Gregory J. Davis

Fatal Rhizopus Pneumonia in Allogeneic Stem Cell Transplant Patients Despite Posaconazole Prophylaxis: Two Cases and Review of the Literature

Posaconazole is a triazole with broad spectrum of activity against multiple fungi including members of the fungal order Mucorales. This activity has been shown both in clinical and in vitro studies, which are critically reviewed here. It has become very popular in prophylaxis in acute myelogenous leukemia (AML) induction and in the graft-versus-host disease (GVHD) settings after 2 recent prospective trials that showed advantage of posaconazole prophylaxis compared to fluconazole or itraconazole. In this report, 2 patients are presented, in whom, despite posaconazole prophylaxis, invasive and ultimately fatal Rhizopus pulmonary infections developed. These cases are similar to a previously reported case of Rhizopus infection in a stem cell transplant recipient who also received posaconazole, indicating a potential newly recognized pattern of breakthrough infections in patients receiving posaconazole prophylaxis.

Case report nonfracture associated fatal fat embolism in a case of child abuse

Fatal fat embolism is usually thought of as a sequel to long-bone fracture, although cases secondary to soft tissue injury and atraumatic conditions have been infrequently reported. In this case of a two-year-old child-abuse victim who sustained multiple blunt traumatic injuries without skeletal fractures, pulmonary and systemic (brain and kidney) fat emboli were identified. At autopsy, all thoracic and abdominal viscera were intact; cranial contents exhibited only diffuse symmetrical petechial hemorrhages of the white matter. Because of the severe and widespread nature of soft tissue hemorrhage, and the absence of a grossly discernible cause of death, fat embolism was suspected. Using a combination of frozen section with oil red O staining and formalin-fixed osmium stained tissues, the immediate cause of death was determined to be diffuse fat embolism. Review of the literature reveals a pathophysiologic basis for fat embolism in the absence of fracture, both as a consequence of an acute increase in local pressure at the site of trauma and an alteration of the emulsification of blood lipids during shock. In light of these findings, we present this case to remind the forensic science community to consider fat embolism as the cause of death in cases of blunt-force injury without fracture.

Accidental Electrocution During Autoeroticism: A Shocking Case

A case of atypical autoerotic death is described. An 18-year-old white man clad in two brassieres was found dead in his bedroom by his brother. Two wet green terry cloths were under the brassiere cups, connected to the house current via two metal washers and a bifid electrical cord. Literature depicting nude women was found near the victim. Autopsy revealed second-degree and third-degree burns of the mammary regions. Death was attributed to accidental self-electrocution. The authors will discuss typical and atypical forms of autoerotic death.

Death of a toddler due to ingestion of sulfuric acid at a clandestine home methamphetamine laboratory

Exposure to strong acids such as sulfuric acid to either the skin or the gastrointestinal or respiratory mucosa will result respectively in significant—occasionally fatal—cutaneous chemical burns as well as devastating corrosive damage to the respiratory and gastrointestinal tracts. Most injuries are accidental, but there are reports of using acids as weapons or as a means of suicide. The primary mechanism of acid injury is coagulative necrosis of the tissues. Sulfuric acid is a chemical often used in industrial and chemical laboratories, and it is an ingredient in household products like drain cleaner. Easily accessible, over-the-counter, household drain cleaner is one of several common materials used to manufacture methamphetamine. With increasing clandestine methamphetamine laboratories in the United States, exposure to methamphetamine and the toxic chemicals used for its production is a growing problem. In many instances, children living in these laboratories qua homes are at risk for injury and death. We report the death of an unattended toddler, who ingested sulfuric acid drain cleaner in his home. The gross and histopathological autopsy findings in this case are similar to those of previously described cases of sulfuric acid injury

In the shadow of the baron: Sudden death due to Munchausen Syndrome

The authors describe a woman who died suddenly in an emergency department restroom after self-injection of corn starch in an attempt to gain admission to the hospital. At autopsy, multiple pulmonary vascular corn starch granulomata were identified, as well as pulmonary arteries filled with brewers yeast. Retrospective evaluation of the patients medical history showed multiple signs of Munchausen Syndrome. The authors suggest that the case illustrates the importance of scene investigation and review of the medical history by emergency department personnel and the forensic pathologist.

