Gabapentin-related Deaths: Patterns of Abuse and Postmortem Levels.

Gabapentin, a GABA analogue, is a nonopioid prescribed for seizure control and neuralgic pain. Its abuse for recreational purposes has been increasing in recent years as the number of prescriptions also increases. In our series, we review 104 cases of decedents who tested positive for gabapentin in postmortem blood samples and an additional 53 nonfatal cases of motor vehicle drivers suspected of driving under the influence. In 47.1% of the fatality cases, gabapentin was directly involved in death. Most gabapentin fatalities had several other intoxicants present (opioids, over-the-counter medications, antianxiety, and antidepressant medications). In cases in which gabapentin was determined to be a cause of death, the blood concentrations ranged from 1.1 to 134.0 mg/L. Persons who died of a gabapentin-related drug death were prescribed the drug legitimately 91.4% of the time, with 84.2% of those also having a known prior history of abuse or misuse of prescription medications.

Anomalous parietal suture mimicking skull fracture.

Anomalous sutures of the parietal bone are exceedingly rare events. We present the case of a child admitted to the hospital after a near-drowning incident who subsequently expired. He was diagnosed with a parietal skull fracture by computed tomography scan before death. This was found to be an anomalous suture by postmortem histologic examination. Division of the parietal bone is an unusual event with anomalous sutures, which can be mistaken for fractures on radiographic or postmortem examination. Although fractures are much more common, it is prudent to evaluate all fractures and/or fracture-like abnormalities by histologic examination when possible to avoid misdiagnosing blunt trauma to the head.

A first time for everything: homicide involving the Brenneke SuperSabot shotgun slug.

Sabot shotgun slugs are not a new projectile, but the Brenneke SuperSabot shotgun slug has never been reported in a homicide. We present the case of a 28-year-old man killed with multiple gunshot wounds during an alleged "drive-by" shooting. At autopsy, a 496.2 grain slightly deformed projectile with a base diameter of 5/8'' (1.7 cm) was found within the decedent's clothing. Six distinct bullet tracks were identified. An entrance of the anterior right thigh was 3/4 x 5/8'' and ovoid, having only passed through the decedent's jeans. This bullet track passed through the soft tissue of the right thigh, exiting out the medial aspect and partially transecting the right greater saphenous vein, re-entering the medial left thigh and re-exiting out the posterior left upper thigh. With the exception of an irregular entrance on the sole of the left foot, which passed through the decedent's shoe, all other entrances were less than 1/2'' in greatest dimension. Investigating officers recovered an additional projectile of the same type, which had undergone more extensive deformation after striking and penetrating the tailgate of a truck. Further investigation identified the projectiles as the Brenneke SuperSabot shotgun slugs.

Fatal intravenous fentanyl abuse: four cases involving extraction of fentanyl from transdermal patches.

The transdermal fentanyl system delivers a specific dose at a constant rate. Even after the prescribed application time has elapsed, enough fentanyl remains within a patch to provide a potentially lethal dose. Death due to the intravenous injection of fentanyl extracted from transdermal patches has not been previously reported. We present 4 cases in which the source of fentanyl was transdermal patches and was injected. In all of these cases, the victim was a white male who died at home. Case 1 was a 35-year-old with no known history of drug use, who was found by his wife on the floor of his workshop. Police recovered a fentanyl patch, needle, and syringe at the scene. Case 2 was a 38-year-old with a known history of drug use whose family claimed that he was in a treatment program that used fentanyl patches for unknown reasons. His brother found him dead in bed, and law enforcement officers found a hypodermic needle beside the body; a ligature around his left hand, and apparent needle marks between his first and second digits were also noted. Case 3 was a 42-year-old with a recent attempted suicide via overdose who was found dead at his home. An empty box of fentanyl patches, Valium, Ritalin, and 2 syringes were found at the scene. Case 4 was a 39-year-old found by his mother, who admitted to removing a needle with attached syringe from the decedent's arm. Medications at the scene included hydrocodone, alprazolam, zolpidem, and fentanyl patches. All reported deaths were attributed to fentanyl intoxication, with blood concentrations ranging from 5 to 27 microg/L.

IgD-kappa myeloma: an unusual case.

A rare case of biclonal IgD-kappa and IgG-kappa myeloma is described. The patient initially presented with anemia, renal insufficiency, and proteinuria. The IgD-kappa, initially, was overlooked as a light chain; however, it decreased in serum concentration after treatment by approximately 90%, in contrast to the IgG-kappa that decreased in serum by approximately 40 % over a 9-yr period. Clinically, the patient responded well to treatment and improved greatly during this period. Practical recommendations are suggested in order to detect such cases.