Sudden death due to metronidazole/ethanol interaction.

Metronidazole (Flagyl), a commonly prescribed antimicrobial agent, can produce a reaction similar to that of disulfiram (Antabuse) when administered to patients drinking ethanol. This drug/chemical interaction results in accumulation of acetaldehyde in the blood. Acetaldehyde is hepatotoxic, cardiotoxic, and arrythmogenic; no lethal serum acetaldehyde level has been established. Sudden death has been reported in patients taking disulfiram while using ethanol; no fatalities have been reported due to ethanol/ metronidazole interactions. Described is a case of a 31-year-old woman who died moments after an assault by a male companion, during which he inflicted minor physical trauma to her upper arm. Toxicologic analysis yielded elevated concentrations of serum ethanol (162 mg/d), acetaldehyde (4.6 mg/d), and metronidazole (0.42 mg/L). The cause of death was reported to be cardiac dysrhythmia due to acetaldehyde toxicity due to an ethanol/ metronidazole interaction. Autonomic stress associated with the assault is likely to have contributed to this woman's death. The mechanism of death is examined.

Firearm-related hunting fatalities in North Carolina: impact of the 'Hunter Orange' Law.

In the decade spanning 1983 through 1992, 68 people were killed by firearms while hunting in North Carolina (average of 1.66 fatalities/100,000 licenses issued). Of these, 58 deaths involved two parties, a shooter and a victim. In 22% of the incidents the victims were mistaken for game. During the 1987-1988 hunting season a "Hunter Orange" law was initially enforced. This law requires sportsmen to wear an article of bright orange clothing while hunting. After enactment of this law, a reduction in the incidence of hunters being killed because they were "mistaken for game" has proven statistically significant. The present study documents that legally mandating bright orange clothing has resulted in fewer firearms-related fatalities due to the victim's being mistaken for game while hunting. The North Carolina experience implies that governmental intervention can influence the incidence of accidental deaths during recreational hunting.

Dyadic deaths involving Huntington's disease: a case report.

Huntington's disease is a hereditary neurodegenerative disorder characterized by involuntary choreiform movements and progressive dementia. Although controversy exists regarding the exact risk of suicide in patients with Huntington's chorea, the literature supports an increased risk of suicide, especially in the early stages of this disease. We describe a case of homicide-suicide involving a father and son. The 60-year-old father, the homicide victim, suffered from advanced Huntington's disease; his 30-year-old son, the assailant, had a history of depression but had not been diagnosed with Huntington's disease at the time of his suicide. The psychiatric implications of this dementing disease, including the risk of suicide, are discussed. The gross, histologic, and molecular genetic features of this neurodegenerative disease are also described. The recognition of this autosomal dominantly inherited disorder at autopsy can make a profound impact on the lives of surviving family members.

Suicidal cyanide ingestion as detailed in Final Exit.

Final Exit is an "informational aid" advocating the practice of active euthanasia and describing the proper method for the foolproof commission of suicide. Although it has been directed toward assisting the terminally ill patient who desires to terminate suffering, it has been suggested that the widespread availability of this book may result in its abuse. Specifically, there is growing concern that "do-it-yourself suicide manuals" could bring about the fruition of suicidal ideations that are relatively common among mentally ill patients and impressionable adolescents. Described is the suicidal ingestion of cyanide by a physically healthy 30-year-old man. His diary, found next to the body, contains a recipe for suicide copied verbatim from Derek Humphry's Final Exit. Although the decedent's history, the scene investigation, and the external examination strongly suggest an underlying psychiatric disorder, postmortem examination disclosed minimal underlying physical disease. This case graphically illustrates the abuse potential of this literary genre. To our knowledge, this is the first case of its kind to appear in the literature. We recommend that forensic pathologists and medical investigators familiarize themselves with the methods of suicide described in Final Exit.

Suicide by environmental hypoxia (forced depletion of oxygen).

Suicidal suffocation by forced oxygen depletion (environmental hypoxia) with carbon dioxide (CO2) and with propane is discussed in two cases. No toxicologic proof was available with the former and circumstantial evidence weighed heavily. The latter case demonstrated inhaled propane by an on-scene transthoracic aspirate; all other toxicology specimens, including brain, liver, blood, kidney, fat, and vitreous, did not contain hydrocarbons. This second fatality was complicated by multi-agent overdose, including diphenhydramine, fluoxetine (Prozac), and nordiazepam. The designation of these deaths as due to oxygen depletion involved careful scrutiny of the autopsy, toxicologic, and scene findings. Complete analysis of all factors surrounding these rarely encountered suffocation deaths is stressed.

A decade of train-pedestrian fatalities: the Charleston experience.

