobarbital (100 mg/kg) or vehicle. In a hot plate test performed to assess physiological impairment, drug-administered animals showed prolongation of the response latency. Serum drug concentrations were also sufficient to observe the effect of drug overdose. The levels of benzoyl-derivatized neurotransmitters were measured using liquid chromatography-tandem mass spectrometry (LC-MS/MS) analysis. Noradrenaline, adrenaline, serotonin, melatonin, phosphoethanolamine, and histamine levels in the CSF decreased as the response latencies in the hot plate test increased. These reduced CSF neurotransmitter levels may represent physiological dysfunction through CNS depression.

Development of a fluvoxamine detection system using a Quenchbody, a novel fluorescent biosensor.

The misuse of psychotropic drugs intended for medical treatment represents a recent worldwide public health concern. Quenchbody (Q-body) is a novel fluoroimmunosensor that can detect an antigen immediately without additional reagents or washing steps. Here, we describe creating Q-bodies for the detection of the antidepressant fluvoxamine (FLV) and determining optimal conditions to achieve the highest fluorescence intensity (FI). We prepared five Q-bodies with the fluorophore labeled at either the N- or C- terminus and with different linker lengths. Fluorescence was measurable within minutes, indicating the interaction of Q-bodies with FLV. The normalized FI (FI ratio) of the N-terminus labeled Q-body increased approximately 1.5-fold upon FLV addition; Q-bodies labeled at the C-terminus did not significantly increase FI. Among the fluorescence dyes used in this study, Rhodamine 6G labeled Q-body showed the best FI ratio. EC50 values of the N-terminus labeled Q-bodies were similar (23.2-224nM) regardless of linker length or labeling dye. We examined whether the Q-body could be applicable to serum matrix instead of phosphate-buffered saline. The intact serum interfered strongly with the Q-body fluorescence. However, the FI ratios of the Q-body for FLV-spiked serum filtrate, for which proteins were removed by filtration, showed a dose-dependency for detecting FLV levels. Deproteinization, which does not interfere with Q-body fluorescence measurements, is likely necessary to detect serum FLV with high sensitivity. This study demonstrates the potential of Q-body probes as a tool towards developing creative immunoassay applications.

Liquid chromatography-tandem mass spectrometry detection of benzalkonium chloride (BZK) in a forensic autopsy case with survival for 18 days post BZK ingestion.

We report a forensic autopsy case of an elderly man who ingested unknown amount of germicidal disinfectant containing 50% benzalkonium chloride (BZK). He survived for 18 days after BZK ingestion and then died because of pneumonia. A liquid chromatography-tandem mass spectrometry (LC-MS/MS) method was used to detect three BZK compounds (C12-BZK, C14-BZK and C16-BZK) in the blood. Extraction of BZK was carried out according to a modified QuEChERS method. Chromatographic separation was achieved on an ODS column and detection was performed in selected reaction monitoring mode. The accuracy and the precision were acceptable for quantitative analysis in the concentration range of 10-200 ng/mL for the three BZK compounds. BZK was detected in heart and femoral vein blood samples even 18 days after BZK ingestion. Taking into consideration clinical information during 18 days hospitalization and the autopsy findings, the cause of death was attributed to BZK poisoning. Several toxico-kinetic factors regarding absorption and excretion of BZK in the body were also discussed to elucidate the detection of BZK such a long time after ingestion.

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.

Postmortem serum tenascin-C (TN-C) concentrations in forensic autopsy cases: A pilot study.

In forensic investigations, autopsy findings offer major clues for the diagnosis of the cause of death. Thus, various clinical biochemical markers are now being tested to complement conventional investigation in the field of forensic medicine. In this study, we focused on tenascin-C (TN-C), a glycoprotein present in the extracellular matrix and expressed in pathological states. We reviewed autopsy cases for a 4-year period (2006-2009) using autopsy records, and analyzed the blood serum concentrations of TN-C and C-reactive protein (CRP) in these cases (N=101). The TN-C levels were relatively higher in the postmortem serum samples than in the samples from healthy individuals, and in cases of head injury, both TN-C and CRP levels were high in the postmortem serum sample. Moreover, high TN-C levels were observed particularly in cases with a long survival period. These findings indicate that postmortem serum TN-C levels may represent a useful tool for identifying the cause of specific fatal traumas.

Quantitative evaluation of volatile hydrocarbons in post-mortem blood in forensic autopsy cases of fire-related deaths.

