Psychosocial complications of Crohn's disease and cause of death.

Patients who suffer from Crohn's disease are prone not only to the complications of a relapsing, unpredictable disease, but also to feelings of stigmatization; depression; and increased risk of suicidal ideation, suicide, or drug and alcohol abuse. Cases performed at the Jackson County Medical Examiner's Office from 2008 to 2010 were reviewed. Autopsy findings, investigator reports, toxicology results, medical records, and interviews with survivors were analyzed. Twelve cases of Crohn's disease were recovered. In 10 of these cases, inflammatory bowel disease was not the cause of death. Instead, psychosocial consequences of the disease had significant implications in the deaths. The mean age of decedents was 45 years, with a female predominance. In eight cases, the decedents lived alone. Five patients had issues of acute or chronic drug or alcohol use. Five patients committed suicide. These cases underscore the role of psychosocial factors that can contribute significantly to the cause of death in patients with Crohn's disease.

Fatal child abuse presenting with multiple vertebral and vascular trauma.

This case study involves the unexplained death of a previously healthy 30-month-old child. Reportedly, she was found unresponsive by her foster father following a 2-hour nap. She was transported to the hospital and died in the emergency room of unknown causes. Blood drawn in the ER showed hemoglobin of 4.3 mg/dL. Postmortem skeletal survey, magnetic resonance imaging (MRI) of the brain, and retinal examinations were negative. The medical examiner assumed jurisdiction of the body. The autopsy showed massive retroperitoneal hemorrhage, transections of the abdominal aorta, and inferior vena cava, and complete tears of the anterior longitudinal ligament of the spine at C5/C6 and L1/L2 with diastases of the vertebral bodies at the corresponding intervertebral disk spaces. The case is believed to be extraordinary due to both the extent of injury that does not match the reported history and the mechanism of vertebral and vascular injuries.

Fatality involving complications of bupivacaine toxicity and hypersensitivity reaction.

This case represents unusual findings of elevated bupivacaine and tryptase concentrations following local anesthetic, bupivacaine, administered as a scalene nerve block for elective rotator cuff repair surgery. Following bupivacaine injection, the patient exhibited almost immediate seizure activity, bradycardia, and cardiac arrest. Resuscitative efforts including cardiopulmonary bypass restored a cardiac rhythm. However, the clinical medical status of the patient progressively declined and he died 7 h following administration of the local anesthetic. Autopsy revealed several abnormalities of the heart including cardiomegaly, myocardial bridging, and lipomatous hypertrophy of the intraatrial septum, which may have contributed to bradycardia and arrhythmia. Postmortem toxicology results revealed elevated bupivacaine and tryptase concentrations. Elevated postmortem bupivacaine concentrations 7 h following administration and abrupt onset of seizures indicate unintentional intravascular injection instead of nerve and tissue infiltration. An elevated postmortem tryptase concentration points to the possibility of a hypersensitivity reaction to bupivacaine.

Optic nerve trauma with unilateral edema as a result of head injury.

We encountered a patient who suffered a head injury that translated to the optic nerves, leading to dramatic unilateral right optic nerve edema. The decedent was a 20-year-old unsecured passenger in a convertible. The car collided with a pickup truck. The patient survived for 8 h. At autopsy, a comminuted skull fracture involving the right frontal bone including the right orbital plate was found. The right optic nerve measured 1.2 cm in diameter, compared to only 0.4 cm for the left optic nerve. Microscopically, the right optic nerve was markedly edematous, but the nerve fibers and nuclei were viable and intact. The dramatic difference in size between the right and left optic nerves can be attributed to several mechanisms. The survival interval was essential for the asymmetrical swelling to take place. Optic nerve trauma is relatively rare in head injuries, reported to be present in 0.5% of automobile accidents and assaults. Other causes of optic nerve trauma and edema include tumors, osteopetrosis, or reaction to a peripheral hemodialysis shunt.

A fatality involving an unusual route of fentanyl delivery: Chewing and aspirating the transdermal patch.

We recently encountered a subject who died from an uncommon misuse of a fentanyl transdermal patch, chewing, followed by complications of aspiration of the patch. We report this case to alert medical examiners to the troubling trend of increased fentanyl patch abuse and its expanding range of misuses and associated morbidities. The decedent was a 28-year-old white male with a past medical history of prescription drug abuse who was pronounced dead in the emergency department shortly after arrival. An autopsy was completed and a tough but stretchy beige foreign body was identified lodged in a mainstem bronchus. Toxicological analysis of femoral blood showed methamphetamine, fentanyl and norfentanyl concentrations of 1456, 8.6 and 1.4 ng/mL, respectively. Individuals who abuse prescription medications often modify the route of administration of the drug from the intended method. As this case demonstrates, this choice can be fatal. The novel findings include a chewed patch, aspiration of a drug patch, and combination with an illicit drug at potentially lethal blood levels for both methamphetamine and fentanyl in a novice user.

Fatal capnocytophaga infection associated with splenectomy.

A case of fatal sepsis due to Capnocytophaga species is described. Capnatophaga canimorsus and C. cynodegmi can cause localized wound infections and/or systemic infections in people who have been bitten, licked, scratched, or merely exposed to cats or dogs, especially splenectomized individuals. A thorough social, medical, and surgical history, the clinical presentation, and cultures are important in making the diagnosis of Capnocytophaga infections. It is important that the forensic pathologist be aware of this zoonotic disease.

Correlation of clinical findings and autopsy results after fatal injury from motor vehicular-related crashes.

In the past, autopsy served as the gold standard to document diagnostic accuracy. Although a valuable contributor to medical education, information collected from autopsies is frequently delayed and poorly used. The purpose of this study was to determine the degree of concordance between clinical findings and autopsy results of trauma patients involved in fatal vehicular-related crashes. A 10-year retrospective review of trauma patients involved in fatal vehicular-related crashes who subsequently had an autopsy performed was conducted at an American College of Surgeons-verified Level I trauma center. The clinical record, trauma registry data, and autopsy results were reviewed. Degree of concordance was evaluated using the Goldman Type Errors Criteria. A total of 207 decedents were included (mean age, 41; 63% male; median Glascow Coma Scale score, 3; median Injury Severity Score, 37). The majority (69.6%) of decedents were injured in motor vehicle crashes. Total treatment time was < 15 minutes in 29.0 per cent of cases, < 6 hours in 59.4 per cent of cases, and < 24 hours in 73.9 per cent of cases. Location of death was the emergency department (43.0%), the intensive care unit (49.8%), the operating room (5.4%), and the nursing floor (1.0%). There were no Goldman Class I or IV type errors, (i.e., no major or minor discrepancies, respectively, that may have altered therapy or survival of the patient). Following ATLS-based protocols results in appropriate identification of clinically significant injuries in patients involved in motor vehicular-related crashes. The routine use of autopsy results offers little additional information to a mature American College of Surgeons-verified Level I trauma program.