Anne-Laure Pelissier-Alicot

Malnutrition, a Rare Form of Child Abuse: Diagnostic Criteria

ABSTRACT: Infantile malnutrition is often difficult to diagnose as it is rarely observed in industrialized countries. It may be associated with physical violence or occur in isolation. The essential clinical sign is height and weight retardation, but malnutrition also causes a variety of internal and bone lesions, which lead to neuropsychological sequelae and death. We report a rare case of death by malnutrition in a female child aged 6½ months. The infant presented height and weight growth retardation and internal lesions related to prolonged protein–energy malnutrition (fat and muscle wasting, thymic atrophy, liver steatosis) resulting in a picture of marasmus or kwashiorkor. We detail the positive and negative criteria that established the diagnosis of abuse, whereas the parents had claimed a simple dietary error.

Abusive Prescription of Psychostimulants: A Study of Two Cases

ABSTRACT: Because psychostimulants have serious possible side effects and particular potential for abuse, their therapeutic indications are today exclusively limited to disorders such as obesity, narcolepsy, or attention deficit/hyperactivity disorder. We report two cases of abusive prescription of these drugs. The first concerns a woman who was treated for a 3 kg weight gain with fenproporex for 5 years and presented a withdrawal syndrome when this drug was no longer marketed in France. In the second case, a woman who complained of atypical sleep problems was prescribed modafinil, methylphenidate, clobazam, lormetazepam, meprobamate, and aceprometazine, and was found dead in her home a few weeks later in unexplained circumstances. For these two patients, neither the indications, nor the contraindications, nor the prescribing rules for these restricted drugs had been complied with. This case report highlights the extreme danger of these substances and stresses the importance of adhering to the rules of prescription.

Buprenorphine-related deaths: unusual forensic situations

The success of high-dose buprenorphine (HDB) as substitution therapy for major opioid dependence is related to its partial agonist effect on opioid receptors, which in theory makes it very safe to use. However, numerous deaths directly attributable to buprenorphine have been described in the literature. These deaths are generally related to misuse of HDB with intravenous administration and/or concomitant use of benzodiazepines, and they usually occur in patients on HDB substitution therapy for opioid dependence. We present three deaths attributed to HDB which arose from uncommon mechanisms and led to unusual forensic situations. The first death was that of a patient admitted to hospital after simultaneous prescription of HDB, clonazepam, oxazepam, and cyamemazine. The second death followed forcible administration of a very low dose of HDB to a patient with post-hepatitis C cirrhosis and heart failure. The third death was subsequent to an HDB overdose, probably with suicidal intent, in a young woman who had not been prescribed the drug as opiate substitute. Such deaths raise the question of the mechanisms involved and draw attention to the resulting unusual forensic situations.

Fatal poisoning due to intravasation after oral administration of barium sulfate for contrast radiography

A fatal poisoning after oral administration of barium sulfate for contrast radiography is reported. Barium sulfate is an insoluble salt and therefore is almost nontoxic. The case described here involves a 61-year-old woman who underwent two CT scans of the digestive tract with oral administration of barium sulfate during a surgical procedure. Within several hours after the first barium swallow examination the patient presented nonspecific neurologic and cardiovascular manifestations that rapidly progressed and led to death a few days later. Laboratory findings demonstrated elevated levels of barium in the blood and cerebrospinal fluid. The most likely mechanism of poisoning was progressive intravasation of barium due to stasis of contrast material related to intestinal obstruction.

Fatal Accidental Hydrogen Sulfide Poisoning: A Domestic Case

Hydrogen sulfide (H2S) poisonings are classically reported in occupational settings. We describe an unusual domestic case of fatal acute poisoning by H2S inhalation. A mother and her infant daughter were found dead in the kitchen of their home. The emergency medical team described a strong smell of rotten eggs, suggesting acute H2S poisoning. Autopsies revealed only multiorgan congestion. H2S was measured in blood and lung tissue samples by gas chromatography/mass spectrometry. Body fluids were negative, but H2S was found in the lungs of both the mother and the child at concentrations of 1.46 and 1.92 mg/kg, respectively, concentrations described in the literature as potentially lethal. Expert surveys of the premises suggested a complex mechanism involving both defective maintenance of the pipes and drains of the building and faulty assembly of the sink siphon, which led to stagnation of waste water and formation of a pocket of H2S.