Although the cause of death is rarely in doubt in train-pedestrian fatalities, the manner of death is often unclear. The distinction between accident and suicide can only be made after careful evaluation of the history, scene investigation, autopsy findings, and toxicologic data. A retrospective analysis of 25 consecutive train-pedestrian fatalities investigated by our office between 1982 and 1992 is reported. The victims were predominantly healthy, young males. All but one person died at the scene. The cause of death was massive blunt trauma in 88% of the cases. In one case, the sole injury was decapitation. A tissue or blood ethanol level greater than 99 mg/dL was detected in 80% of the cases. A total of 60% of the cases involved persons likely to have been sitting or lying across the railroad tracks; all but one of these victims were intoxicated. The manner of death was determined to be accidental in 92% of our cases. Decapitation by a moving train is an injury highly suggestive of suicide. Massive blunt trauma, especially in the setting of ethanol intoxication, was highly associated with accidental death. Toxicologic analysis is essential in discriminating willful suicide from alcohol-induced incapacitation resulting in accidental death. Homicide, disguised as an accident or suicide, must be ruled out in all cases. Accurate determination of the manner of death is an important issue regarding civil litigation and dispersal of insurance benefits.

From emergency room to morgue: deaths due to undiagnosed perforated peptic ulcers. Report of four cases with review of the literature.

Peptic ulcer perforation is well recognized as a cause of peritonitis and can result in death. Although amenable to surgery, delay in making the correct diagnosis results in increased mortality. Accurate diagnosis has been hindered by demographic changes in the affected population. In recent years, the population at risk has increased. Specifically, a rising incidence has been observed in women, in the elderly, and in patients with previously undiagnosed peptic ulcer disease. Described are four patients with perforated peptic ulcers, three of which were not detected prior to autopsy. In three of the four instances the patient had been observed in and discharged from a hospital emergency room during the 30 h prior to death. In the fourth case, the decedent had been seen in and discharged from the emergency room four times during the month prior to death. In all patients, the presenting historical, physical, and/or radiographic findings were indicative of perforation. The death of a patient within days of a visit to an emergency room should prompt a forensic autopsy. The role of medical examiners in providing quality assurance feedback to emergency rooms located within their jurisdiction is emphasized.

Acute pancreatitis in a prisoner with AIDS. Bugs or drugs?

Acute pancreatitis has been the cause of death in several patients with AIDS and AIDS-related complex (ARC). Documented etiologies include several microorganisms and adverse drug reactions. We present a case of an HIV-positive prison inmate who died of acute necrotizing pancreatitis. Although he was infected with Mycobacterium avium-intracellulare, it is more likely that 2',3'-dideoxyinosine, an antiretroviral agent, induced pancreatitis. It is important to obtain a thorough pharmaceutical history in HIV-positive patients. Fatal medicinal reactions may result in death in ARC or AIDS patients. Documentation of opportunistic infection in AIDS patients may prove difficult and expensive, but costs may be minimized and diagnostic accuracy optimized if appropriate tissue samples, including lymph nodes, are submitted for histologic analysis.

Hydrogen peroxide: a source of lethal oxygen embolism. Case report and review of the literature.

Hydrogen peroxide is a readily available clear, odorless liquid that is commonly used as an irrigant for superficial wounds. It is not widely thought of as a poison; however, it may rarely be the cause of accidental death. A case of fatal oxygen embolism in a child after ingestion of hydrogen peroxide is reported. A total of five similar cases have been previously described. Morbidity and mortality have also been reported with the use of hydrogen peroxide in hospitals. Gastric catabolism of hydrogen peroxide produces oxygen and water. When the amount of oxygen evolved exceeds its maximal blood solubility, venous embolization occurs. Hydrogen peroxide should not be considered to be innocuous; it should neither be ingested nor used in situations where the evolved oxygen gas cannot dissipate freely. The ubiquitous nature of household peroxide and its erroneous benign reputation suggest that child-resistant containers are in order. A protocol delineating the medicolegal investigation and postmortem examination of fatalities caused by the ingestion of this substance is offered.

Sudden death associated with terbutaline sulfate administration.

We present a case of sudden maternal death occurring during the ambulatory treatment of preterm labor in a twin pregnancy. The ultimate cause of death was cardiac arrhythmia, the origin of which was probably multifactorial. The patient was being treated with the use of a subcutaneous terbutaline sulfate infusion pump.

Sudden death caused by coronary artery aneurysms: a late complication of Kawasaki disease.

