Myocardial contraction bands. Definition, quantification and significance in forensic pathology.

Pathological contraction bands affecting myocardial cells are observed in many different human conditions and in different experimental models. Their morphology was defined long ago but we need to understand the pathogenesis and functional meaning. A distinction between different histological forms of contraction bands and their quantification in a large spectrum of human diseases (262 cases) and a normal population sample where death was due to various types of accidental death (170 cases) produced the following conclusions: 1) The term "contraction band necrosis", as used presently, is ambiguous and should be reserved for a specific morpho-functional entity induced experimentally by intravenous catecholamine infusion and seen in equivalent human cases with pheochromocytoma. 2) In human pathology it may represent a sign of adrenergic stress linked with malignant arrhythmia/ventricular fibrillation. 3) Beyond a histological threshold of 37+/-7 foci and 322+/-99 myocells/100 mm2, the lesion may indicate sympathetic overdrive in the natural history of a disease and associated arrhythmogenic supersensitivity. 4) The detection of few pathological contraction bands in normal subjects in some types of accidental death correlates with the survival time, suggesting an agonal adrenergic stimulation to promote the cardiac pump.

In-vivo glutaraldehyde fixation of the brain stem and spinal cord after inadvertent intrathecal injection.

A 64-year-old diabetic man underwent total maxillectomy with orbital exenteration because of recurrent carcinoma. In order to decrease pressure at the surgical site, 50 mL of cerebrospinal fluid were withdrawn. After the procedure was completed, 5% glutaraldehyde was inadvertently injected into the subarachnoid space instead of reinjection of the original cerebrospinal fluid. The patient suffered hypotension and coma culminating in death five days after the procedure. Postmortem examination revealed exquisite fixation of the outer cortical shell of the spinal cord and brain stem. The mishap occurred because an unlabeled vial was mistaken for the withdrawn cerebrospinal fluid. Graicunas' theory and formula on relationship complexities in organizations is exemplified by this occurrence. One may calculate the theoretical potential for 24,708 miscommunications during such a complex and lengthy surgical procedure. Proper operating room procedures must be developed and followed in order to prevent such tragedies.

Xylazine toxicity--literature review and report of two cases.

Xylazine is a veterinary sedative, analgesic or general anesthetic. Its pharmaceutical action results in sympathetic discharge via stimulation of alpha-2-adrenoceptors. In humans, toxicity consists of central nervous system depression, bradycardia and hypotension. The dosages known to produce toxicity in humans vary from 40 mg up to 2400 mg. Because of decomposition, xylazine blood concentrations in two homicide victims were unknown; however, the concentrations in the brain, liver, and kidneys were much higher in the 23-year-old female versus the 33-year-old male victim. A bottle of xylazine found on the crime scene had a concentration of 100 mg/mL. This 50 mL bottle had 32 mL remaining. Therefore at some point in time 18 mL had been utilized. The amount of available milligrams of xylazine (1800 mg) were enough to cause toxicity in both the woman and the man. Of interest was the fact that the partially skeletonized heads were found remote from the torsos, however, the concentration of xylazine in the body tissues provided a toxicological match of which head belonged to which body. Xylazine toxicity in humans and its relationship to these homicides will be the focus of this report.

Practical approach to investigative ethics and religious objections to the autopsy.

The application of investigative ethics to religious objections to the autopsy is essential for harmony in achieving the mission of medical legal death investigations. In Florida, an ethical advisory committee composed of religious, ethics, legal, and medical leaders established a unified statement for the practice of discretionary judgment and liaison with clergy. Our approach to religious objections to the autopsy as well as illustrative cases will be discussed.

Endotracheal tube ignition by electrocautery during tracheostomy: case report with autopsy findings.

This case of upper airway tract fire resulting from the use of electrocautery during elective tracheostomy has significance for surgeons, anesthetists, and forensic pathologists alike. The major autopsy findings are described and illustrated. Suggestions that may help to prevent or minimize the risk of fire in this context are reviewed.

Hypopharyngeal lipoma as a cause for sudden asphyxial death.

Lipomas of the hypopharynx are uncommon tumors that are rarely life threatening. When positioned in the hypopharynx, asphyxia may be the result of the tumor size or sudden displacement into the oropharynx. We present a case of a large hypopharyngeal lipoma, review the literature, and discuss mechanisms by which these lesions may cause sudden asphyxial death.

Tissue distribution of cocaine in a pregnant woman.

Reports of cocaine-related obstetrical problems, including abruptio placentae and spontaneous abortion, have become increasingly evident in the medical literature; however, little is known about tissue distribution of cocaine in the pregnant woman. We report the toxicologic results of distribution studies performed on a pregnant woman and her fetus. Maternal/fetal cocaine concentration ratios were high when comparing blood (9:1), brain (6:5), and kidney (10:6). Possible explanations of the mechanism for lower fetal cocaine concentrations may include uterine vasoconstriction, incomplete maternal/fetal equalibration, or rapid placental/fetal clearance.

An unusual case of Phormia regina myiasis of the scalp.

The authors report a case of Calliphorine myiasis in the scalp of a 64-year-old woman caused by the larvae of Phormia regina (Black Blowfly). There was extensive blackening of the scalp and necrosis of the soft tissues, which is unusual in Phormia regina myiasis.

Cervical airway injuries as a result of impact with steering wheel rim.

Motor vehicle occupants may suffer severe cervical airway injuries as the result of impaction with the steering wheel, dashboard, windshield, backseat, and seat belt. Although the steering column is well recognized as a general site of injury infliction, less attention has been directed to components which may be the actual focal point of contact, such as the steering wheel rim. Two cases of cervical airway injury as a result of impact with the steering wheel rim are presented, including one instance of complete laryngotracheal transection. Correlation of injury with crash and postcrash sequences as well as the damaged vehicle will often provide excellent crash injury reconstruction.

