Multidisciplinary investigation of an unusual apparent homicide/suicide.

The investigation of deaths of individuals whose bodies are decomposed, mummified, or skeletonized is particularly difficult for medical examiners and medicolegal death investigators. Determination of the cause and manner of death in such cases frequently requires consultation with experts in a variety of disciplines in the forensic sciences and necessitates correlation of the autopsy results, scene investigation, medical and social history of the deceased, and laboratory studies. The authors report an unusual case of an apparent homicide/suicide involving 2 individuals and a canine that went undetected for almost 4 years. Determination of the cause and manner of death in these cases involved a multidisciplinary, intercontinental investigation and necessitated the performance of toxicologic studies on specimens not commonly analyzed. These cases illustrate the importance of the multidisciplinary approach to medicolegal death investigations and the necessity of considering nontraditional sources of potential information and specimens for laboratory analysis in selected cases.

Parasailing fatalities in southwest Florida.

Parasailing is a recreational sport that is generally considered to be of little risk to the participants. Typically, the passenger launches from a motorboat with a specially designed winch that pulls him or her back to the boat at the end of the ride. The sport is not regulated at the federal, state, or county level. There have been few reports of injuries to parasailors. Additionally, there have been only 2 fatalities reported to the United States Coast Guard in a 10-year review. We report the details of these 2 deaths, those of a mother and daughter riding in a tandem parasail, which occurred on Fort Myers Beach in 2001, as well as an additional case of a parasailing fatality that occurred in southwest Florida in 1999. These cases illustrate the injuries seen in such fatalities and the hazards posed by adverse weather conditions and faulty equipment, as well as the impairment of passenger judgment by drugs and/or alcohol.

Investigative and autopsy findings in sport aircraft-related deaths in southwest Florida.

Aircraft designated for sport or recreational use only, including ultralights, experimental aircraft and light-sport aircraft, have become increasingly popular. Because of their relative safety and the rarity of fatalities resulting from crashes of these aircraft, the forensic literature contains little information concerning the pathologic findings in such deaths. We report 9 deaths resulting from 6 sport aircraft crashes in southwest Florida, 6 pilots and 3 passengers. The vehicles involved 3 experimental aircraft, 1 ultralight and 2 "ultralight-like" aircraft. The patterns of injuries included trauma predominantly to the chest (3 cases), abdomen (1) or head (1), as well as multiple blunt force injuries involving the chest and abdomen (1) or the head and torso (3). Extremity fractures were found in only 2 cases, whereas injuries to the symphysis pubis were found in six. No "control-type" injuries were identified. These cases illustrate the varied pathologies associated with deaths due to crashes of sport aircraft and reveal the lack of uniformity associated with the investigations of such deaths.

Case report of suicide by inhalation of nitrogen gas.

Nitrogen is an inert gas that is a normal constituent of the air that we breathe. It is a suffocating gas that does not support life and that can be a cause of death by the displacement of oxygen in the atmosphere. The majority of deaths associated with nitrogen have occurred in the setting of scuba diving. Although other suffocating gases have been used as a means of committing suicide, the literature contains little information about the use of nitrogen as a suicidal agent. A case of a 50-year-old man who committed suicide using a homemade suicide device and nitrogen gas is presented.

Patterns of injury in a fatal BASE jumping accident.

Skydiving is a popular and relatively safe sport. The patterns of injury and mechanisms of death in the rare fatalities resulting from skydiving accidents have been well-documented. In contrast, BASE jumping, that is, jumping from a fixed object using a parachute, is a more dangerous and unregulated sport practiced by few individuals. There are no reports in forensic literature documenting the injuries found in deaths occurring in the practice of BASE jumping. We report the case of the death of an experienced BASE jumper who died after jumping from the antenna of a radio broadcast tower in southwest Florida to illustrate the unique hazards inherent in this sport.

Accidental boric acid poisoning following the ingestion of household pesticide.

Borate-containing compounds were formerly used as topical antiseptics and were components of many medicinal preparations including skin powders and ointments used for the treatment of burns and diaper rash. These compounds were also used as irrigants for body cavities, including the pleural, vaginal, and rectal cavities. These applications were subsequently discontinued by the medical community when the toxicity and potential lethality of borates were recognized. Although documented cases of borate poisoning are now rare, the chemical is still an active component commonly used in high concentrations in household disinfectants/cleaners, pesticides, and wood preservatives. While the majority of documented borate-related deaths have occurred in infants, the toddler population is currently at risk due to possible exposure to these household products. We present the case of an 18-month-old child who died following the accidental ingestion of a boric acid-containing, commercially available roach pesticide product.

