Sudden death in an adolescent due to undiagnosed classic Hodgkin lymphoma.

Few cases of natural sudden death presenting as an undiagnosed lymphoma have been reported in the literature, especially in adolescents. Herein we provide a report of sudden death caused by undiagnosed classic Hodgkin lymphoma (cHL). We describe an 18-year-old female who collapsed after several weeks of weight loss, decreased appetite, and dyspnea. At autopsy, a bulky mass arising in the mediastinum and neck compressed the esophagus and trachea, surrounded the great vessels, obliterated the pericardial sac, and infiltrated the myocardium. The lungs were collapsed and large pleural effusions were present. The tumor burden, which weighed at least 2710 g in aggregate, was entirely above the diaphragm. Microscopic examination of the masses showed features typical for nodular sclerosis cHL including large bands of sclerosis, numerous Hodgkin/Reed-Sternberg (HRS) cells, and an eosinophil-rich mixed inflammatory cell infiltrate. Immunohistochemical stains showed the HRS cells to be uniformly positive for CD30 and CD15 and negative for CD3, CD20, CD45, and PAX5. This case exemplifies a rare sudden natural death due to previously undiagnosed cHL in a young patient.

Reassessing the cardiac box: A comprehensive evaluation of the relationship between thoracic gunshot wounds and cardiac injury.

BACKGROUND: High-energy missiles can cause cardiac injury regardless of entrance site. This study assesses the adequacy of the anatomic borders of the current "cardiac box" to predict cardiac injury. METHODS: Retrospective autopsy review was performed to identify patients with penetrating torso gunshot wounds (GSWs) 2011 to 2013. Using a circumferential grid system around the thorax, logistic regression analysis was performed to detect differences in rates of cardiac injury from entrance/exit wounds in the "cardiac box" versus the same for entrance/exit wounds outside the box. Analysis was repeated to identify regions to compare risk of cardiac injury between the current cardiac box and other regions of the thorax. RESULTS: Over the study period, 263 patients (89% men; mean age, 34 years; median injuries/person, 2) sustained 735 wounds (80% GSWs), and 239 patients with 620 GSWs were identified for study. Of these, 95 (34%) injured the heart. Of the 257 GSWs entering the cardiac box, 31% caused cardiac injury, whereas 21% GSWs outside the cardiac box (n = 67) penetrated the heart, suggesting that the current "cardiac box" is a poor predictor of cardiac injury relative to the thoracic non-"cardiac box" regions (relative risk [RR], 0.96; p = 0.82). The regions from the anterior to posterior midline of the left thorax provided the highest positive predictive value (41%) with high sensitivity (90%) while minimizing false-positives, making this region the most statistically significant discriminator of cardiac injury (RR, 2.9; p = 0.01). CONCLUSION: For GSWs, the current cardiac box is inadequate to discriminate whether a GSW will cause a cardiac injury. As expected, entrance wounds nearest to the heart are the most likely to result in cardiac injury, but, from a clinical standpoint, it is best to think outside the "box" for GSWs to the thorax. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Concordance Rate for the Identification of Distant Entrance Gunshot Wounds of the Back by Experienced Forensic Pathologists Examining Only Images of Autopsies.

The images of 66 gunshot entrance wounds with a defect on the back, a bullet in the body, hemorrhage along the wound track, and logical certainty that it was an entrance wound were collected from the files of a moderately busy medical examiner's office. Participants numbering 22 board-certified forensic pathologists viewed a single digital archival image of each of the 66 entrance wounds randomly mixed with 74 presumptive exit wounds to determine whether they were entrance or exit wounds. The concordance rate for correctly identifying the 66 logically known entrance wounds was 82.8% with a range from 58% to 97%. This pilot study was conducted to provide an evidence-based approach to the interpretation of the direction of gunshot wounds by reviewing pathologists with access only to archival photographs, and it is not a measure of the accuracy to distinguish entrance from exit wounds when given all of the circumstances.

An Unusual Feature of Graze Gunshot Wounds.

