Fatal poisoning by MDMA (ecstasy) and MDEA: A case report

The first observation of lethal recreational use of MDMA (ecstasy) and MDEA in Italy is reported, together with extensive toxicological and histopathological documentation. Findings such as disseminated intravascular coagulation, rarely reported before, are colocated in the framework of the toxic syndrome for a better definition of criteria for forensic diagnosis.     

Fatal intoxication due to transrectal methamphetamine overdose: A case report

Methamphetamine (MA) abuse is common in Asian countries. The major ways of abuse include intravenous injection, absorption, and ingestion. Although two cases of survival after transrectal MA administration have been reported in the clinical field, to the best of our knowledge, there is no report of death due to intentional transrectal MA overdose. This is the first report of such a death. A single, 42-year-old male with a history of habitual MA use was found dead at his home. The police found numerous unused injectors in his closet. A rapid test of his urine was positive for MA. The cause of death was unclear, so a medicolegal autopsy was performed.ResultsAutopsy findings revealed a tubular plastic container without a lid in the rectum at the time of excision, with a small, open plastic bag inside. MA was detected in both the plastic container and the plastic bag. The MA concentration in the femoral vein blood was enough to cause death, and the cause of death was considered transrectal MA overdose. MA was absorbed through the lower part of the rectum, so the absorbed MA bypassed the liver and was transported directly to the systemic circulation. Since MA is largely metabolized in the liver, the absorbed MA was unaffected by the hepatic first-pass effect and may have caused more rapid and serious intoxication.     

Fatal aorto-esophageal fistula in child: A case report

Esophageal foreign body ingestion is especially frequent in childhood and may cause fatal complications in case of late diagnosis and delayed treatment. We present a case of 2-year old girl who was admitted to emergency department with massive bleeding. However, she died due to an unrecognized foreign body resulted an aorto-esophageal fistula.At autopsy an aorto-esophageal fistula was detected by gross examination. Tissue samples were obtained from the organs and fistula region. In histopathological examination, a calcified body with multinucleated giant cell and surrounding granulation tissue was detected at the bleeding site. An ulcerated fistula tract ran from the intima to the adventitia, passing through layers of esophageal wall was also noticed.The mortality rate for foreign body ingestion is less than 1%, except in cases of perforation. Therefore the presented case is among rare examples of fatal foreign body ingestions.     

Fatal self administration of tramadol and propofol: A case report

We describe a case of unintentional intoxication due to tramadol and propofol self administration, occurred in a middle aged man, healthcare provider, deceased despite advanced medical assistance an hour later the onset of severe and increasing dyspnea. Toxicological analysis performed with gas chromatography-mass spectrometry in blood sample, evidenced a lethal tramadol concentration and therapeutic level of Propofol. Quantitative determination was also performed in other specimens such as bile, tissues (liver, spleen, kidney) and pubic hair, to assess chronic exposure. Toxicological results and autopsy findings, supported by clinical and hematochemical data, suggested a myocardial damage, associated with respiratory failure.     

Fatal hemorrhage following sacroiliac joint fusion surgery: A case report

Threaded pins and wires are commonly used in orthopedic practice and their migration intra- or post-operatively may be responsible for potentially serious complications. Vascular and visceral injury from intra-pelvic pin or guide-wire migration during or following hip surgery has been reported frequently in the literature and may result in progression through soft tissues with subsequent perforation of organs and vessels. In this report, we describe an autopsy case involving a 40-year old man suffering from chronic low back pain due to sacroiliac joint disruption. The patient underwent minimally invasive sacroiliac joint arthrodesis. Some intra-operative bleeding was noticed when a drill was retrieved, though the patient died postoperatively. Postmortem investigations allowed the source of bleeding to be identified (a perforation of a branch of the right internal iliac artery) and a potentially toxic tramadol concentration in peripheral blood to be measured.     

Transcatheter occlusion of inferior mesenteric arteriovenous fistula: A case report

Transcatheter embolization of the inferior mesenteric artery with steel coils was performed for the control of massive lower gastrointestinal bleeding and sepsis. The bleeding and sepsis was caused by a very large arteriovenous fistula of the inferior mesenteric vessels. This iatrogenic lesion developed and became symptomatic just 5 weeks after an anterior resection of the rectum was performed. Following embolization, the patient made a speedy recovery from the sepsis and no recurrent bleeding was noted.     

