"Tranq-dope": The first fatal intoxication due to xylazine-adulterated heroin in Italy.

BACKGROUND AND AIMS: The number of xylazine-involved overdose deaths tremendously increased from 2019 onwards in the US. This is due to the "tranq-dope" trend consisting in mixing opioids with the sedative to reduce drug manufacturing costs and enhance their effects. In this study, we report the first fatality involving xylazine-adulterated heroin in the EU. MATERIALS AND METHODS: The subject was a 33-year-old Caucasian male with a documented history of drug abuse who was found dead in a public area with puncture marks at the elbow. Peripheral blood and urine were collected at the autopsy and analyzed by liquid chromatography-high-resolution tandem mass spectrometry (LC-HRMS/MS) after protein precipitation. RESULTS: 6-Monoacetylmorphine, total/free morphine, and codeine blood concentrations of 20.3, 236/105, and 38.3 ng/mL, respectively, indicated recent heroin consumption. Methadone blood concentration was below 10 ng/mL. Alprazolam, nordiazepam, and flurazepam blood concentrations were 23.9, 61.4, and 55.0 ng/mL, respectively. Benzoylecgonine blood concentration was below 5 ng/mL. Xylazine blood and urine concentrations were 105 and 72.6 ng/mL, respectively. CONCLUSION: The combination of central nervous system depressants, i.e., opioids, benzodiazepines, and xylazine, was the principal cause of death by cardiorespiratory failure. The case was promptly reported to the UE Early Warning System on drugs.

Fatal Community-Acquired Clostridioides difficile Infection as a Cause of Listeria Meningitis: A Case Report.

A 77-year-old woman with a history of total gastrectomy was transferred to our hospital with complaints of fever and consciousness disturbance for five days. She had fever and consciousness disturbance with positive meningeal signs. Laboratory findings indicated an elevated inflammatory response and hypoalbuminemia, and computed tomography (CT) of the body indicated intestinal gas retention and mild ascites. Cerebrospinal fluid analysis revealed pleocytosis with elevated protein levels and a diagnosis of Listeria meningitis was made. Treatment with ampicillin/sulbactam was started, and her fever and consciousness disturbance resolved on day 2. However, on day 3, her fever and conscious disturbance deteriorated, and she went into shock subsequently. Laboratory findings revealed deteriorated inflammatory response and hypoalbuminemia. Body CT showed an obvious distended bowel loop and intestinal edema. A stool culture revealed positive Clostridioides difficile toxin B, and we diagnosed her with Clostridioides difficile infection (CDI). Although intravenous metronidazole was initiated, she died due to prolonged hypovolemic shock. We considered she had community-acquired CDI because her CDI emerged immediately after the initiation of antibiotics, symptom deterioration within 48 hours of admission, and abnormal abdominal CT findings at admission. Listeria meningitis can develop based on community-acquired CDI. Because CDI can have a very rapid and fatal course and is sometimes complicated by other infectious diseases, clinicians should pay attention to this complication.

First Known Human Death After Infection With the Avian Influenza A/H3N8 Virus: Guangdong Province, China, March 2023.

Here, we report on a case of human infection with the H3N8 avian influenza virus. The patient had multiple myeloma and died of severe infection. Genome analysis showed multiple gene mutations and reassortments without mammalian-adaptive mutations. This suggests that avian influenza (A/H3N8) virus infection could be lethal for immunocompromised persons.

A fatal case of tick-borne encephalitis in an immunocompromised patient: case report from Northeastern Poland and review of literature.

Tick-borne encephalitis (TBE) is an infectious illness of the central nervous system caused by the TBE virus, which is commonly transmitted through a tick-bite. TBE is endemic in Europe and mid-Asia. In this study, we report a case of a 36-year-old woman, living in Northeastern Poland, with a history of double corneal transplantation and post-transplant immunosuppressive therapy who was admitted to hospital because of progressive weakness, acute headache, nausea, vertigo, vomiting, and fever. The patient was diagnosed with TBE. However, the diagnosis was challenging as the initial serological tests for antibodies against the TBE virus were negative. We want to raise the awareness among the clinicians that the course of TBE is often unpredictable and that it tends to be more severe in immunocompromised individuals.. Delayed production of antibodies against TBE virus, which might inhibit the diagnosis of the disease, is observed in some immunocompromised patients.