All graze wounds that occurred in the jurisdiction of the Fulton County Medical Examiners Center over a ten-year period (2005-2014) were inspected. Of a total of 227 graze wounds, 31 (14%) exhibited a previously not well-described feature. At one end of the graze wound, two small, subtle, parallel abrasions separated by a band of spared skin extended away from the wound. This finding occurred more often at the proximal corner (16 times) than the distal corner (seven times) when a direction was able to be determined. The mechanism of this feature does not appear to be related to jacketed ammunition expected to deform into petals. Possible mechanisms for the creation of this feature are random irregularities in skin resistance along with slight wobble (yaw) of the bullet or pressure waves generated by the bullet that causes buckling of the skin.

Acute bacterial meningitis with coincident methamphetamine use: a case report and review of the literature.

Methamphetamine is a synthetic stimulant that can adversely affect the central nervous system and the immune system. Through various mechanisms, methamphetamine is toxic to neurons, endothelial cells, lymphocytes, granulocytes, and macrophages resulting in systemic damage. Reported is the sudden demise of an otherwise healthy 31-year-old woman with a history of stimulant abuse. At autopsy, acute bacterial meningitis was identified. Microbiology cultures grew a single isolate of Streptococcus pneumoniae. Toxicology was positive for amphetamine (0.13 mg/L) and methamphetamine (0.8 mg/L). The cause of death was classified as acute bacterial meningitis with methamphetamine use. Either the acute bacterial meningitis or the methamphetamine toxicity would have been sufficient to result in death; however, the concurrent pathophysiology of the two entities must be understood. A review of the current literature assesses the mechanisms of injury attributed to acute and chronic methamphetamine use, bacterial meningitis, and the synergy between the two.

Subdural hematoma occurrence: comparison between ethanol and cocaine use at death.

OBJECTIVE: The objective of this study was to show that, in a medical examiner population, ethanol intoxication is associated with an increase in the occurrence of subdural hematoma (SDH), whereas the presence of cocaine is not associated with an increase in the occurrence of SDH. DESIGN: This was a retrospective evaluation of 967 SDH including the investigative information, autopsy, and toxicological findings derived from 18,314 medical examiner cases over 8 years. RESULTS: Subdural hematoma is found in 7% to 9% of cases with either no ethanol or less than 100 mg/dL of ethanol. Subdural hematoma is found in 18% of cases with ethanol levels of greater than 100 mg/dL. Subdural hematoma is found in 11% of cases negative for cocaine, whereas SDH is found in 9% of cases with any form of cocaine present at death.

Postmortem vitreous beta-hydroxybutyrate: interpretation in a forensic setting.

Vitreous beta-hydroxybutyrate (BHB) was retrospectively analyzed in 1795 forensic cases using the Pointe Scientific method. Comparison of vitreous BHB with vitreous glucose in 1781 of the cases showed moderately good correlation r = 0.731. Comparison with blood alcohol levels in 1561 of the cases showed no correlation r = -0.053. Vitreous BHB was a marker of diabetic ketoacidosis when above 6.0 mM with a vitreous glucose over 200 mg/dL. It was an indicator (>50%) for alcoholic ketoacidosis when above 6.0 mM with a vitreous glucose below 200 mg/dL. Recommendations for interpretation of vitreous BHB: <0.4 mM normal; 0.41-1.2 mM slightly elevated, rarely (<1%) of concern; 1.21-2.0 mM moderately elevated, less rarely (2.5%) of concern; 2.01-6.0 mM significantly elevated, frequently of concern (12-48%); >6.0 mM usually (100% in this study) indicated life-threatening conditions. Vitreous BHB was helpful evaluating cases with ketogenic conditions, especially diabetes and alcoholism.

The Fulton County Medical Examiner's experience with the Federal Bureau of Investigation National Missing Person DNA Database Program, 2004-2007.

