Christopher M. Milroy

“Ecstasy” associated deaths: what is a fatal concentration ? Analysis of a case series

Amphetamine derivative drugs, particularly 3,4-methylenedioxymethamphetamine (MDMA), commonly known as ecstasy, are popular recreational drugs. MDMA is associated with causing death by a number of mechanisms, including hyperpyrexia, cardiac arrhythmia water intoxication and liver failure. Seventy-seven deaths where MDMA was detected in body fluids/organs were reviewed. Of these cases 59 deaths had MDMA present in blood. In 13 cases death was attributable to the toxic effects of MDMA alone with a range of 0.478–53.9xa0mg/l, mean 8.43xa0mg/l, median 3.49xa0mg/l. In 22 cases death was due to polydrug use, with an MDMA range of 0.04–41.5xa0mg/l, mean 2.90xa0mg/l, median 0.76xa0mg/l. In 24 cases death was due to trauma with an MDMA range of 0.035–4.81xa0mg/l, mean 0.862xa0mg/l, median 0. 483xa0mg/l. There is considerable overlap between the concentration of MDMA seen in deaths from direct MDMA toxicity and deaths associated with trauma. These findings show, that like other stimulant drugs, no specific concentration can be used to determine death without consideration of the history and full autopsy findings.

The histopathology of drugs of abuse

Milroy C M & Parai J L u2028(2011) Histopathology 59, 579–593

Armanni-Ebstein lesion, ketoacidosis and starvation in a child.

The Armanni- Ebstein lesion was first reported in 1877 and has been associated with deaths due to diabetic ketoacidosis. The lesion consists of subnuclear vacuolation of the kidneys, which contain fat. We report a case of the Armanni- Ebstein lesion in a non-diabetic child with documented ketoacidosis who died of starvation.

Sudden unexpected death in epilepsy in childhood

Sudden unexpected death in epilepsy (SUDEP) is the most feared complication of a seizure disorder. It has been less studied in childhood, probably because the incidence of sudden death is higher in adults than in children. SUDEP occurs more commonly in children where there is an underlying neuropathological disorder and a high rate of seizure. The literature reports rates of SUDEP in childhood between 1.1 and 4.3/10,000 patient years. Children with what has been called idiopathic epilepsy have an incidence of sudden death that is similar to the general population. Many children have a witnessed seizure before death, but in other witnessed deaths no seizure was identified. Cardiac arrhythmias and central apnea have been proposed as mechanisms of sudden death in SUDEP. At autopsy, apart from the underlying neuropathological disorder, there may be evidence of seizure activity in the form of bite marks and a voided bladder, though often the autopsy will prove negative. These autopsies remain challenging for the pathologist because acute findings are often absent. Before a diagnosis of SUDEP is made, a full knowledge of the history and scene information is required, as well as autopsy and ancillary investigation information.

Alcoholism and the Armanni–Ebstein lesion

The Armanni–Ebstein lesion is a histological change in the kidney consisting of sub-nuclear vacuolation of the proximal tubules. It has been most associated with diabetic ketoacidosis. The vacuoles have been reported to contain glycogen. More recent studies show them to contain fat. Recent papers have associated the Armanni–Ebstein lesion with non-diabetic ketoacidosis. We present 11 cases of alcoholic ketoacidosis where the Armanni–Ebstein lesion was identified. None had a history of diabetes mellitus and none showed any changes of diabetic nephropathy. All 11 cases had raised acetone levels (3–67xa0mg/100xa0mL (mean 17.9xa0mg/100xa0mL and median value of 16xa0mg/100xa0mL). In addition a case of isopropanol poisoning was found to have the Armanni–Ebstein lesion. Isopropanol is converted to acetone but is not associated with acidosis. These results indicate that the Armanni–Ebstein lesion is not specific to diabetes mellitus.

Nonthrombotic Pulmonary Embolism: A Radiological Perspective

In this review, the authors highlight the clinical setting, symptoms, and imaging findings in nonthrombotic pulmonary embolism that radiologists may encounter in their clinical practice. We illustrate the imaging features based on the inciting agent with an emphasis on computed tomography. The diagnosis of nonthrombotic pulmonary embolism usually requires a high index of clinical suspicion and knowledge of the typical radiological findings.

