Andrew M. Baker

Fentanyl Concentrations in 23 Postmortem Cases from the Hennepin County Medical Examiner’s Office*

Abstract:  The purpose of this study was to compare blood fentanyl concentrations in fentanyl‐related deaths with fentanyl concentrations found incidentally at autopsy, as well as with fentanyl concentrations found in hospitalized patients receiving fentanyl. Between the years 1997 to 2005, 23 fentanyl‐positive postmortem cases were identified. Nineteen of 23 (82.6%) cases were deemed to be drug overdoses. Fentanyl alone was responsible for 8 of the 19 (42.1%) overdose deaths. Mean and median fentanyl concentrations were 36 (SD 38) μg/L and 22 μg/L, respectively, range 5–120 μg/L. Seven of the cases were accidental, one undetermined. The remaining 11 of the 19 (57.9%) cases were mixed drug overdoses. Fentanyl concentrations in these cases were 31 (SD 46) μg/L, range 5–152 μg/L. All of the mixed drug overdoses were determined to be accidental. Four cases where fentanyl was considered an incidental postmortem finding were determined to be natural deaths. In hospitalized inpatients (n = 11) receiving fentanyl 2 of the patients receiving fentanyl for chronic pain for more than 3 months had concentrations of 8.5 μg/L and 9.9 μg/L. The other nine inpatient concentrations were less than 4 μg/L. In conclusion, blood fentanyl concentrations found in cases where fentanyl alone was determined to be the cause of death were similar to cases where fentanyl was part of a mixed drug overdose. There was also considerable overlap between fentanyl concentrations in fentanyl‐related overdose deaths compared to hospitalized patients being treated for chronic pain. Fentanyl concentrations in postmortem cases must be interpreted in the context of the deceased’s past medical history and autopsy findings.

Polyclonal Systemic Immunoblast Proliferation: An Unusual Hematologic Entity Presenting as a Medical Examiner Case

A 43-year-old woman who was receiving oral antibiotics for several days for a superficial foot infection developed a persistent rash, fever, and lymphadenopathy, despite discontinuation of the antibiotic and administration of steroids for a presumed drug reaction. Hours after a subsequent visit to the emergency room for worsening symptoms, she died at home. At autopsy, there was a florid, systemic proliferation of polyclonal plasma cells and immunoblasts infiltrating nearly every organ and tissue of the body, most notably the lymph nodes and spleen. The polyclonal nature of the process was confirmed by immunofixation electrophoresis and immunohistochemistry. Cases of fatal polyclonal systemic immunoblast proliferations are extremely rare, and the trigger for such proliferations is not always known. We review the literature on this unusual entity and discuss the clinical and pathologic findings.

An Association of Hippocampal Malformations and Sudden Death? We Need More Data

Two recent studies from the San Diego SUDC Research Project describe a case series of 151 children, age 1–7 years, who died suddenly and unexpectedly [1, 2]. Cases were not population based and accrued retrospectively from offices across the US and abroad, with varied and unstandardized investigations. Limitations of this retrospective study are reflected in deficiencies of available data (56 % lacked radiology, 31 % lacked microbiology, 51 % lacked vitreous electrolytes, and 97 % lacked genetic testing). In addition, neuropathology sections were incomplete: 57 % hippocampus, 50 % medulla, and 72 % cortex. Thus, most investigations were limited in scope. These children died at a mean age of 1.7 years, were predominantly male, nearly always died during sleep, and half were associated with a personal or family history of febrile seizures. Hippocampal anomalies, including a combination the authors term hippocampal maldevelopment associated with sudden death (HMASD) were found in almost half of cases with available hippocampal sections; i.e., a quarter of the overall SUDC cohort. The authors described HMASD as a frequent finding in sudden unexplained death in childhood (SUDC), but did not suggest that this represents an entity distinct from SUDC without hippocampal abnormalities. Notably, there were no differences in SUDC children with and without HMASD with respect to a wide range of clinical and circumstances of death parameters [2]. Nevertheless, the question arises whether HMASD children should be removed from the SUDC group and considered a separate cause of death.

To hold or not to hold.

It is common for hospital personnel, police, and death investigators to allow a family to hold their child and have time with their child before the body is transported for a postmortem evaluation. But this is not universal. Why is this so? The literature is scant on this issue. Police and death investigator training might not address this issue directly. This particular aspect of a death scene may be based on the personal perspective of the police officer or death investigator or the historical policy of their department. What is the rationale for not granting a family’s request to hold and have time with their child before their body is transported? Investigative concerns appear to center on evidence collection, the emotional response of the family that might delay the investigation process, and postmortem alteration of the body that would impact the pathologist’s ability to determine the cause and manner of death.

