Dorothy E. Dean

Asphyxia due to angiotensin converting enzyme (ACE) inhibitor mediated angioedema of the tongue during the treatment of hypertensive heart disease.

This report describes seven deaths caused by angioedema of the tongue related to angiotensin converting enzyme (ACE) inhibitors. These seven cases were received in our office between 1998 and 2000. In that time frame we performed approximately 2000 autopsies. The cases involved African-American men and women, aged 51 to 65 years, all of whom had been prescribed an ACE inhibitor for the treatment of hypertensive heart disease. In each case, the external examination revealed markedly swollen tongues. The autopsies confirmed massive tongue swelling due to angioedema, and some patients also had swelling of the lips, pharynx, and larynx. Toxicologic analyses on postmortem blood samples were negative for ethanol and drugs of abuse. Although oral and pharyngeal swelling related to angioedema is well known in the clinical literature, its fatal potential has rarely been described.

The Temporal Fate of Drugs in Decomposing Porcine Tissue

Abstract:  Drug levels in decomposed individuals are difficult to interpret. Concentrations of 16 drugs were monitored in tissues (blood, brain, liver, kidney, muscle, and soil) from decomposing pigs for 1 week. Pigs were divided into groups (n = 5) with each group receiving four drugs. Drug cocktails were prepared from pharmaceutical formulations. Intracardiac pentobarbital sacrifice was 4 h after dosing, with tissue collection at 4, 24, 48, 96, and 168 h postdosing. Samples were frozen until assay. Detection and quantitation of drugs were through solid phase extraction followed by gas chromatograph/mass spectrometer analysis. Brain and kidneys were not available after 48 h; liver and muscle persisted for 1 week. Concentration of drugs increased during decomposition. During 1 week of decomposition, muscle showed average levels increasing but concentrations in liver were increased many fold, compared to muscle. Attempting to interpret drug levels in decomposed bodies may lead to incorrect conclusions about cause and manner of death.

Identification of decomposed human remains from radiographic comparisons of an unusual foot deformity.

A case of positive identification from decomposed human remains using an unusual foot deformity is presented. Scrutiny of the decedent revealed foot deformities, which upon examination, prompted further inquiry. Radiographic comparisons and defleshing each foot established bilateral talipes equinovarus (TEV, clubfoot). Positive identification was based upon unique skeletal features present in the radiographs.

Efficacy of OKT3 as primary therapy for histologically confirmed acute renal allograft rejection.

BACKGROUND OKT3 is often used as primary treatment for acute renal allograft rejection. In a retrospective study, we sought to determine the efficacy of OKT3 as a first-line agent in reversing histologically confirmed acute renal allograft rejection. METHODS Patients with mild to moderate, moderate, or severe acute cellular and acute vascular rejection who had not received any other anti-rejection treatment were included in this analysis. A total of 88 patients, who received OKT3 between 1987 and 1995, fulfilled these criteria. RESULT Seventy of these patients were renal transplant recipients, and 18 were combined kidney and pancreas transplant recipients. The median time to the diagnosis of rejection from transplantation was 32 days (range, 6 days to 13 years). On histology, 6 were graded as mild to moderate, 36 as moderate, 29 as moderate to severe, and 17 as severe rejection. The mean baseline serum creatinine was 1.62 mg/dl (range, 0.7-10.1 mg/dl), and the mean serum creatinine at the time of diagnosis of rejection was 2.60 mg/dl (range, 1.4-12.7 mg/dl) (P=<0.0001). The mean duration of OKT3 treatment was 11.2 days (range, 8-18 days). The mean serum creatinine at the end of OKT3 treatment was 1.73 mg/dl (range, 0.6-5.0 mg/dl; P=0.24 compared with baseline serum creatinine). Rejection was reversed in 86 (98%) patients. Graft survival at 1 year after OKT3 therapy was 87.5% (77 of 88). At a mean follow-up of 38 months, 8 patients had died and 26 grafts were lost. The mean serum creatinine level in the 64 patients with a functioning graft was 1.76 mg/dl (range, 0.8-4.0 mg/dl) at the last follow-up. CONCLUSION OKT3 when utilized as first-line therapy reversed 98% of the acute rejection episodes, with a 1-year post-OKT3 graft survival of 87.5%.

A blinded retrospective analysis of renal allograft pathology using the banff schema : Implications for clinical management