Paths to destruction: the lives and crimes of two serial killers.

Although research into the phenomenon of serial murder has revealed that serial killers frequently do not fit the initially described paradigm in terms of their physical and psychological profiles, backgrounds, and motives to kill, the media continues to sensationalize the figures of such killers and the investigators who attempt to analyze them on the basis of aspects of their crimes. Although the so-called "typical" profile of the serial murderer has proven accurate in some instances, in many other cases the demographics and behaviors of these killers have deviated widely from the generalized assumptions. This report details two unusual cases in which five and eight murders were committed in upstate New York. The lives and crimes of these offenders illustrate the wide spectrum of variations in the backgrounds, demographics, motivations, and actions witnessed among serial murderers, and highlight the limitations and dangers of profiling based on generalities.

Independence day explosion on lovers key.

The display of fireworks is a popular holiday celebration in the United States. Because injuries due to recreational fireworks-related explosions among private consumers are relatively common, the sale of fireworks is regulated by the federal government and is also limited by state and local laws. In contrast, because fireworks display companies are under tight safety regulations, explosions in the professional pyrotechnics industry are uncommon occurrences, and the literature contains rare reports of injuries and fatalities resulting from such explosions. We report the 2003 Fourth of July commercial fireworks explosion on Lovers Key in southwest Florida that resulted in five fatalities. Events occurring during the investigation of the scene of this explosion illustrate the unique considerations and hazards for medicolegal death investigators, law enforcement and other investigative agencies. Additionally, this case demonstrates unusual aspects of the postmortem examinations performed on victims of fireworks-related incidents.

Sudden cardiac death due to giant cell inflammatory processes.

Granulomatous inflammation of the myocardium may occur in a number of systemic disease processes including those with infectious etiologies such as fungal, mycobacterial and parasitic infections, as well as hypersensitivity reactions, and rarely autoimmune disorders. In many of these disorders, giant cells are components of the inflammatory infiltrate. Systemic granulomatous processes of unknown pathogenesis, most notably sarcoidosis, may also be associated with involvement of the myocardium. Occasionally, these disorders are associated with sudden death due to pathologic involvement of the heart. In contrast, giant cell myocarditis, also known as idiopathic myocarditis, a rare, frequently fulminant and fatal disorder of unknown etiology, is isolated to the heart and lacks systemic involvement. This disorder is most commonly diagnosed at autopsy. We present two cases in which sudden death resulted from a giant cell inflammatory process affecting the myocardium. Both individuals lacked antemortem diagnoses and collapsed at their respective places of employment. These cases compare and contrast the clinical and pathologic issues involved in the differential diagnoses of the subgroup of sudden cardiac deaths resulting from giant cell inflammatory processes that affect the myocardium, as well as the value of histologic examination and immunohistochemical studies.

Alligator attacks in southwest Florida.

The American alligator inhabits bodies of fresh water in Florida and other southeastern states. Although attacks on pets are frequent, alligator attacks on humans are relatively rare because of the animal's natural fear of man. Because of the rarity of attacks on humans, the pathologic findings and pathophysiology of death in such cases have not been well characterized in the literature. We report three cases of fatal alligator attacks that occurred in southwest Florida, each with different pathologic findings and mechanisms of death. Although the cause of death in each case was attributed to the alligator attack, the mechanisms of death differed and included exsanguination because of amputation of an extremity, overwhelming sepsis, and drowning. These cases illustrate the varied pathophysiologies associated with deaths due to alligator attacks on humans and the features that distinguish alligator bites from those of other aquatic predators.

One hundred seventy two deaths involving the use of oxycodone in Palm Beach County.