What is a Complete Autopsy

Postmortem examinations have taken place over the past several thousand years. Despite this, the definition of a “complete” autopsy remains nebulus and the subject of controversy. Although ‘minimal autopsy practice standards’ have been published by professional bodies globally, recognition of, and adherence to those standards remains sporadic. An underlying refutation that ‘autopsies can never be complete’ – the reductio ad absurdum fallacy – has influenced many forensic pathologists’ opinions about autopsy. More pragmatic pathologists attempt to balance the financial and workload burdens of autopsies with the principles of adequacy and accuracy. Some medical examiners cite “statutory duty” as the force guiding the nature and completeness of their work, and as such, external examinations, partial autopsies and other limited variants are substituted for complete autopsies. Although it is impossible to perform every conceivable test in any one autopsy, an evidence-based approach guided by three forensic autopsy goals – statutory duty, the creation of a minimal dataset for societal and governmental inquiry, and maintenance of practitioner competency – ensure the completeness of any one postmortem examination.

Fatal traumatic aneurysm of the posterior inferior cerebellar artery with delayed rupture

Traumatic aneurysms of intracranial arteries are rare, forming less than 1% of all intracranial arteries. They may be associated with penetrating and non-penetrating trauma. Most cases are associated with fracturing of the skull. Rupture of traumatic aneurysms occur in up to 50% of cases and are typically delayed from days to weeks following the initiating trauma. We report a case of a 22-year-old man who was punched to the head. He was rendered unconscious but recovered and had a GCS of 14 on admission. CT scans showed subarachnoid hemorrhage. An initial angiogram was negative but on day 7 following the incident he was noted to have a 1 mm aneurysm of the posterior inferior cerebellar artery on CT angiogram. On day 9 he collapsed and was found to have new subarachnoid hemorrhage and to have a 4.0 mm × 3.7 mm. He did not recover and was declared brain dead on day 12. At autopsy, there was a 4.0 mm aneurysm of the left PICA just after the origin of the artery. Histological examination confirmed the presence of a traumatic false aneurysm in the left PICA. This case study shows sequential radiological imaging with pathologiocal correlation.

Histologic Changes In Recreational Drug Misuse

Use of recreational drugs is associated with a number of histologic changes. These may be related to the method of administration or due to systemic effects of the drugs. This paper reviews the histopathological features seen following recreational drug use. With injection, there may be local effects from abscess formation and systemic effects may result in amyloidosis. Injections have been associated with necrotizing fasciitis, anthrax, and clostridial infections. Systemic effects include infective endocarditis, with the risk of embolization, and abscesses may be seen in organs in the absence of infective endocarditis. Viral complications of injection include hepatitis and human immunodeficiency virus (HIV) infection. Injecting crushed tablets can result in intravascular granulomata in the lungs. Smoking drugs is associated with intraalveolar changes, including blackand brown-pigmented macrophages in crack cocaine and cannabis smoking, respectively. Snorting may result in intraalveolar granulomata forming when crush tablets are used and there may be systemic granulomata. Stimulants are associated with cardiovascular and cerebrovascular pathology, including contraction band necrosis and myocardial fibrosis, as well as coronary artery dissection. Stimulants may cause hyperpyrexia and rhabdomyolysis, which may be associated with changes in multiple organs including myoglobin casts in the kidney. Opioids cause respiratory depression and this can be associated with inhalational pneumonia and hypoxia in other organs if there is resuscitation and a period of survival. Ketamine use has been associated with changes in the urothelium and the liver. This paper reviews histology changes that may be seen in drug-related deaths using illustrative cases.

The Utility and Scope of Forensic Histopathology

Forensic histopathology is the use of histology to aid in the identification of disease and injuries in forensic pathology practice. The value of routine microscopy has been challenged in various studies and discussions have taken place in forensic journals about how useful microscopic diagnosis is in medicolegal autopsies. This paper reviews the literature on the value of histological examination in forensic practice and discusses routine histochemical stains that can be used in postmortem examinations to aid in the diagnosis and add value by confirming or refuting macroscopic findings.