A fatal case of persistent bacteremia and acute cholecystitis caused by Staphylococcus aureus: A case report.

Biliary tract infections caused by Staphylococcus aureus are rare. Here, we describe a case of fatal acute cholecystitis and persistent bacteremia caused by S. aureus in a patient with newly diagnosed diabetes mellitus. Staphylococcus aureus can cause bacteremic biliary tract infections, which are associated with higher mortality rates compared to biliary Klebsiella pneumoniae bacteremia. Early aggressive treatment and consultations with infectious disease specialists are recommended when biliary S. aureus bacteremia is clinically suspected.

'Flying high?'-Jump from a height in a 'Spice' high?: A case report on the synthetic cannabinoid 5F-MDMB-P7AICA.

Regarding the high potency of synthetic cannabinoids (SC), many intoxications and fatal cases are reported in literature. Here, we report on a fatality with 5F-MDMB-P7AICA contributing to the occurrence of death. A 31-year-old man died 10 h after he fell from the rooftop of a house. Police investigations revealed that he had consumed a 'legal high' herbal blend some hours earlier. An initial toxicological screening for new psychoactive substances (NPS) was negative. One year after, the analysis of confiscated drug samples revealed the SC 5F-MDMB-P7AICA being unknown at the time of the first investigations. Hence, post-mortem specimens were retrospectively analysed for 5F-MDMB-P7AICA and its dimethylbutanoic acid (DBA) metabolite. Lung, liver, kidney and bile fluid (BF) of the decedent were analysed following solid-phase extraction and standard addition, heart blood (HB) and peripheral blood (PB) by fully validated liquid-liquid extraction and protein precipitation methods. Additionally, hair specimens were analysed to examine a possible chronic consumption of the SC. All specimens were analysed by liquid-chromatography tandem mass spectrometry. 5F-MDMB-P7AICA was detected in HB (0.69 ng/ml), PB (1.2 ng/ml) and hair. DBA was found in HB (46 ng/ml) and PB (5.7 ng/ml) and could additionally be identified in liver and kidney (approximately 4-5 ng/g), lung (approximately 12 ng/g) and BF (approximately 60 ng/g). Compared with the parent compound, much higher concentrations of DBA were quantified. This case shows that drugs found at the scene can provide helpful initial information for further toxicological screenings in biological samples, especially when there is evidence of NPS consumption.

Follow-up and retrospective investigation of pneumoconiosis cases in a county of Ningbo City from 1974 to 2019 / 环境与职业医学

Background Pneumoconiosis is one of the most common and widespread prescribed occupational diseases in China, and there is no cure for it at present. The Healthy China 2030 underlines that the prevention and treatment of pneumoconiosis are the critical element of promoting occupational health. Objective To understand the basic characteristics, social security, and death causes of pneumoconiosis cases in Ninghai County, and to provide a basis for scientific prevention and treatment of pneumoconiosis. Methods Information on pneumoconiosis cases in Ninghai County from 1974 to 2019 was obtained by consulting occupational disease and occupational health information monitoring systems, occupational disease diagnosis institutions, and employers, which may retain original data on occupational pneumoconiosis diagnosis, as well as specialized epidemiological survey projects on pneumoconiosis. Telephone or face-to-face follow-up visits were conducted based on relevant information to complete or verify relevant information such as length of service with dust exposure, type, stage, and diagnosis date of pneumoconiosis. ANOVA, chi-square test, and rank-sum test were used to analyze age of diagnosis and age of death, entitlement to social security and mortality rate of cases/length of service. Results As of the end of 2019, a total of 420 cases of pneumoconiosis were diagnosed among workers exposed to dust in Ninghai County, with 409 cases (97.38%) followed up and 11 cases (2.62%) lost to follow-up. Since the first case of pneumoconiosis was reported in 1974, 39 cases, 278 cases, and 101 cases of pneumoconiosis were reported before 2000, from 2000 to 2009, and from 2010 to 2019, respectively. Two other cases of pneumoconiosis were diagnosed with an unknown year, one as a dead case and one as a lost case. There were 294 surviving pneumoconiosis cases, who mainly lived in Sangzhou Town. The mean age of diagnosis was (58.68±15.37) years old, and the median length of service with exposure to dust was 8.0 (4.0, 15.7) years. The age of diagnosing stage III pneumoconiosis was less than that of stage I and stage II, and the difference between the age of diagnosing stage III and stage II pneumoconiosis was significant (P <0.05). There were 231 cases (78.57%) aged ≥ 60 years, while there were 74 cases aged ≥ 80 years (25.17%). There were 160 cases (54.42%) whose length of service was < 10 years. There were 12.59% and 7.82% of the total cases compensated by work injury insurance and civil compensation by employers, respectively. From the perspective of diagnosis period, the proportion of patients who collected work-related injury insurance and civil compensation from employers in the 2010—2019 year group was higher than that in the <2000 year group or the 2000—2009 year group (P<0.01). There were 115 fatal pneumoconiosis cases, and the fatality rates of stage I, II , and III pneumoconiosis were 23.86%, 18.18%, and 50.75%, respectively. The fatality rate of stage III pneumoconiosis was higher than that of stage I or II (P <0.05). The age of diagnosis and age of death of stage III pneumoconiosis cases were lower than those of stage I and II (P <0.05). The cause of death was definite in 65 patients, including 25 cases (38.46%) of respiratory diseases (except lung cancer) and 28 cases (43.07%) of tumors, and lung cancer accounted for 1/2 of the pneumoconiosis cases that died due to tumors. Conclusion The surviving pneumoconiosis cases in Ninghai are mainly older than 60 years old and largely live in Sangzhou Town. Constructing local rehabilitation stations should be taken as an opportunity to actively prevent and treat pneumoconiosis complications, further improving the quality of life of pneumoconiosis patients.