BACKGROUND: Medical examiners and coroners occasionally encounter unidentified human bodies, which remain unidentified for extended periods. In such cases, when traditional methods of identification have failed or cannot be used, DNA profiling may be used. The Federal Bureau of Investigation has a National Missing Person DNA database (NMPDD) laboratory to which samples may be submitted on such cases and from possible relatives or environments of unidentified decedents. This article describes the experience of the Fulton County Medical Examiner (FCME) in submitting samples to the NMPDD laboratory. METHODS: A database was established at the FCME to track the submission of samples from unidentified decedents to the NMPDD laboratory for DNA testing along with the results and turnaround times. In December 2004, the FCME inventoried all cases for which samples were available and began to submit them to the NMPDD laboratory for testing. DNA testing and isolation rates, sample type, and turnaround times were tabulated in October 2006 for samples submitted between December 16, 2004 and December 16, 2005. An overall summary of data was also prepared concerning the status of all samples submitted as of April 17, 2007. RESULTS: During the 1-year study period, samples from 77 unidentified decedents were submitted to the laboratory. As of October 2006 (22 months after submission of the first samples and 10 months after submission of the last samples), testing had been completed on 53% of the samples submitted, and 68% of those tested resulted in a mitochondrial DNA profile. Turnaround times ranged from 66 to 557 days, improved with time, and had a mean of 107 days for specimens submitted during the latter part of the study period. As of April 17, 2007, we had submitted samples involving 84 unidentified decedents. Seventy-five percent of the samples have now been tested. Data from the NMPDD laboratory have resulted in 4 identifications by comparison with putative relatives, 4 exclusions, and no cold hits through comparison NMPDD DNA profiles from missing persons. More extensive data are presented in the body of this article. CONCLUSIONS: The NMPDD laboratory provides useful and free services to medical examiners, coroners, and law enforcement agencies that require DNA services regarding missing and unidentified persons. Turnaround times have improved. The success of the system in getting cold hits will be heavily dependent on law enforcement filing missing persons reports and submission of reference samples from putative relatives of the decedent. We recommend collecting specimens for DNA analysis early on in the postmortem investigation, submitting samples to the NMPDD laboratory or one of its participating laboratories when traditional methods for identification cannot be used or have failed, not burying bodies until a DNA profile has been obtained, and not cremating unidentified remains.

Postmortem blood cadmium, lead, and mercury concentrations: comparisons with regard to sampling location and reference ranges for living persons.

This study's goal was to determine cadmium (Cd), lead (Pb), total mercury (THg), and inorganic mercury (IHg) levels in human cadavers to compare measured levels with established reference ranges for living persons and to determine whether blood levels varied with time from death to sample collection or by body collection site. Subjects (n = 66) recruited from the Fulton County Medical Examiner's Office in Atlanta, GA, were 20 years of age or older, had no penetrating trauma, no obvious source of environmental contamination of the vasculature, and had whole blood accessible from the femoral (F) site, the cardiac (C) site, or both. Geometric mean results were as follows: 2.59 microg/L F-Cd; 11.81 microg/L C-Cd; 1.03 microg/L F-THg; 2.01 microg/L C-THg; 0.29 microg/L F-IHg; 0.49 microg/L C-IHg; 1.78 microg/dL F-Pb; and 1.87 microg/dL C-Pb. Both F- and C-Cd levels as well as C-THg levels were significantly higher than reference values among living persons (C- and F-Cd, p < 0.0001 and C-THg, p = 0.0001, respectively). Based on regression modeling, as the postmortem interval increased, blood Cd levels increased (p < 0.006). Postmortem blood Cd concentrations were elevated compared to population values and varied with respect to sampling location and postmortem interval.

Differential association of socioeconomic status in ethnic and age-defined suicides.

Suicide rates vary among racel- and age-defined groups, yet little is known about how suicide risk factors differentially impact individual groups. This study assessed differential associations of socioeconomic status among age- and race-defined groups of suicide victims. A database containing demographic information on declared suicides in Fulton County, GA, from 1 January 1988 through 31 December 2003 was combined with annual per capita income by zip code in Atlanta, GA. Analyses were performed to evaluate differential associations of socioeconomic status among age- and race-defined groups of suicide victims. Compared with the respective ethnic populations of Fulton County, white suicide victims lived in areas with lower per capita income ($51,232 vs. $35,893); African American suicide victims did not ($17,384 vs. $18,179). Elderly suicide victims (>or= 65 years) were more likely to live in the lowest per capita income areas compared with other age groups (OR 1.80, 95% C.I. 1.14, 2.84). Cox proportional hazards models showed increasing income increased the instantaneous risk of suicide among adolescents (HR 2.76; 95% C.I. 2.15, 3.53), particularly African American adolescents (HR 4.22; 95% C.I. 2.19, 8.11), and decreased risk among the elderly (HR 0.58; 95% C.I. 0.50, 0.68). Socioeconomic status had differential associations among age- and race-defined groups of suicide victims.