BACKGROUND We sought to determine whether diagnoses established through the Banff schema for evaluation of renal allograft pathology have implications for clinical management, compared with diagnoses established using descriptive terminology. METHODS All patients included in this study had mild to severe allograft rejection diagnosed, and, as part of a therapeutic protocol, they received OKT3 as primary anti-rejection therapy. We conducted a retrospective review of their renal allograft biopsy specimens and reclassified them, using the Banff schema, without knowledge of clinical information, laboratory data, or previous biopsy interpretation. Although there is no strict correspondence between descriptive diagnostic terminology and the criteria used in the Banff schema, for the purpose of comparisons, the following approximation was used: mild and mild to moderate rejection=Banff borderline and Banff grade 1, moderate and moderate to severe rejection=Banff grades 2A and 2B, and severe rejection=Banff grade 3. The diagnosis was considered concordant when the diagnosis by descriptive terminology and Banff grading were within the adopted approximation. RESULTS Of 96 biopsies specimens with mild to severe allograft rejection, 10 were insufficient for diagnosis, and three had changes of chronic allograft rejection. Of the remaining 83 biopsy specimens, 34 (41%) were concordant in interpretation of rejection grades, whereas 49 (59%) were discrepant. The greatest degree of concordance was in grades 2A (66.7%, 18 of 27) and 2B (64.7% 11 of 17), and the lowest was in the borderline category (11.8%, 2 of 17). The greatest degree of discrepancy was in normal and grade 3 (100%, 3 of 3 and 2 of 2, respectively), and the lowest was in grade 2A (33.3%, 9 of 27). Although primary anti-rejection therapy with OKT3 resulted in a high reversal rate of rejection (98%), there were 5 deaths, 12 graft loses, six episodes of serious infections, and three malignancies in this group of patients during a mean follow-up period of approximately 38 months. CONCLUSIONS Because patients with borderline changes and grades 1 and 2A rejection may be treated differently from patients with higher grades (2B and 3), the use of the Banff schema may allow for better adjustment of immunosuppressive therapy in response to specific grades of acute allograft rejection and may result in decreased complications of immunosuppressive therapy.

Impacted foreign body in the sigmoid colon presenting as recurrent diverticulitis

We report on a patient with left-sided abdominal pain thought to be caused by recurring diverticulitis. Computed tomography of the sigmoid colon revealed diverticulosis without the presence of a foreign body. During colonoscopy, a phytobezoar in the form of a vegetable stem was discovered transversely impacted within two diverticular openings in the lumen of the sigmoid colon. A localized inflammatory reaction was present without obstruction or perforation. After endoscopic removal of the phytobezoar, the abdominal pain resolved. The patient’s presumed diverticulitis was an inflammatory reaction caused by the phytobezoar. This case highlights the importance of early detection and endoscopic removal of a colonic foreign body to prevent abscess formation, fistulas, obstruction, perforation, or peritonitis. Foreign bodies masquerading as colonic diverticulitis should be considered in the absence of more common diseases.

Methanol Detected in a Subdural Hematoma as an Embalming Artifact

Analysis of subdural hematomata has been used to suggest antemortem drug concentrations, with the assumption that materials within the hematoma are less subject to metabolism or degradation during any survival period and postmortem interval. We report the case of an 87‐year‐old woman whose death had not been reported to the coroners office until postembalming. Autopsy revealed a traumatic brain injury with subdural hematoma causing a mass effect. Testing of the clot indicated a methanol concentration of 51.8 mg%. No additional analyses were detected. These findings suggest that methanol can be present in a postmortem hematoma sample, yet not represent a poisoning. Our findings also suggest that while the interior of hematomata do not necessarily represent completely “protected space” from postmortem diffusion of some blood constituents, such diffusion is not facile, and analysis may still provide useful indications of antemortem drugs present, if not actual concentrations.

Health Issues and Medical Care in the Ohio Penitentiary, 1833–1907

Ohio, once part of the West, rapidly became a center for settlement and transportation as America continued to expand. Though not of the geographical size or population density of larger cities such as New York, Ohio cities such as Cincinnati, Cleveland, and Columbus became hubs for industrialization and transportation even as the surrounding rural regions contributed significantly to the agricultural production of the United States. Columbus became Ohio’s capital city in 1816. Around the same time, the first buildings of what would become a large state penitentiary were located along the waterfront. Growing into one of the most significant penal institutions in the nation, the Ohio Penitentiary would occupy a central place in the state’s history for the next century and a half. Located on the corner of Spring Street near the Scioto River, the institution eventually covered twenty-five acres and held thousands of prisoners. Early in its history, the penitentiary’s officials recognized that inmate health should be a primary concern in day-to-day operations. A physician was appointed, and his reports began to be included in the annual reports to the governor. These documents included aggregate information about the health of all incarcerated inmates. Because these inmates were drawn from all over the country, examining their health and health care opens a window into the medical history of diseases present in the United States from

Forensically Significant Skeletal Anatomy

Forensically significant cases are those in which remains are recovered that have come from humans who died violently or unexpectedly, or for which the cause of death or manner of death is potentially a legal or otherwise significant issue (this may exclude very old or prehistoric remains). This text discusses the subset of forensically significant remains that are partially or completely decomposed, fragmented, or unidentified. This chapter is not meant to reiterate what other experts have described. Rather, we present the authors’ philosophy regarding the evaluation of cases in which the lower extremities, or parts thereof, represent the majority of the forensically significant and useful remains recovered. Results expected from the analysis of such remains form a biological profile that is potentially capable of providing positive identification (which is discussed further in later chapters) leading to and perhaps facilitating the determination of the cause and manner of death, a task that usually requires the integration of data from multiple sources and which is outside the scope of this book.