Volatile hydrocarbons in post-mortem blood from victims of fires were analyzed quantitatively by headspace gas chromatography mass spectrometry. The benzene and styrene concentrations in the blood were positively correlated with the carboxyhemoglobin (CO-Hb) concentration, which is evidence that the deceased inhaled the hydrocarbons and carbon monoxide simultaneously. By contrast, the concentrations of toluene and CO-Hb in the blood were not significantly correlated. This lack of correlation could be explained by two different sources of toluene, with low blood concentrations of toluene arising when the deceased inhaled smoke and high blood concentrations of toluene arising when the deceased inhaled petroleum vapor or other unknown vapors. The quantity of soot deposited in the respiratory tract was classified into four grades (-, 1+, 2+, 3+). The mean CO-Hb concentration in the 1+ soot group was significantly lower than those in the 2+ (p<0.05) and 3+ (p<0.01) soot groups. The blood CO-Hb concentrations in the 1+ soot group were all below 30%. Those indicated that the deceased aspirated smoke that contained both soot and carbon monoxide. The wide variation in CO-Hb concentrations for each soot classification could be caused by the different types of smoke produced by different materials. For example, petroleum combustion with a limited supply of oxygen, like in a compartment fire, may produce a large volume of dense black smoke that contains a large quantity of soot. Soot deposits in the airways and the blood CO-Hb concentration are basic and essential autopsy findings that are used to investigate fire-related deaths. The quantitative GC-MS analysis of blood volatile hydrocarbons can provide additional useful information on the cause of the fire and the circumstances surrounding the death. In combination, these three findings are useful for the reconstruction of cases.

Immunohistochemical demonstration of the distribution of chloroquine (CQ) and its metabolites in CQ-poisoned mice.

Chloroquine (CQ) distribution in tissues of acutely poisoned mice was demonstrated by immunohistochemistry using anti-CQ polyclonal antibodies (PAC). PAC recognized 4-amino-7-chloro-quinoline structure and sufficiently reacted with CQ and CQ's metabolite bisdesethyl-chloroquine. In the brain, CQ and its metabolites (CQs) localized in the region of the choroids plexus, indicating an important role in the blood-cerebrospinal barrier system. In the heart, most regions showed diffused positive staining, and relatively strong reaction was observed in Purkinje cells, indicating an important role in acute CQ toxicity. In the lungs, CQs were observed in the bronchial epithelium, type II pneumocytes, and on the surface of alveolar walls. It was suggested that CQs were excreted to the alveolar wall with surfactant phospholipids, which are produced by type II pneumocytes. In the liver, CQs were concentrated in the centrolobular area rather than in the periportal area, in agreement with CQ's metabolic pathway. In the kidneys, tubular cells were strongly stained compared to glomerular capsules, and the distal part of renal tubules was better stained than the proximal tubules. These findings suggested that CQs were predominantly excreted or reabsorbed through the distal tubules and the collecting duct. Distribution of CQs in tissues presented here were mostly consistent with the physico-chemical properties of CQ and its metabolites. However, the elucidation of CQs' localization in Purkinje cells remains open. Further experimental studies at the level of microorganella will be needed to clarify the present result.

[Two cases of diphenhydramine related suicide].

Two suicidal cases associated with ingestion of diphenhydramine (DPH) were reported. Case 1 is a typical DPH overdose case of a young man with the blood DPH concentration of 12.2 microg/ mL. Case 2 is a double suicide of a man and a woman. They ingested DPH and fell asleep in a vehicle which had a cooking clay charcoal stove. Their blood DPH concentrations were 0.4 and 0.7 microg/mL, which were high enough to make them sleep. Their cause of death, however, was carbon monoxide poisoning with blood CO-Hb concentration of 14 and 19%. DPH is a low toxic agent and is available as an OTC drug in Japan. Similar fatal cases can be expected to happen in Japan.

Sudden death of a young woman due to aortic dissection caused by Turner's syndrome.

A 24-year-old woman was found dead in her bed. There had been an episode of fainting with cervicodynia 1 day before death but no significant past medical history, except for menstrual irregularities. Post-mortem examination revealed that death was due to hemopericardium caused by rupture of the ascending aorta by thoracic aortic dissection (Stanford type A). Microscopically, weakness of the aorta was due to cystic medial necrosis. On external examination, short stature, a short neck and multiple pigmented nevi were observed, while internal examination revealed coarctation of the aorta and funicular ovaries. Examination of the X chromatin showed a decrease in numbers of Barr bodies in the tissues, and a 45,X/46,XX mosaicism was suspected. It is concluded that the cause of death was aortic dissection due to Turner's syndrome.