Oxycodone is a potent semi-synthetic narcotic prescribed for the management of pain. Previous investigators have reported that the abuse of oxycodone is most frequently seen in conjunction with the abuse of other drugs, although fatalities have been reported with oxycodone alone. We undertook a retrospective review of cases investigated by the Palm Beach County Medical Examiner's Office in which postmortem toxicologic studies indicated the presence of oxycodone. A total of 172 consecutive cases were studied, including 18 in which death was attributed to oxycodone toxicity, 117 to combined drug toxicity, 23 to trauma, 9 to natural causes and 5 to another drug or drugs. The postmortem blood concentrations of oxycodone overlapped among the groups. The mean blood oxycodone concentration among the cases of oxycodone toxicity was 0.69 mg/L, combined drug toxicity 0.72 mg/L and trauma 0.62 mg/L. Concentrations were lower in cases of deaths attributed to natural causes and to another drug or drugs (mean each 0.087 mg/L). Benzodiazepines, detected in 96 cases, were the most common co-intoxicants in the cases of combined drug toxicity, followed by cocaine, which was found in 41. The most frequently encountered benzodiazepine was alprazolam. This study confirms that deaths in which oxycodone is a factor are most commonly cases of combined drug toxicity. The high incidence of alprazolam as a co-intoxicant has not been previously recognized.

The Phenomenon of the Urban Mummy.

The environmental mummification of a body in an urban setting is an unusual event. Florida is known for its high temperatures and humidity, which typically result in the rapid putrefaction of bodies. However, under certain circumstances, Florida's climate provides an environment suitable for mummification, typically in isolated areas. We previously reported a case of a homicide/suicide in a residential neighborhood in which the mummified remains were undetected for several years. We have subsequently encountered two additional cases in which mummified bodies were discovered in urban settings. Presented in the historical context of the environmental conditions and postmortem processes involved in mummification, these cases illustrate the particular constellation of human behaviors and scenarios, as well as environmental conditions, which must coincide for this phenomenon to occur and highlight the necessity of the multidisciplinary approach to the medicolegal investigation of such deaths and the determination of the cause and manner of death.

Cosleeping and sudden unexpected death in infancy.

CONTEXT: The practice of infants cosleeping with adults has long been the subject of controversy. Autopsy findings in cases of sudden infant death syndrome (SIDS) are usually indistinguishable from those found with unintentional or intentional suffocation, and the determination of the cause of death in cases of sudden unexpected death in infancy is often based on investigative findings and the exclusion of natural or traumatic causes. OBJECTIVE: To further elucidate the risk of cosleeping. METHODS: We reviewed 58 cases of sudden unexpected infant deaths. Cases were excluded if there was any significant medical history or evidence of trauma or abuse. RESULTS: Twenty-seven of the infants were cosleeping. Eleven of these cases had been previously diagnosed as SIDS, and in 7 cases parental intoxication was documented. CONCLUSION: Our findings support recent studies that suggest that cosleeping or placing an infant in an adult bed is a potentially dangerous practice. The frequency of cosleeping among cases diagnosed as SIDS in our study suggests that some of these deaths may actually be caused by mechanical asphyxia due to unintentional suffocation by the cosleeping adult and/or compressible bedding materials.

Sudden death associated with food and exercise.

Exercised-induced anaphylaxis occurs in conjunction with significant physical exertion. Anaphylaxis occurring when an individual exercise within a few hours of ingesting a particular food is an unusual variant. Cardiovascular symptoms can be the sole manifestation of exercise-induced food allergies, in which case death may mimic sudden cardiac death during physical exertion due to other pathologic causes. We report the sudden and unexpected death of an individual following the ingestion of hazelnuts and almonds, to which the individual was not previously known to be allergic. The decedent collapsed during vigorous dancing. The death was not associated with cutaneous or laryngeal manifestations of anaphylaxis. Awareness of the variable manifestations of food-precipitated anaphylaxis is necessary to correctly establish the diagnosis. An elevated serum tryptase level may be indicative of an allergic reaction, and allergen-specific IgE levels may be used to confirm the particular antigen.

The significance of pulmonary interstitial emphysema in live birth determination.

The utility of pulmonary interstitial emphysema (PIE) in live birth determination is not well established. Because the distinction between live birth and stillbirth may be important in criminal proceedings, we undertook this study to investigate the relationship between the histologic finding of PIE and live birth. Sixty-six cases of infant death were retrieved and compared with 21 stillborn infants. Histologic sections of the lungs were characterized as "florid PIE," "equivocal PIE," or "absent PIE." Sixteen cases of florid PIE were identified, all in live born infants. Forty-seven cases of equivocal PIE were found in 36 live born and 11 stillborn infants. In 24 cases (14 live born infants and 10 stillborns), no PIE was identified. We examined the relationship between florid PIE in infants with sudden infant death syndrome (SIDS) or "sudden unexpected death in infancy, manner undetermined" (SUDI), and also its relationship to other variables. No association was found. The presence of equivocal PIE may be an artifact of tissue processing. Florid PIE is found only in live born infants. No correlation between the presence of florid PIE and cause of death could be determined.