Nonnatural deaths of adolescents and teenagers: Fulton County, Georgia, 1985-2004.

CONTEXT: Childhood deaths are carefully scrutinized by many different government agencies, fatality review panels, researchers, and other groups. Many such deaths, especially those that involve external causes such as injury and poisoning, are amenable to prevention. Characterizing the causes and circumstances of nonnatural childhood deaths may provide information that is useful for development of prevention strategies and programs. METHODS: This is a retrospective review of all nonnatural deaths investigated and certified by the Fulton County Medical Examiner involving persons 10 to 19 years of age during the years 1985-2004, inclusive. Cases were identified by searching electronic death investigation files maintained during the study period. Demographic and circumstantial information were tabulated for homicides, suicides, motor-vehicle fatalities, and other accidental deaths, and crude death rates were calculated for each 5-year period during the study. RESULTS: During the 20 year period there were 961 nonnatural deaths among persons 10 to 19 years of age. Most deaths were due to homicide (48%) followed by motor-vehicle fatalities (30%), suicide (12%), and nontraffic accidental fatalities (10%). Black males had the highest death rates among the homicide, suicide, and nontraffic accidental deaths, although the rates for each of these were lower in the most recent 5 year period than the first 5-year period. The number of deaths increased in each category as age increased, and this observation was most marked for homicides and least marked for nontraffic accidental deaths. Firearms were involved in 88% of homicides and 61% of suicides. Most nontraffic accidental deaths were due to water-related accidents, followed by drug and/or alcohol toxicity, fire-related injuries, and accidental firearms injuries. CONCLUSIONS: Homicide accounts for almost half of all deaths among persons 10 to 19 years of age. Black males are at particularly high risk for nonnatural death in comparison with other race/sex groups, especially for homicide. If effective firearm fatality prevention strategies and programs could be implemented, data in this study suggests that such a measure alone could cut in half the nonnatural mortality rate in the 10 to 19 year age group in Fulton County. Although homicide and suicide rates have declined, there remains room for improvement in these areas, as is the case for traffic-related and other accidental fatalities.

Combined pathological effects of cocaine abuse and HIV infection on the cardiovascular system: an autopsy study of 187 cases from the Fulton County Medical Examiner's office.

This autopsy study evaluates the possible cumulative effects of cocaine use in HIV-infected adult individuals on cardiovascular tissue. A total of 187 autopsy case reports and available H&E sections of myocardium and coronary arteries were reviewed. Four major study groups were defined: (A) a total of 63 cases positive for cocaine and negative for HIV (COC); (B) 40 cases positive for HIV/AIDS and negative for cocaine (HIV), (C) 23 cases both HIV/AIDS and cocaine (HIV/COC), and (D) a control group of 61 age-, sex- and race-matched, negative for cocaine and for HIV (CONT). The following morphologic and demographic data were analyzed: heart weight, left ventricular hypertrophy, myocardial fibrosis, thickening of the intramyocardial vessels, myocarditis, acute or remote myocardial infarcts (MI), age, sex, and race. Increased frequency of coronary wall and adventitial infiltrates, myocarditis, and thickened intramyocardial vessels present in HIV/COC group (14.5%, 17.4%, and 17.4% vs. 6.5%, 3.3%, and 0% in CONT group) may indicate possible combined and/or cumulative effects of HIV and cocaine on cardiovascular pathology.

Cocaine and alcohol use preceding suicide in African American and white adolescents.