A fatal case involved in pyrethroid insecticide ingestion: quantification of tetramethrin and resmethrin in body fluids of a deceased by LC-MS/MS.

PURPOSE: The quantification of parent molecules of pyrethroids tetramethrin and resmethrin in human specimens by a mass spectrometry (MS) technique has not been reported yet. A woman in her 60s was found dead in a wasteland. At the scene, an empty beer can and a spray for insecticides containing tetramethrin and resmethrin were found. Therefore, the concentrations of tetramethrin and resmethrin in postmortem specimens and the methanol solution used for rinsing the inside of the beer can were determined using liquid chromatography (LC)-tandem mass spectrometry (MS/MS). METHODS: The quantification method by LC-MS/MS for intact parent molecules of tetramethrin and resmethrin in whole blood and urine has been devised and validated in this work. The method was applied to the quantification of tetramethrin and resmethrin in whole blood, urine and stomach contents obtained from a cadaver at autopsy. RESULTS: The limits of detection of tetramethrin and resmethrin were 0.06 and 0.03 ng/mL; limits of quantification were 0.2 and 0.1 ng/mL in blood and urine, respectively. The concentrations of tetramethrin of the deceased were 11.1 ± 1.2 and 0.425 ± 0.017 ng/mL for stomach contents and urine, respectively; the concentration of resmethrin in stomach contents was 1.77 ± 0.18 ng/mL. The tetramethrin and resmethrin were unstable in blood and urine at room temperature; they should be kept at not higher than 4 â„ƒ. CONCLUSIONS: To our knowledge, this is the first report for quantification of unchanged tetramethrin and resmethrin in human specimens obtained in a fatal case.

Autopsy Findings and Causality Relationship between Death and COVID-19 Vaccination: A Systematic Review.

The current challenge worldwide is the administration of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine. Considering that the COVID-19 vaccination represents the best possibility to resolve this pandemic, this systematic review aims to clarify the major aspects of fatal adverse effects related to COVID-19 vaccines, with the goal of advancing our knowledge, supporting decisions, or suggesting changes in policies at local, regional, and global levels. Moreover, this review aims to provide key recommendations to improve awareness of vaccine safety. All studies published up to 2 December 2021 were searched using the following keywords: "COVID-19 Vaccine", "SARS-CoV-2 Vaccine", "COVID-19 Vaccination", "SARS-CoV-2 Vaccination", and "Autopsy" or "Post-mortem". We included 17 papers published with fatal cases with post-mortem investigations. A total of 38 cases were analyzed: 22 cases were related to ChAdOx1 nCoV-19 administration, 10 cases to BNT162b2, 4 cases to mRNA-1273, and 2 cases to Ad26.COV2.S. Based on these data, autopsy is very useful to define the main characteristics of the so-called vaccine-induced immune thrombotic thrombocytopenia (VITT) after ChAdOx1 nCoV-19 vaccination: recurrent findings were intracranial hemorrhage and diffused microthrombi located in multiple areas. Moreover, it is fundamental to provide evidence about myocarditis related to the BNT162B2 vaccine. Finally, based on the discussed data, we suggest several key recommendations to improve awareness of vaccine safety.