The authors describe three cases (two blacks and one Latin American) of sudden death caused by late complications of Kawasaki disease (mucocutaneous lymph node syndrome). At autopsy each heart contained multiple coronary artery aneurysms with luminal stenosis caused by intimal hyperplasia and thrombi. Although virtually all fatal cases of Kawasaki disease occur within six months of the onset of symptoms, there have been other reported deaths up to 14 years after the acute illness. The coronary artery aneurysms of Kawasaki disease may persist and cause death years after the acute illness.

Two fatalities resulting from Tessalon (benzonatate).

Two fatal cases involving Tessalon (benzonatate) were quantitated by ultraviolet (UV) and high performance liquid chromatography (HPLC). The first case involved an infant found choking; Tessalon perles were found with the child. The second case involved a successful suicide of an 18-year-old that consumed a "handful" of phenytoin and benzonatate and expired within 1 hr of the ingestion. Blood, brain and kidney concentrations are reported. These are believed to be the first two reported cases involving this compound.

Fatality due to paraquat intoxication: confirmation by postmortem tissue analysis.

A brief case report is presented describing a patient who unknowingly ingested a fatal amount of paraquat, presumably mixed in some illicit moonshine alcohol. Despite an initial clinical presentation typical of paraquat intoxication, the herbicide was absent upon analysis of multiple urine and blood specimens, and the diagnosis was confirmed only postmortem after determination of high paraquat tissue concentrations in all the major organs. Autopsy results are presented along with a discussion of the histopathologic changes observed in the lungs, liver, and kidneys. Because the combination of toxicologic sequelae attributable to acute paraquat poisoning is fairly unique to this agent, the diagnosis must be suspected highly early in the clinical course of such cases and appropriate therapy initiated, despite the inability to isolate paraquat on preliminary laboratory screening.

New aluminum-jacketed ammunition: the case of the "invisible" jacket.

The recovery of the metallic jacket fired from higher-velocity weapons is crucial for ballistics testing. Therefore, even when exit wounds are present, radiographs should routinely be made. The use of the new Winchester Western Silvertip ammunition may present a problem to the forensic pathologist because of the use of aluminum-jacketed bullets. Aluminum is only faintly radiopaque and may easily be overlooked on x-ray. An illustrative case is reported.

Primary amebic meningoencephalitis.

Primary amebic meningoencephalitis a rapidly fatal CNS infection caused by the free-living ameba Naegleria fowleri. The disease is acquired by swimming in fresh water and is being recognized with increasing frequency. Results of early diagnosis and treatment with amphotericin and other drugs suggest therapeutic optimism. Epidemiological surveys have shown the organism to be commonly present in fresh-water lakes in the warmer parts of the world. Prompt recognition and treatment is vital.

Effects of perhexiline on survival time and infarct size in experimental myocardial infarction.

The effects of perhexiline on survival time and infarct size were studied in three animal models. Dogs pretreated orally with perhexiline, 200 mg/day/14 days, and monitored under anesthesia for 30 hours after ligation of the left anterior descending coronary artery (LAD) had infarct weights of 9.1+/-1.9 g as compared to 15.2+/-1.0 g in paired untreated controls (P less than .02). Twelve of 15 perhexiline-pretreated dogs survived the duration of these studies while only 5 of 15 control animals survived for the same period of time (P less than .05). Serum creatine phosphokinase activity was significantly lower in the treated dogs at 9, 12 and 15 hours after ligation (P less than .05). Conscious dogs, pretreated orally with perhexiline 200 mg/day/7 days or 400 mg/day/7 days and monitored without anesthesia or analgesia for 72 hours after coronary ligation had smaller infarcts (P200=26+/-5; P400=26+/-4; C=39+/-5 g; P less than .05) lower plasma peak creatine phosphokinase activity (P less than .05) and reduced heart rate (P400=198+/-8; C=226+/-8 beats/min; P less than .05) and reduced incidence of ventricular ectopic beats (P less than .05). In pentobarbital anesthetized open-chest dogs, perhexiline (3 mg/kg i.v.) reduced the sum of S-T segment elevation after left anterior descending coronary artery occlusion from 32+/-3 to 14+/-1 mV (P less than .001); this effect was associated with and/or preceded by a reduction in arterial pressure (101+/-4 to 78+/-5 mm Hg; P less than .001) and heart rate (151+/-8 to 138+/-7 beats/min P less than .025; Circumflex flow increased from 38+/-4 to 83+/-8 ml/min (P less than .01). In noninfarcted open-chest dogs, perhexiline administration (3 mg/kg i.v.) resulted in increases in coronary blood flow, narrowing of arterial-coronary sinus O2 difference and a 14% reduction in myocardial O2 consumption. The protective effects of perhexiline on the ischemic myocardium appear to result from reductions in heart rate and associated decrease in myocardial O2 demand as well as an antiarrhythmic effect.