Methadone-related deaths in Palm Beach County.

The authors reviewed cases investigated by the Palm Beach Medical Examiner's Office in which postmortem toxicologic studies indicated the presence of methadone over the period from 1998 to 2002, to examine the role of the drug in these deaths. There were 139 methadone-positive cases, including 75 in which the death was attributed to combined drug toxicity and 23 to methadone toxicity alone. Methadone was most frequently used in conjunction with other prescription or illicit drugs, most commonly benzodiazepines and/or cocaine. There was considerable overlap in the postmortem blood methadone concentrations among the groups. Concentrations ranged from 0.114 mg/L-1.939 mg/L (mean .0559 mg/L) in cases where death was attributed to methadone toxicity; 0.050 mg/L-1.903 mg/L (mean 0.411 mg/L) in cases of combined drug toxicity; 0.069 mg/L-0.644 mg/L (mean 0.224 mg/L) in deaths attributed to other drugs; 0.062 mg/L-1.090 mg/L (mean 0.344 mg/L) among deaths attributed to natural causes and 0.072 mg/L-2.7 mg/L (mean 0.605 mg/L) among deaths due to trauma. The concentrations of methadone detected indicate that it may not be possible to establish a lethal methadone range because some deaths occurred at methadone concentrations below previously reported lethal ranges, and because of the presence of other drugs. Determining the cause of death in methadone-positive cases necessitates correlation with autopsy results and investigative findings.

Fatalities due to indigenous and exotic species in Florida.

Florida's climate is suitable for many potentially hazardous animals, including both indigenous and exotic species, which are frequently kept as in zoos or as pets. This has resulted in many unforeseen fatal encounters between animals and the ever expanding human population. While the literature and knowledge pool for more common types of deaths referred to medical examiner/coroner's offices is abundant, the appreciation of wildlife and exotic pet-related deaths is far less widespread. We report seven animal attack-related deaths that occurred in Florida. The inflicted injuries included blunt and sharp force injuries, asphyxia, drowning, and envenomation. The underlying cause of death, however, was always a result of the human/animal interaction and in many cases related to human error and failure to appreciate the potentially dangerous behavior of nondomesticated species. These cases illustrate the varied circumstances and pathophysiologies associated with deaths due to indigenous and exotic species and the importance of the multidisciplinary approach in the medicolegal investigation of these cases.

Household furniture tip-over deaths of young children.

The potential for the injury or death of a child resulting from the tip-over of a piece of household furniture or a domestic appliance has not been previously well recognized. We reviewed nine accidental deaths of young children that resulted from avoidable residential hazards and/or lapses in supervision of the children by their caregivers. The offending household items included televisions, bedroom dressers, a kitchen stove, and a lounge chair. The causes of death were mechanical asphyxia, blunt trauma, and combined blunt head trauma and asphyxia. All of the deaths could have been prevented by appropriate anchoring of the piece of furniture and/or closer supervision of the child. A thorough multidisciplinary investigation is essential in establishing the cause and manner of death in such cases and in identifying risk factors that may aid in the prevention of future childhood deaths.

Sudden unexpected death due to a previously undiagnosed plasma cell dyscrasia.

The plasma cell dyscrasias are a diverse group of disorders characterized by the production of a clonal paraprotein. Sudden death is a recognized complication of the plasma cell dyscrasias, most commonly in individuals with cardiac involvement by amyloidosis. However, the current forensic literature has no reported cases in which sudden death resulted from complications of a plasma cell dyscrasia that was first diagnosed by postmortem histologic examination. We present the case of a woman whose sudden and unexpected death resulted from a seizure. Postmortem examination revealed no evidence of trauma or a grossly identifiable natural disease process that would have accounted for her death. However, microscopic and immunohistologic studies revealed a previously undiagnosed plasma cell dyscrasia, the clonality of which was determined by immunohistochemical studies for immunoglobulin light chains, that was not associated with amyloid deposition. This case elucidates a previously unrecognized cause of sudden unexpected death and illustrates the importance of microscopic studies in selected cases examined in medical examiner/coroner offices.