Hepatitis B virus detected in a golden monkey fatal case, China.

Hepatitis B virus (HBV) is distributed worldwide and poses a significant threat to human health. Cross-species transmission of HBV from human to non-human primates could occur, which has been confirmed in three individual events. In this study, HBV DNA was detected in one golden monkey fatal case in China. The following genetic sequencing and analysis demonstrated the virus had a close genetic relationship with HBV genotype C in humans. To our knowledge, this is the first report suggested that HBV is related with a non-human primate fatal case in China.

Systemic dengue infection associated with a new dengue virus type 2 introduction in Brazil - a case report.

BACKGROUND: Dengue infection is caused by an arbovirus with a wide range of presentations, varying from asymptomatic disease to unspecific febrile illness and haemorrhagic syndrome with shock, which can evolve to death. In Brazil, the virus circulates since the 1980s with many introductions of new serotypes, genotypes, and lineages since then. Here we report a fatal case of dengue associated with a Dengue virus (DENV) lineage not detected in the country until now. CASE PRESENTATION: The patient, a 58-year-old man arrived at the hospital complaining of fever and severe abdominal pain due to intense gallbladder edema, mimicking acute abdomen. After 48 h of hospital admission, he evolved to refractory shock and death. DENV RNA was detected in all tissues collected (heart, lung, brain, kidney, spleen, pancreas, liver, and testis). Viral sequencing has shown that the virus belongs to serotype 2, American/Asian genotype, in a new clade, which has never been identified in Brazil before. The virus was phylogenetically related to isolates from central America [Puerto Rico (2005-2007), Martinique (2005), and Guadeloupe (2006)], most likely arriving in Brazil from Puerto Rico. CONCLUSION: In summary, this was the first fatal documented case with systemic dengue infection associated with the new introduction of Dengue type 2 virus in Brazil during the 2019 outbreak.

Spontaneous perforation as a fatal presentation of esophageal tuberculosis: A case report.

INTRODUCTION: Tuberculosis is a multisystematic disease and is the most common cause of infectious disease-related mortality worldwide. Gastrointestinal tract is an uncommon site for extrapulmonary tuberculosis (TB). Esophageal TB is exceedingly rare. PRESENTATION OF CASE: We report a 22-years-old male with esophageal TB that presented in septic shock from esophageal perforation. Despite all measures including surgical intervention and aggressive support in the intensive care unit, patient passed away. DISCUSSION: The most common mechanism for esophageal involvement is secondary to direct spread from mediastinal structures and/or spreading the inoculation of swallowed sputum, or hematogenous or lymphatic spread. Once the diagnosis of TB is established, antibiosis is the cornerstone of treatment. Surgery is reserved only for complications of TB such as fistula, abscess, strictures or perforation. Less than 50% of cases are diagnosed within 24 h, and delay in diagnosis lead to significant increases in the mortality. CONCLUSION: In countries with high prevalence of TB, this diagnosis should be considered in those with esophageal perforation with no underlying etiology and medical treatment for TB should be initiated in addition to conventional treatment in appropriate group of patients.

WU Polyomavirus Infection in Children With Acute Lower Respiratory Tract Infections in China, 2017 to 2019: Case Reports and Multicentre Epidemiological Survey.

