Filicide-Suicide: Case Series and Review of the Literature.

Homicide-suicides or "dyadic deaths" refer to a homicide followed by the suicide of the perpetrator within 1 week of the homicide. A unique subset is filicide-suicide: a parent kills his/her child before committing suicide. Shooting is the preferred method for both the homicide and suicide. The perpetrator has depression in most cases.We present 3 cases of filicide-suicide. In case 1, a divorced mother with schizophrenia and bipolar disorder shot her son and herself. In case 2, a father shot his son and himself while involved in a child-custody dispute. In case 3, a father, experiencing a divorce and financial difficulties, and his daughter with Angelman syndrome succumbed to carbon monoxide poisoning.The forensic pathologist should be aware of the psychosocial dynamics that interplay in filicide-suicide. Diligent attention to a parent's life stressors may aid in determining risk factors for filicide-suicide.

Hypothermic Death in the Arctic State.

Hypothermic deaths are seen across the United States, but are more commonly seen in Alaska compared to the other states due to its northern latitude and variable climate. Vulnerable populations, such as the homeless and people with substance abuse are at increased risk. Our approach is to examine the scene circumstances, patient health factors, and autopsy findings to arrive at an accurate categorization of cause and manner of death in these cases. Literature on hypothermia is reviewed and various features of hypothermia including scene findings and pathophysiological findings of the victims are discussed. Various Alaskan cases demonstrating common features seen in hypothermia death are discussed. Photographic demonstration of the typical findings in the cases are shown and described. Methods of diagnosis and prevention are given at the conclusion of the article.

Sudden death due to forced ingestion of vinegar.

Vinegar is a clear colorless liquid that commercially consists of 5% acetic acid. It has numerous benefits in everyday use, including culinary, medical, and cleaning. The ingestion of concentrated acetic acid is strongly discouraged and may have detrimental consequences, such as acute pancreatitis, disseminated intravascular coagulopathy, gastric and hepatic complications, upper airway obstruction, or death. We report the first case in the literature of a 5-year-old boy who experienced a sudden death due to ingestion of distilled white vinegar. The manner was homicide. There was evidence of nonfatal blunt force impacts of the head, trunk, and extremities. A pungent aromatic odor of the viscera, gastric/small bowel contents, and cranial cavity was noted at autopsy. A dusky gray discoloration of the gastric mucosa, small bowel, and pancreas was observed. Forensic pathologists should consider ingestion of vinegar when confronted with a compelling history as well as an aromatic odor suggesting vinegar and dusky gray discoloration of the gastric mucosa and small bowel. While vinegar is a common household item and has several advantages, it may prove fatal if ingested in large quantities.

Sudden Death Due To Acute Cocaine Toxicity-Excited Delirium in a Body Packer.

Excited delirium denotes a life-threatening medical condition characterized by the acute onset of agitated and violent behavior that often results in a sudden and unexplained death. Cocaine-induced excited delirium refers to fatal cocaine intoxication with the following symptoms occurring sequentially: hyperthermia, delirium with agitation, respiratory arrest, and death. We present a case of cocaine-induced excited delirium in a cocaine "body packer" or a "mule", specifically an individual who attempts to smuggle cocaine within the body. Investigators at the scene initially suspected homicide due to the victim's sharp and blunt force injuries. Three rubber packets containing cocaine were removed from the victim's rectum. Blood toxicological analysis revealed an alcohol concentration of 0.016 g/100 and cocaine >1 mg/L. The forensic pathologist should consider cocaine-induced excited delirium when an individual exhibits aggressive behavior, unexpected strength, and resistance to pain who dies suddenly. Further analysis should be performed during the scene investigation and autopsy for evidence of body packing.

Medium-Chain Acyl-CoA Dehydrogenase Deficiency in Adulthood: A Potential Diagnosis in a Patient with Mental Status Changes Suspected of Drug Toxicity.

Medium-chain acyl-CoA dehydrogenase (MCAD) deficiency is a rare but important component of the differential diagnosis for adults with a history of premortem mental status changes and the postmortem finding of hepatic steatosis. This case report describes a 30-year-old white man who, following a period of nausea and vomiting, was admitted to the hospital with sudden mental status deterioration followed rapidly by clinical deterioration and death. Treating physicians in this case suspected acute illicit drug toxicity with synthetic cathinones based on social history. Clinicians and medical examiners should be aware that the presentation, signs, and symptoms described may indicate an underlying inborn error of metabolism such as MCAD deficiency and take action accordingly.

Death by late-presenting Bochdalek hernia in infant soon after congenital cardiac repair.

Congenital diaphragmatic hernia (CDH) presenting beyond the neonatal period is commonly perceived to be rare. With reported frequencies of 2.6% to 20% of all CDH, it may be an overlooked cause of mortality. Variable symptomatology makes its diagnosis challenging. We report the sudden death of a 3-month-old patient shortly after hospital discharge following congenital heart surgery. Autopsy findings associated the patient's demise with migrated abdominal contents in the chest through a Bochdalek hernia defect. No indications of CDH existed before hospital discharge. Relevant issues pertaining to congenital heart disease, CDH, and importance of autopsy in this context are discussed.

Sudden and unexpected death in three cases of Ehlers-Danlos syndrome type IV.

Ehlers-Danlos syndrome (EDS) type IV is a connective tissue disorder characterized by the inability to produce sufficient amounts of collagen or a defect in the structure of collagen. The most serious complications include a rupture of a viscus or vascular rupture with or without mural dissection. Death may result from internal hemorrhage. This report describes three cases of sudden and unexpected death caused by EDS type IV. Two cases involved hemothorax as a result of dissection of the subclavian artery and aorta, respectively. The third case represented spontaneous pulmonary rupture and hemorrhage. A detailed family history should be sought, and additional specimens collected to confirm the diagnosis, including skin fibroblasts for collagen testing and blood for DNA testing. The forensic pathologist should consider the possibility of EDS type IV upon discovery of spontaneous visceral or arterial rupture and should alert the family members of this hereditary and potentially fatal condition.

Glial fibrillary acidic protein mutations in infantile, juvenile, and adult forms of Alexander disease.

Alexander disease is a progressive, usually fatal neurological disorder defined by the widespread and abundant presence in astrocytes of protein aggregates called Rosenthal fibers. The disease most often occurs in infants younger than 2 years and has been labeled a leukodystrophy because of an accompanying severe myelin deficit in the frontal lobes. Later onset forms have also been recognized based on the presence of abundant Rosenthal fibers. In these cases, clinical signs and pathology can be quite different from the infantile form, raising the question whether they share the same underlying cause. Recently, we and others have found pathogenic, de novo missense mutations in the glial fibrillary acidic protein gene in most infantile patients examined and in a few later onset patients. To obtain further information about the role of glial fibrillary acidic protein mutations in Alexander disease, we analyzed 41 new patients and another 3 previously described clinically, including 18 later onset patients. Our results show that dominant missense glial fibrillary acidic protein mutations account for nearly all forms of this disorder. They also significantly expand the catalog of responsible mutations, verify the value of magnetic resonance imaging diagnosis, indicate an unexpected male predominance for the juvenile form, and provide insights into phenotype-genotype relations.