Prostaglandin E1 for alleviating symptoms of ergot intoxication: A case report

A woman was admitted after ergotamine tartrate overuse for migraine headaches and her symptoms of arterial vasospasm were treated with PGE₁, the first reported use of the vasodilator for ergot intoxification. The advantages of producing local vasodilatation without systemic effect, as well as inhibiting the formation of arterial microthrombi, suggest PGE₁ as the agent of choice for relief of symptoms due to peripheral vasoconstriction caused by ergot. Treatment with PGE₁ may allow sufficient collateral to preserve limb function and integrity, while awaiting remission of anatomic changes after withdrawal of ergot.     

Heart rupture as an acute complication of cocaine abuse: A case report

The purpose of this study is to show a very rare complication of acute cocaine poisoning, namely heart rupture. In the present case report, acute cocaine intoxication caused massive myocardial infarction, resulting in heart rupture and cardiac tamponade. A crime scene investigation found a dead body on the street in a drug dealing district. Examination of the body showed no external injuries. A thorough autopsy was performed showing massive cardiac tamponade with 510 ml of blood within the pericardium and full-thickness tissue lesion at the posterior wall of the left ventricle of 3.5 × 3 cm. Histological examination in hematoxylin and eosin was performed and confirmed the interruption of the posterior wall of the left ventricle with the presence of blood. In fact, although the correlation between cocaine and myocardial damage is well established, the relationship between heart rupture and acute cocaine intoxication is an extremely rare event. Moreover, since there are, to date, few reports of similar deaths, our report provides useful information regarding sudden death in a cocaine abuser. It is, therefore, of crucial importance to report this case to the scientific community.     

Fatal intracranial hemorrhage as the presenting sign of acute promyelocytic leukemia: A case report

Intracranial hemorrhage (ICH) can be a devastating medical event with numerous potential etiologies. In young people under age 40, ruptured vascular malformation is the most common cause of ICH. Without critical review of imaging and laboratory findings and clinical suspicion beyond vascular malformation, alternative etiologies of hemorrhage may be overlooked in the younger age group. Here we present a case of a 22-year-old male presenting with large ICH originally thought secondary to ruptured vascular malformation. After careful review of all imaging and laboratory findings, the patient was found to have hemorrhage secondary to acute promyelocytic leukemia (APL). Though ICH proved fatal in this case, early treatment of acute leukemia with appropriate chemotherapeutic agents and correction of coagulopathy could be life saving for patients with less severe intracranial injury.     

Postmortem examination and toxicological analysis for acute metonitazene intoxication in Japan: A case report

Benzoimidazole analgesics (Nitazenes, NZs) are opioid receptor agonists that exhibit very strong pharmacological effects at minute doses, and their abuse has recently become a concern worldwide. Although no deaths involving NZs had been reported in Japan to date, we recently experienced an autopsy case of a middle-aged man who was determined to have died from poisoning by metonitazene (MNZ), a type of NZs. There were traces of suspected illegal drug use around the body. Autopsy findings were consistent with acute drug intoxication as the cause of death, but it was difficult to identify the causative drugs by simple qualitative drug screening. Analysis of compounds recovered from the scene where the body was found identified MNZ, and its abuse was suspected. Quantitative toxicological analysis of urine and blood was performed using a liquid chromatography high-resolution tandem mass spectrometer (LC-HR-MS/MS). Results showed that MNZ concentrations in blood and urine were 6.0 and 5.2 ng/mL, respectively. Other drugs detected in blood were within therapeutic ranges. Quantitated blood MNZ concentration in the present case was in the similar range as those reported in overseas NZs-related deaths. There were no other findings that could have contributed to the cause of death, and the decedent was judged to have died of acute MNZ intoxication. Emergence of NZs distribution has been recognized in Japan similarly to overseas; early investigation of their pharmacological effects as well as crackdown on their distribution is strongly desired.     