The goal of this investigation was to determine whether cocaine and ethanol use was a differentiating factor between African American and white teenage suicide victims. This is a retrospective analysis of medical examiner's records of all completed suicides in Fulton County, GA from 01/1989 to 12/2003, and included 1296 cases. There were 79 suicide victims aged 19 and younger during the study interval, and of this group, 49 (62%) were African American, 26 (33%) were white, and 4 (5%) other race, compared to adults (20 years) where 28.5% were African American, 68.6% white and 2.9% other race (chi(2)=42.678, d.f.=2, p<0.0001). Of the black teenaged victims, 82.2% had no cocaine or alcohol detected at autopsy, while 41.7% of the white victims were positive for one or both substance (chi(2)=4.633, d.f.=1, p=0.04). Only 8.9% of the black teenage suicide victims had used cocaine prior to death compared to 28% of the whites (chi(2)=4.432; d.f.=1; p<0.04). The suicide rate (suicide/100,000/year) for black teens was 5.48 compared to 4.16 for whites, but the rate of cocaine positive teen suicides was 1.12 for whites and 0.45 for blacks. The pattern of cocaine use changes dramatically in the adult group, with 27% of African American suicide victims compared to 7.7% of whites being positive (chi(2)=73.272; d.f.=1; p<0.001). Use of intoxicating substances does differentiate teenage suicide victims, as only a small proportion of black teenagers had used cocaine or alcohol prior to death compared to almost half of all whites.

Methylenedioxymethamphetamine (ecstasy)-related myocardial hypertrophy: an autopsy study.

BACKGROUND: Myocardial hypertrophy is a well-recognized complication of cocaine and methamphetamine abuse and is a strong, independent risk factor for sudden death, myocardial infarction, and congestive heart failure. We sought to determine if use of MDMA (methylenedioxyamphetamine or "ecstasy") is associated with myocardial hypertrophy at death. METHODS AND RESULTS: A matched, retrospective study using medical examiner (ME) death reports. Consecutive MDMA positive (+) and MDMA negative (-) deaths identified from MEs in 10 states and a local county, respectively. Five MDMA(-) cases were matched to each MDMA(+) case for age, sex, and ethnicity. MDMA(+) cases were confirmed using GC/MS and other drugs of abuse (e.g., cocaine and methamphetamine) were absent. Matched MDMA(-) cases were trauma fatalities with intact hearts and blood negative for all illicit stimulants. Cardiac weights were compared between the two groups. Twenty seven MDMA(+) deaths and 135 matched MDMA(-) deaths were enrolled. Mean age was 20 years (range 16--33 years); 44% were female. 70.4% were Caucasian, 14.8% African-American, 11.1% Asian, and 3.7% Hispanic. Mean heart weight of MDMA(+) fatalities was 315.7 and 277.2g for MDMA(-) fatalities (Diff=38.5 g; 95% CI=18.3--8.7). Multivariate analysis revealed that MDMA(+) fatalities were more likely to have an enlarged heart (OR=18.3; 95% CI=3.6--1.6). CONCLUSION: The findings of this study suggest that MDMA users might also be at risk for myocardial hypertrophy and possible cardiac toxicity, similar to other stimulants.

Ethnic differences in patterns of suicide across the life cycle.

OBJECTIVE: The authors analyzed suicide across the life cycle of different ethnic groups in an urban population equally divided between blacks (44.6%) and whites (48.1%). METHOD: Two data sets were used: 1) all suicides in Fulton County, Ga., from January 1994 through December 2002 and 2) all U.S. suicides reported by the National Center for Injury Prevention in 1999 and 2000. RESULTS: The population rates for suicide in Fulton County were 1.22 per 100,000 black females, 10.74 per 100,000 black males, 9.89 per 100,000 white females, and 21.04 per 100,000 white males. In Fulton County, age at completed suicide was more than a decade lower in blacks than in whites. The median age of black victims was 32 years, with an interquartile range (IQR) of 23-45, and the median for whites was 44 years (IQR=31-58); the difference was significant. The mean ages of victims who were black (mean=36.1 years, SD=17.0) and of "other" race (mean=35.7, SD=14.3) were significantly lower than the mean for whites (mean=46.2, SD=18.5). The national data were similar, but minorities accounted for an even smaller percentage of suicides. Median age at completed suicide for African Americans nationally was 34 years (IQR=24-45) compared to 44 years (IQR=32-58) for Caucasians. CONCLUSIONS: African Americans commit suicide at rates much lower than those for whites, but they do so when much younger and they have a narrow, age-defined window of vulnerability. Age-specific psychopathological processes and protective factors may define suicide risk for each demographic group.