Aortoesophageal fistula and sudden death. A report of two cases and review of the literature.

Two cases of aortoesophageal fistula are presented. The etiology, symptoms, and diagnosis of aortoesophageal fistula are reviewed. Signs and symptoms of gastrointestinal hemorrhage followed by sudden collapse hours to days later should prompt consideration of an aortoesophageal fistula. Accidental ingestion of foreign bodies, particularly by children, is a frequent etiology.

Hepatic rupture due to metastatic lung carcinoma.

A 62-year-old man died from hemoperitoneum secondary to nontraumatic hepatic rupture. At autopsy, the liver was massively enlarged by undiagnosed metastatic small cell carcinoma of the lung. The site of exsanguination was distended by tumor, culminating in sudden bursting of the hepatic capsule. Nontraumatic rupture may result from a variety of neoplastic and nonneoplastic diseases. Hemoperitoneum secondary to lung carcinoma is rare, and even more so is the association with sudden unexpected death.

Cocaine and sudden "natural" death.

The cardiovascular effects of cocaine may culminate in clinical episodes of angina pectoris, myocardial infarction, arrhythmias, and intracranial hemorrhage. To clarify whether or not cocaine causes fatalities by these mechanisms, we studied 24 cases of sudden, apparently natural deaths as a result of coronary arteriosclerosis (15 cases), hypertensive cardiovascular disease (4 cases), and intracranial hemorrhage (5 cases) associated with cocaine use. In 11 cases, cocaine was found in the blood (average concentration: 0.57 mg/L, range: 0.05 to 1.45 mg/L), whereas in the remainder, cocaine or its major metabolite was found in the urine or other tissues. In the majority of decedents, autopsy disclosed the existence of severe natural disease which could have been exacerbated by the administration of stimulant drugs, including cocaine. These data, and a review of the current medical literature, indicate that cocaine may precipitate the sudden death of an individual with undiagnosed cardiovascular disease. A contributory role of cocaine should be considered in any apparently natural death occurring in a population where cocaine abuse is prevalent.

Unusual deaths associated with polyphagia.

Perversion of appetite may be manifest in either qualitative (pica), quantitative (polyphagia), or combined derangements of eating. Ingested materials are capable of serving as dangerous physical agents through interference with normal cardiac and/or respiratory function. Since the mechanisms of injury are similar to those that might occur as a result of violence or serious natural disease, a thorough investigation of the history and circumstances immediately preceding the final event is warranted in addition to a complete autopsy. Three cases of asphyxia of unusual etiology are presented along with a rationale regarding the mechanisms believed to be involved. In case 1, sudden subdiaphragmatic viscus expansion with resultant lung volume displacement and impediment of venous return from the lower half of the body are believed to have been operative. In cases 2 and 3, both asphyxial loci are infraglottic. The common denominator in all of these fatalities is the physical impairment of vital air exchange as a complication of an abnormal eating pattern.

Suicide by ingestion of methyl ethyl ketone peroxide.

Methyl ethyl ketone peroxide (MEKP) is a free radical-generating compound used as a fiberglass resin hardener. A 41-year-old Haitian man developed severe metabolic acidosis, hemolysis, esophageal and gastric necrosis, and perforation of the stomach after drinking an undetermined amount of MEKP in a successful suicide attempt. The biochemical effects of free radicals explain the necrosis and hemolysis observed.

Phlegmonous gastritis associated with the acquired immunodeficiency syndrome/pre-acquired immunodeficiency syndrome.

Unusual infections in the immunocompromised host often present a diagnostic dilemma to the physician. We describe a 29-year-old Haitian man with acquired immunodeficiency syndrome/pre-acquired immunodeficiency syndrome who died of phlegmonous gastritis.

Death caused by recreational cocaine use. An update.

The epidemiologic, pathological, and toxicological findings of 60 cocaine-related overdose deaths from middle 1978 through 1982 were studied and compared with a previous publication by this office. In addition, 180 deaths where cocaine was an incidental toxicological finding are also discussed. Currently, the average street cocaine fatality victim is 29 years old, and 42% of the victims are female. Blacks comprise 39% of the cases. The blood cocaine concentration in "street cocaine" fatality victims averaged 6.2 mg/L with a wide range, necessitating careful interpretation of the toxicological results in conjunction with terminal events. Although autopsy findings were generally nonspecific, multiple needle-puncture marks with surrounding ecchymoses are typical of IV cocaine abuse. An increase in cocaine-related overdose deaths is anticipated because of its popularity, increasing availability, and, currently, the increased purity of street cocaine.

Fatal choking in infants and children.

Food asphyxiation in infants/children follows a different pattern from the adult "cafe coronary." In the absence of ethanol intoxication, infants/children are prone to mishandling nonfriable, firm, slippery foods/objects with a rounded contour. The Dade County Medical Examiner's files were searched from 1956 to mid-1983 for accidental pediatric choking deaths. Seventeen food and six foreign body asphyxiations were found. The male/female ratio was 1.4/1 and 1/1, respectively. The white/black ratio was 0.9/1 for food asphyxiation whereas no black victims were encountered choking upon foreign objects. Seventy-eight percent of all victims were between 2 months and 4 years of age. Infants/children asphyxiated on items such as a hot dog, hard candy, peanut, toy rattle, tissue paper, balloon, marble, etc. The choking event was recognized by nearby adults in most instances. Risk factors include the availability of riskful foods/objects, natural diseases with difficulty feeding, poor eating habits, and uneducated or ignorant parents/others at the scene. Although public education, package labeling, and changes in food/object design may be appropriate, the ubiquituous risk foods and small foreign objects will, on occasion, escape the eye of even the most watchful parent.