Pulmonary artery rupture during Swan-Ganz catheterisation: A case report

Catheter-induced pulmonary artery rupture is an infrequent complication that may occur during invasive cardiopulmonary monitoring. Fatal cases are uncommon and result from hemoptysis and flooding of the opposite lung with resulting hypoyxia. Alpha-1-antitrypsin deficiency is a rare genetic disorder characterised by low serum levels of alpha-1-antitrypsin, critical in maintaining connective tissue integrity. Besides pulmonary emphysema, recent observations suggest that alpha-1-antitrypsin deficiency may also be involved in vascular wall weakening, thereby predisposing arteries to dissection and aneurysm formation. In this article, we describe an autopsy case of pulmonary artery iatrogenic rupture due to insertion of a Swan-Ganz catheter in an 82-year-old woman suffering from pulmonary hypertension and alpha-1-antitrypsin deficiency. The exact source of bleeding could not be precisely identified during autopsy due to the extent of tissue hemorrhage, though postmortem angiography revealed a contrast medium extravasation from a branch of the left pulmonary lower lobar artery. The case herein emphasises the importance of postmortem angiography in facilitating the detection of vascular injuries, the importance of familiarity with intensive care techniques and procedures on behalf of forensic pathologists as well as in-depth knowledge of all possible contributing conditions and predisposing disorders in the pathogenesis of death.     

Neonatal infratentorial subdural hematoma contributing to obstructive hydrocephalus in the setting of therapeutic cooling: A case report

BACKGROUNDSymptomatic neonatal subdural hematomas usually result from head trauma incurred during vaginal delivery, most commonly during instrument assistance. Symptomatic subdural hematomas are rare in C-section deliveries that were not preceded by assisted delivery techniques. Although the literature is inconclusive, another possible cause of subdural hematomas is therapeutic hypothermia.CASE SUMMARYWe present a case of a term neonate who underwent therapeutic whole-body cooling for hypoxic ischemic encephalopathy following an emergent C-section delivery for prolonged decelerations. Head ultrasound on day of life 3 demonstrated a rounded mass in the posterior fossa. A follow-up brain magnetic resonance imaging confirmed hypoxic ischemic encephalopathy and clarified the subdural hematomas in the posterior fossa causing mass effect and obstructive hydrocephalus. CONCLUSIONThe aim of this report is to highlight the rarity and importance of mass-like subdural hematomas causing obstructive hydrocephalus, particularly in the setting of hypoxic ischemic encephalopathy and therapeutic whole-body cooling.     

Fatal outcome of posterior reversible encephalopathy syndrome (PRES) in a lupus nephropathy patient: A case report

Posterior reversible encephalopathy syndrome is a rare underestimated condition, that generally complicates a rise in blood pressure in an acute setting. This entity has been increasingly identified in patients with systemic lupus erythematosus disease. PRES is challenging to diagnose seeing as it presents with nonspecific neurological symptoms, such as head-aches, confusion, seizures, visual changes or a coma, and can mimic neuropsychiatric lupus. Imaging plays a necessary role in confirming this diagnosis, as it is characterized by vasogenic edema of the posterior white matter, in which the distribution is bilateral and symmetrical. Although this syndrome is rare, early diagnosis allows a prompt treatment and therefore a favorable outcome. We present a case report of PRES in a 14-year-old female previously diagnosed with lupus nephropathy, who presented to the emergency department with seizures and uncontrolled hypertension, that was unfortunately not reversible is this patient.     

Knot formation of a guidewire during subclavian venous catheterization: A case report

Central venous catheters are used for a variety of purposes, including emergency care, parenteral nutrition, and chemotherapy, but their insertion can cause mechanical complications such as malposition, arterial puncture, and pneumothorax. Here, we describe a rare case of guidewire knot formation during subclavian vein catheterization. A 70-year-old woman presented to our facility for central venous port placement for chemotherapy after surgical resection of a retroperitoneal liposarcoma. The left subclavian vein was selected and punctured under ultrasound guidance, and a guidewire was introduced. However, strong resistance prevented both advancement and withdrawal of the guidewire. Radiograph revealed a knot like shadow near the tip of the guidewire. After placement of a central venous port in the opposite site, the knotted guidewire was surgically removed. Intraoperatively, the guidewire was found to penetrate the vein and form a knot on the outside of the posterior wall. Although the guidewire was able to be removed, a postoperative chest x-ray revealed a left pneumothorax, which required 10 days of treatment. If a knot forms in a guidewire during catheterization, surgical removal is recommended because forcible pulling can damage the vessel. In conclusion, guidewire knot formation is a very rare complication, but physicians performing central venous catheterization should be aware of it, and this report describes how to prevent and manage it.     