WU polyomavirus (WUPyV) is a novel member of the family Polyomaviridae recently detected in respiratory tract specimens. So far, it has not been proven whether WUPyV is a real causative agent for respiratory diseases. In this study, we described two patients with fatal infection who had WUPyV detected in their nasopharyngeal swabs. Furthermore, we conducted a multicentre study in six hospitals from different districts of China. WUPyV was detected by real-time polymerase chain reaction assays, and the clinical and molecular epidemiological characteristics of WUPyV strains among hospitalized children with acute lower respiratory tract infections all around China from 2017 to 2019 were analysed. Two complete WUPyV genome sequences were assembled from fatal patients' airway specimens. Phylogenetic tree analysis revealed that they were most closely related to strains derived from Fujian and Chongqing, China, in 2008 and 2013, respectively. In 2017-2019, a total of 1,812 samples from children with acute lower respiratory tract infections were detected for WUPyV, of which 11 (0.6%) were positive. Children aged ≤5 were more susceptible to WUPyV infection. A total of 81.8% of WUPyV-positive patients were coinfected with other viruses, of which rhinovirus enjoyed the highest frequency. The main clinical symptoms of infected patients include fever, coughing and sputum expectoration. Most patients were diagnosed with pneumonia, followed by bronchial surgery. Three patients manifested severe infection, and all patients improved and were discharged. Our results show that WUPyV persistently circulates in China. Further investigations on the clinical role and pathogenicity of WUPyV are necessary.

GHB concentration in a related post-mortem case.

Gamma-hydroxybutyrate (GHB) is a central nervous system depressant, primarily used as a recreational drug of abuse and as a therapeutic substance both in U.S.A. and Europe for the treatment of narcolepsy with cataplexy in adult patients and as adjuvant in the control of alcohol withdrawal syndrome. Several cases of GHB related deaths have been reported in the literature and GHB was found alone or in association to other drugs of abuse. However, only few biological matrices are often analyzed, therefore data on GHB distribution are lacking. Here we report a case involving a 45-year-old man, who was found dead in his bedroom.

A fatal paediatric case infected with reassortant avian influenza A(H5N6) virus in Eastern China.

Avian influenza A(H5N6) keeps evolving, causing outbreaks in birds and sporadic infections in human. Here, we report a fatal paediatric infection caused by a novel reassortant H5N6 virus. The patient was an obese 9-year-old girl. She initiated with fever and cough, then developed pneumonia, acute respiratory distress syndrome (ARDS) and respiratory failure. Lower respiratory tract aspirates and anal swabs were serially taken till the patient's death. Viral isolation, genome sequencing and phylogenetic analysis were conducted. A novel reassortant H5N6 virus was isolated from the patient. Except the PA gene, all other 7 genes of the virus belonged to H5N6 genotype A (S4-like virus). The PA gene was probably obtained from Eurasian waterfowl influenza viruses. The H5N6 virus was consistently detected from the patient's respiratory samples till the 17th day after symptom onset, but not from anal swabs or urine sample by real-time reverse transcription polymerase chain reaction (RT-PCR). Significantly elevated (32-fold) serum antibodies to H5N6 virus were observed during the patient's course of disease. Aside from the identified novel reassortant H5N6 viral strain, obesity, delayed confirmation of aetiology and specific antiviral treatment, and prolonged virus shedding could have contributed to the poor clinical outcome.

Case analysis of antithyroid drug-induced agranulocytosis combined with fatal complications / 西安交通大学学报(医学版)

Objective: To investigate the clinical characteristics of patients with antithyroid drug (ATD)-induced agranulocytosis in the treatment of hyperthyroidism and analyze factors associated with the death rate of patients with fatal outcomes. Methods:Patients diagnosed with ATD-induced agranulocytosis in Department of Endocrinology, the First Affiliated Hospital of Xi'an Jiaotong University from January 2000 to December 2018, were included in this study and their medical records were reviewed retrospectively. We compared the clinical characteristics of patients in death group and survival group. Results: We recruited 70 patients with ATD-induced agranulocytosis in the study. Five of them died. All fatal cases were females, aged between 33 to 54 years. Three patients also had hyperthyroidism crisis, and two had hyperthyroid heart disease. Compared with the survival cases of ATD-induced agranulocytosis, patients with fatal agranulocytosis were elderly [47.00±8.12)years vs. (35.58±11.10) years, P=0.028] and had a longer duration of hyperthyroidism [1 800 (315-2 880)d vs. 60(40-120)d, P=0.002]. The interval days between symptoms and the diagnosis of agranulocytosis were significantly longer in patients with fatal cases than the survival ones[5.0(3.5-11.0)d vs. 0(0-2.5) d, P=0.002]. In addition, the proportion of patients with hyperthyroid crisis was greater in the death group (60% vs. 0%, P<0.001). Conclusion: Age, duration of hyperthyroidism, and timely diagnosis of agranulocytosis could affect the mortality of agranulocytosis. Mortality in patients with hyperthyroidism was significantly increased. It is recommended that patients with hyperthyroidism should be reminded to monitor routine blood cells immediately. In the event of agranulocytosis, other methods should be chosen as soon as possible to treat hyperthyroidism and avoid serious outcomes.