Establishing a Multidisciplinary Network for the Workup of Sudden Cardiac Death

Sudden cardiac death (SCD) often falls under the jurisdiction of the medical examiner (ME). A recent expert consensus statement recommends cardiac evaluation for all first degree blood relatives of an individual with SCD and supports the referral of these family members to a multidisciplinary inherited arrhythmia clinic; however, most MEs lack the appropriate clinical network for a specific referral and family members are often not followed up. In 2010, Minnesota MEs and cardiovascular pathologists began collaborating with a cardiology referral center specializing in familial cardiac conditions to form a regional Sudden Death Network (SDN). The cardiac pathologists and MEs have established protocols for appropriate specimen retention in accordance with the National Association of Medical Examiners position paper on postmortem deoxyribonucleic acid (DNA) collection and for referring families for clinical evaluation. The expertise of a genetic counselor has been essential to the evaluation of these families in coordinating appropriate genetic testing and assisting with the identification of at-risk family members in extended pedigrees. This SDN uses a multidisciplinary approach for referral of family members for screening and treatment of SCD risk and represents an important resource for MEs. Development of SDNs across the country would lead to a more uniform approach to SCD follow-up and a more efficient use of clinical resources. The MEs role is essential in consulting cardiac pathologists when needed, establishing the correct diagnosis, collecting and retaining appropriate specimens, and initiating the referral of at-risk family members to specialists.

Cerebral Toxoplasmosis Presenting as a Medical Examiner Case

Toxoplasma gondii is a common parasite, with infection rates ranging from 16–40% of the United States population to up to 80% in some Central and South American and European countries. Clinically significant toxoplasmosis is considerably rarer, primarily affecting those with compromised immune systems. In the era of widespread human immunodeficiency virus (HIV) testing and effective HIV therapies, toxoplasmosis is rarely encountered in the medical examiner setting. We report a case of previously undiagnosed cerebral toxoplasmosis in a prisoner not known to be HIV-positive, who was hospitalized and treated for a presumed head injury. Manifestations of toxoplasmosis, pathology, treatment, and outcomes are discussed. This case highlights the need for thorough autopsies not only for deaths apparently resulting from injuries in jails and correctional institutions, but also when prisoners are hospitalized for seemingly benign reasons, yet the cause of death remains unclear despite clinical evaluation and treatment.

The Perfect Murder: How a Suicide Became a Homicide

This case report describes the death of a 51-year-old female, which presented by autopsy, scene circumstances, and social history as a suicidal ligature hanging. However, when her boyfriend walked into a police department in another state, months later, claiming to have killed the woman and staged a hanging, the medical examiners office was asked to review the admission, as it was thought wholly inconsistent with the timeline provided. Upon reenactment of the admission, the perpetrator perfectly demonstrated the use of a lateral vascular neck restraint (carotid restraint), known to incapacitate and potentially kill an individual within a matter of seconds. The autopsy finding of severe atherosclerotic heart disease was important in understanding the mechanism of death, the timeline of events, and in corroborating the confession. This case demonstrates the value of performing an autopsy even though investigation and history suggested an obvious cause and manner of death.

Suicide by Hypothermia: A Report of Two Cases and 23-Year Retrospective Review

Hypothermia deaths are frequently accidental and associated with impairment by alcohol, injuries, mental illness, or natural disease. Hypothermia as a method of suicide is unusual, with only nine case reports in the scientific literature. In the early months of 2014, during one of the coldest winters on record, the Hennepin County Medical Examiners office investigated and certified two unrelated cases of suicide by hypothermia; we describe the salient features of these cases. A retrospective review of all cases investigated by our office from January 1991-April 2014 identified 146 cases in which “hypothermia” or “environmental cold exposure” was listed as a cause of death, contributing condition, or mechanism of injury. Death investigation narratives and autopsy reports were reviewed to confirm hypothermia and evaluate for the presence or absence of characteristic hypothermia findings. In these cases the manner of death was certified as follows: 116 accident (79.4%), 15 undetermined (10.3%), 8 suicide (5.5%), 6 natural (4.1%), and 1 homicide (0.7%). Further examination of the eight suicide cases revealed that half were female and half were male, and most were younger individuals with only one decedent above 50 years of age. Four of these deaths were associated with drug toxicities, five were associated with additional self-inflicted injuries (blunt force, sharp force, and/or gunshot wounds), and none of them exhibited paradoxical undressing. It is important for medicolegal death investigation professionals to recognize that, while rare, hypothermia deaths may represent intentional injury, and suicide as a manner of death should be considered in all cases.

Unexpected Death from Hemorrhagic Pericarditis Complicating IgA Nephropathy

IgA nephropathy is the most common cause of glomerulonephritis in the developed world; however, it is usually an indolent or slowly progressive disease presenting initially as self-limited hematuria, typically following a viral or bacterial infection. We report a case of previously undiagnosed IgA nephropathy manifesting with end stage renal disease, fibrinous pericarditis, and hemorrhagic pericardial effusion in a 26-year-old white male. Clinical manifestations of IgA nephropathy, the presumed pathogenesis, and complications are reviewed. This case highlights the importance of interdisciplinary collaborations with other specialized pathology services—in this case renal pathology, including direct immunofluorescence and electron microscopy—that may not be routinely available or used in forensic pathology practices. In this instance, such collaboration provided the etiologically specific diagnosis for an unusual presentation of a common disease.