Striking increases in postmortem compared to antemortem drug concentrations in a suicidal overdose: A case report

Toxicology testing revealed dramatic increases in whole-blood concentrations of verapamil and diphenhydramine in the short time between hospital admission and death (53 min) in a subject (with a history of overdosing) found unresponsive. While some degree of post-mortem redistribution (PMR) would be expected for the drugs found in this case, PMR cannot explain the considerable increases observed. It is recommended that in potential overdose cases without a clear manner of death but for which ante-mortem and post-mortem specimens (including gastric content) are available, all should be analysed and considered in order to make a more definitive conclusion regarding that death.     

Comments on "Neonatal infratentorial subdural hematoma contributing to obstructive hydrocephalus in the setting of therapeutic cooling: A case report"

Although therapeutic hypothermia (TH) contributes significantly in the treatment of hypoxic ischemic encephalopathy (HIE), it could result in devastating complications such as intracranial hemorrhages. Laboratory examinations for possible coagulation disorders and early brain imaging can detect all these cases that are amenable to aggravation of HIE after the initiation of TH.     

Hematuria in a runner after treatment with whole body vibration: A case report

The use of whole body vibration (WBV) for therapeutic purposes is far from being standardized and the training protocols reported in the literature vary considerably. Currently, the optimal threshold for a beneficial effect is undetermined, and caution regarding potential health risks due to WBV is always necessary. In this case report, we present a 34‐year‐old otherwise healthy elite athlete (steeplechase runner) who suffered two episodes of hematuria (HT) after WBV training. Shortly after the third WBV, he had an episode of bright red urine. Seven days later, following the next WBV session (and again before his daily running session), a reddish‐colored urine reappeared. Our patient was advised to stop WBV training and to take fluid before and during exertion. He did not experience any episode of HT during a 1‐year follow‐up with periodic check‐ups, in spite of the continuation of his sporting career. The concomitance of the two types of trauma – daily running and WBV – could have been critical in this case for producing HT. In particular, we think that platforms providing side‐alternating vibration (such as the Galileo platform) may pose some health risks if the feet are positioned too far from the axis of rotation.     

Successful streptokinase treatment of a thrombosed,ectopic coronary artery: A case report

Early reperfusion of a thrombosed, ectopically arising coronary artery was accomplished by selective streptokinase infusion therapy. Familiarity with the most common variations of of coronary artery orifices and/or divisions of major branches is important for the angiographer to ensure that selective catheterization of the involved artery can be accomplished promptly.     

Endovascular treatment of ruptured blister-like aneurysms: A case report and review of the literature

A ruptured blister-like aneurysm of the internal carotid artery is a rare event with a high risk of recurrence and mortality. Selecting an appropriate treatment modality remains challenging due to a lack of consensus or specific recommendations in the literature. In this article, we present the case of a 68-year-old man who presented with ruptured blister-like aneurysms in the supraclinoid portion of the internal carotid artery. The patient was diagnosed and successfully managed using an endovascular coil embolization technique at our hospital. We aim to illustrate and share our experiences with this rare occurrence, which may assist in the treatment of similar cases in the future.     

Major cerebral hypoperfusion on an internal carotid loop during an otologic surgery: A case report

An aberrant course of the internal carotid artery, such as a carotid loop or kinking, is a rare type of malformation. These malformations are typically asymptomatic, their occurrence is unpredictable, and they can exacerbate clinical disorders such as heart failure. We report the case of a seven-year-old child who died consecutively to cardiac arrest during otologic surgery for a cholesteatoma. After rapid and effective cardiorespiratory resuscitation, the child was transferred to a paediatric intensive care unit. In the following days, pronounced cerebral hypoperfusion led to the death of the child. The autopsy revealed a right carotid loop and a left carotid kink that presumably led to the cerebral hypoperfusion.