An accidental death due to Freon 22 (monochlorodifluoromethane) inhalation in a fishing vessel.

A case of accidental Freon 22 (monochlorodifluoromethane) poisoning in a fishing vessel is reported. Forensic autopsy revealed severe pulmonary edema and congestion (left lung; 576 g, right lung; 740 g). GC-MS analysis clearly showed that the deceased inhaled Freon 22 gas prior to his death. Freon 22 concentration was 169+/-7.0 microg/ml in the heart blood. The distribution pattern of Freon 22 in tissue samples was similar to that in previously reported cases. The brain had the highest concentration of Freon 22 followed by the spleen, liver, kidney and lung, respectively. Histopathologically, Oil red O staining of the liver showed many small, positive red areas in the cytosol, which have been reported in other cases of Freon 22 poisoning. However, Schmorl staining revealed that most areas of Oil red O positivity were lipofuscin granules. Lipofuscin in the liver, which closely relates to aging and other cell stresses, could have a relevance to Freon 22 exposure, but further experimental studies are needed to confirm it.

Postmortem cytokine levels and severity of traumatic injuries.

The relationship between postmortem serum cytokine levels and severity of traumatic injuries was studied. The postmortem serum levels of interleukin-6 (IL-6) and interleukin-8 (IL-8) of 131 victims who died from traumatic injury were measured by an enzyme-linked immunosorbent assay method and compared with scores of total abbreviated injury scale (total AIS) and injury severity score (ISS) calculated from detailed autopsy reports. A significant positive correlation was observed between IL-6 and total AIS (rs=0.4508, p<0.0001), between IL-6 and ISS (rs=0.3337, p<0.0001), between IL-8 and total AIS (rs=0.6593, p<0.0001), and between IL-8 and ISS (rs=0.5305, p<0.0001). The significant correlation between cytokine levels and anatomical traumatic severity indicated that the cytokine levels are useful objective indexes of traumatic severity. In addition, the total AIS is a suitable marker to evaluate traumatic severity as the coefficient of correlation between the cytokine levels and the total AIS was higher than that for the ISS values.

[Ethanol concentrations in multi-site sampling blood in forensic autopsy cases--a retrospective analysis over a period of six years (1994-1999) in Kumamoto University].

Ethanol and n-propanol concentrations in forensic autopsy cases determined in Department of Forensic Medicine, Kumamoto University School of Medicine were reviewed retrospectively. Out of 388 autopsies in 6 years (1994-1999), ethanol was positive in 88 (22.7%) cases. Higher positive rates were observed in bleeding and burning cases compared to other cases. Histograms of the blood ethanol concentrations in all ethanol positive cases had two peaks at 0.1 mg/ml to 0.5 mg/ml and 1.5 mg/ml to 2.0 mg/ml ranges, which indicated that not only an intermediate but also a weak drunkenness level could be a risk factor of being involved in forensic fatalities. There were no differences in mean ethanol concentrations in the blood samples of the right, left and whole heart blood collected from each victim. The femoral blood, however, was slightly higher than those of heart blood. N-Propanol, an indicator for postmortem ethanol production, was detected in 14.7% of stomach contents samples as early as 6 to 12 hours of post mortem intervals, whereas it was not remarkable in urine and femoral vein blood.

A simple dot enzyme-linked immunosorbent assay for ABO blood typing of biological fluid and stains: effects of heating samples.

A simple dot enzyme-linked immunosorbent assay (Dot-ELISA) using commercially available monoclonal anti-A and anti-B antibodies and biotinylated anti-H lectin was developed for ABO blood typing of biological fluid and stains. Its application to forensic practice was examined with 117 saliva samples and their stains, and practical case samples of 8 seminal, 6 vaginal and 45 aged salivary stains. In the simple Dot-ELISA, a new step to heat biological samples was introduced in the system in order to block unfavorable non-specific reactions of the samples with secondary enzyme conjugate. The simple Dot-ELISA could determine accurately the ABO blood type of a small amount of secretor's and non-secretor's salivary samples. In practical tests of seminal, vaginal and salivary stains, all results were confirmed to be identical to those determined by the conventional absorption-inhibition test and the absorption-elution test. The simple Dot-ELISA is considered to be accurate, rapid, simple, sensitive and easy to perform in routine forensic practice. It is also a unique and helpful method to determine the ABO blood types of various biological samples.