Renal Injury in DENV-4 Fatal Cases: Viremia, Immune Response and Cytokine Profile.

Dengue virus (DENV) infections may result in asymptomatic cases or evolve into a severe disease, which involves multiple organ failure. Renal involvement in dengue can be potentially related to an increased mortality. Aiming to better understand the role of DENV in renal injury observed in human fatal cases, post-mortem investigations were performed in four DENV-4 renal autopsies during dengue epidemics in Brazil. Tissues were submitted to histopathology, immunohistochemistry, viral quantification, and characterization of cytokines and inflammatory mediators. Probably due the high viral load, several lesions were observed in the renal tissue, such as diffuse mononuclear infiltration around the glomerulus in the cortical region and in the medullary vessels, hyalinosis arteriolar, lymphocytic infiltrate, increased capsular fibrosis, proximal convoluted tubule (PCT) damage, edema, PCT debris formation, and thickening of the basal vessel membrane. These changes were associated with DENV-4 infection, as confirmed by the presence of DENV-specific NS3 protein, indicative of viral replication. The exacerbated presence of mononuclear cells at several renal tissue sites culminated in the secretion of proinflammatory cytokines and chemokines. Moreover, it can be suggested that the renal tissue injury observed here may have been due to the combination of both high viral load and exacerbated host immune response.

Fatal Case of Lassa Fever, Bangolo District, Côte d'Ivoire, 2015.

Lassa fever has not been reported in Côte d'Ivoire. We performed a retrospective analysis of human serum samples collected in Côte d'Ivoire in the dry seasons (January-April) during 2015-2018. We identified a fatal human case of Lassa fever in the Bangolo District of western Côte d'Ivoire during 2015.

Cytokine Storm Combined with Humoral Immune Response Defect in Fatal Hemorrhagic Fever with Renal Syndrome Case, Tatarstan, Russia.

Hemorrhagic fever with renal syndrome (HFRS) is endemic in Tatarstan, where thousands of cases are registered annually. Puumalaorthohantavirus is commonly detected in human case samples as well as in captured bank voles, the rodent hosts. The pathogenesis of HFRS is still not well described, although the cytokine storm hypothesis is largely accepted. In this study, we present a comprehensive analysis of a fatal HFRS case compared with twenty four non-fatal cases where activation of the humoral and cellular immune responses, pro-inflammatory cytokines and disturbed blood coagulation were detected using immunological, histological, genetic and clinical approaches. Multiple organ failure combined with disseminated intravascular coagulation syndrome and acute renal failure was the cause of death. Decreased Interleukin (IL)-7 and increased IL-18, chemokine (C-C motif) ligand (CCL)-5, stem cell growth factor (SCGF)-b and tumor necrosis factor-beta (TNF-ß) serum levels were found, supporting the cytokine storm hypothesis of hantavirus pathogenesis.

Dengue Virus and Influenza A Virus Co-Infection in Pregnancy: A Case Report.

Dengue is still an important cause of disease and mortality in tropical countries, as is influenza A virus, which is also a cause of epidemics all over the globe. In this article, we present the case of a 31-year-old woman who was in her second trimester of pregnancy and presented with severe dengue with hematological and neurological complications, and premature labor. She was misdiagnosed with bacterial infection and received antibiotic treatment with no improvement of the clinical manifestations and previous to death, she was diagnosed with dengue infection. She died from cardiorespiratory arrest. In the postmortem evaluation, influenza A co-infection was confirmed and characterization of the tissue damage and immune response in lung, liver, kidney, heart, spleen, and brain was determined, finding a severe inflammatory response in lung with T cells and macrophages infiltrating the tissue. This case report highlights the risks of accepting a single diagnosis, especially in endemic countries to multiple tropical diseases, which can lead to delay in appropriate treatment that could reduce morbidity and mortality.