Endocannabinoids Mediate Muscarinic Acetylcholine Receptor-Dependent Long-Term Depression in the Adult Medial Prefrontal Cortex

Cholinergic inputs into the prefrontal cortex (PFC) are associated with attention and cognition; however there is evidence that acetylcholine also has a role in PFC dependent learning and memory. Muscarinic acetylcholine receptors (mAChR) in the PFC can induce synaptic plasticity, but the underlying mechanisms remain either opaque or unresolved. We have characterized a form of mAChR mediated long-term depression (LTD) at glutamatergic synapses of layer 5 principal neurons in the adult medial PFC. This mAChR LTD is induced with the mAChR agonist carbachol and inhibited by selective M1 mAChR antagonists. In contrast to other cortical regions, we find that this M1 mAChR mediated LTD is coupled to endogenous cannabinoid (eCB) signaling. Inhibition of the principal eCB CB1 receptor blocked carbachol induced LTD in both rats and mice. Furthermore, when challenged with a sub-threshold carbachol application, LTD was induced in slices pretreated with the monoacylglycerol lipase (MAGL) inhibitor JZL184, suggesting that the eCB 2-arachidonylglyerol (2-AG) mediates M1 mAChR LTD. Yet, when endogenous acetylcholine was released from local cholinergic afferents in the PFC using optogenetics, it failed to trigger eCB-LTD. However coupling patterned optical and electrical stimulation to generate local synaptic signaling allowed the reliable induction of LTD. The light—electrical pairing induced LTD was M1 mAChR and CB1 receptor mediated. This shows for the first time that connecting excitatory synaptic activity with coincident endogenously released acetylcholine controls synaptic gain via eCB signaling. Together these results shed new light on the mechanisms of synaptic plasticity in the adult PFC and expand on the actions of endogenous cholinergic signaling.

Can subclavian blood be equated with a peripheral blood sample? A series of 50 cases

If femoral blood is not available at autopsy, toxicological analyses, in particular blood ethanol measurements, are carried out on cardiac blood. This is known to be subject to major redistribution. We aimed to determine whether subclavian blood can be equated with a peripheral blood sample and could be used if femoral blood is not available. The study was based on 50 medicolegal autopsies in which we compared ethanol concentrations between subclavian blood, the different heart blood compartments (right and left cardiac blood), and femoral blood. Mechanisms that could lead to variations in concentration, i.e., postmortem redistribution and/or endogenous production, were also taken into account in interpreting the results. Ethanol concentrations were determined by headspace gas chromatography with a flame ionization detector. In each case, we recorded the circumstances of death, resuscitation attempts if any, degree of putrefaction, chest or abdominal trauma, and/or inhalation of gastric fluid in the airways. Ethanol concentrations in subclavian blood were found to be close to those in peripheral blood (p = 0.948) and were not influenced by the degree of putrefaction (r = 0.017, p = 0.904), gastric ethanol concentration (r = −0.011, p = 0.940), inhalation of gastric contents in the airways (p = 0.461), or cardiac resuscitation attempts (p = 0.368). We discuss the possible explanations for these findings and stress the value of sampling subclavian blood when femoral blood is not obtainable at autopsy.

Planned complex suicide: an unusual case.

Abstract:  We report an unusual case of planned complex suicide. The victim was a woman aged 67 years, who was found dead in her bath in a state of advanced putrefaction. A plugged‐in hairdryer was submerged in the water and the electrical fuses in the room had short‐circuited. A kitchen knife lay below the body of the victim, whose left forearm bore incisions suggestive of wrist‐cutting. At autopsy, no sign suggesting electrocution could be observed because of the advanced state of putrefaction of the body. Toxicological analysis revealed massive ingestion of tianeptine (blood concentration 15.5 mg/L). Although the exact cause of death could not be determined because of the state of the corpse, meticulous examination of the scene and information obtained from the victim’s relatives led to the conclusion of suicide.

Partial agonist therapy in schizophrenia: relevance to diminished criminal responsibility.

Abstract:  Pathological gambling (PG), classified in the DSM‐IV among impulse control disorders, is defined as inappropriate, persistent gaming for money with serious personal, family, and social consequences. Offenses are frequently committed to obtain money for gambling. Pathological gambling, a planned and structured behavioral disorder, has often been described as a complication of dopamine agonist treatment in patients with Parkinson’s disease. It has never been described in patients with schizophrenia receiving dopamine agonists. We present two patients with schizophrenia, previously treated with antipsychotic drugs without any suggestion of PG, who a short time after starting aripiprazole, a dopamine partial agonist, developed PG and criminal behavior, which totally resolved when aripiprazole was discontinued. Based on recent advances in research on PG and adverse drug reactions to dopamine agonists in Parkinson’s disease, we postulate a link between aripiprazole and PG in both our patients with schizophrenia and raise the question of criminal responsibility.

Childhood trauma are not associated with the intensity of transient cocaine induced psychotic symptoms

A personal history of childhood trauma has been associated with the severity of psychotic symptoms in several disorders. We evaluated retrospectively cocaine-induced psychotic symptoms with the SAPS-CIP and childhood trauma with the CTQ in a clinical sample of 144 cocaine users. The SAPS-CIP score was not statistically associated with the presence or number or intensity of trauma, but was associated with rapid routes of administration (intravenous and smoked) and with frequent cocaine use.