An unusual case of maternal-fetal death due to vaginal insufflation of cocaine

Air embolism secondary to vaginal insufflation has been documented as a cause of death in pregnant women. Under pressure, the air enters the uterus, causing air emboli within the uterine venous drainage and subsequently the systemic circulation. Death is usually sudden as the air obstructs the normal flow of circulation. Acute cocaine toxicity is also a well-known cause of sudden death. Cocaine use is prevalent in our society, even among pregnant women. We report the sudden death of a 31-year-old gravid female and 39-week gestational age male fetus. The cause of death was air embolism secondary to oral-vaginal insufflation of cocaine smoke.

Sudden Cardiac Death Associated With Hypoplasia of the Coronary Arteries and Conduction System Alteration

We present a case of sudden cardiac death in a 24-year-old woman with evidence of hypoplasia of the left anterior descending (LAD) and posterior descending (PDA) coronary arteries. These vessels averaged 0.7 mm in internal diameter combined, in contrast to an average of 2.4 mm in control coronary arteries (p < 0.001). The myocardium exhibited areas of acute and chronic ischemic change. Also, the cardiac conduction system (CCS) had diffuse cellular enlargement, believed to be secondary to ischemia. The cells of the sinoatrial node (SAN) and the Purkinje cells of the proximal right bundle branch (RBB) averaged 28.5 and 25.6 microns, respectively. These were significantly larger than the SAN cells (21.6 microns, p = 0.002) and larger than the Purkinje cells (15.9 microns, p = 0.012) of control cases. We report that hypoplastic coronary artery disease is a cause of sudden death, is associated with varying degrees of ischemic change in the heart, and can be associated with condition system alteration.

An atypical shotgun entrance wound caused by a sabot slug. All is not as it seems.

An 18-year-old woman was killed by a single gunshot wound to the head during a high-speed chase on a rural two-lane road. At autopsy, the entrance wound of the calvarium first appeared to be a tangential “keyhole” defect. Upon internal examination, the wound was determined to have been caused by a shotgun sabot slug that had yawed ∼90° during its flight. The unusual characteristics of the wound and the ammunition are discussed.

Sudden death in a child with Carpenter Syndrome. Case report and literature review

Carpenter syndrome (Acrocephalopolysyndactyly type II) is a rare disorder characterized by acrocephaly, mental retardation, congenital heart disease, syndactyly, preaxial polydactyly, obesity, cryptorchidism, hypogenitalism, bony abnormalities, and umbilical hernia. We present a case of unexpected death of a 7-year-old boy with Carpenter Syndrome complicated by twin and premature birth as well as repaired congenital heart disease.

Cardiac dysrhythmia during restraint.

To the Editor: Death during police restraint remains a hot topic in the forensic community. Despite thorough investigation, development of intricate timelines, complete autopsy and toxicological analysis, and adjunctive studies, it can still be unclear what specifically killed an agitated individual who collapses suddenly while being subdued by the authorities. Clearly, toxicity due to the use of illicit drugs such as cocaine, plays a role in some cases whereas excited delirium syndrome (a term quite acceptable to us despite the controversy surrounding it) is the cause of death in other instances. A variety of restraint techniques including pressure to the torso, arm bars, asp or baton blows, and the deployment of electronic control devices (ECDs) may also play a role in a given fatality (albeit the concept of ECDs causing death is still under scrutiny). But how do we determine which factor resulted in death when a multiplicity of choices exist? None of us relishes the concept of determining that the cause and manner of death are undetermined in these high profile cases, though in fact this may ultimately be true. While such a determination remains a valid option, we would like to offer an alternative. Most anecdotal and clinical evidence suggests that persons who suddenly collapse during vigorous restraint suffer from lethal cardiac dysrhthymias (though other mechanisms such as respiratory arrest may predominate in some cases). That being the case, the term Cardiac Dysrhythmia During Restraint (CDDR) may be the most intellectually honest cause of death in some challenging cases. This diagnosis should not be used indiscriminately. Rather, CDDR would be appropriate when many factors collide in a Bperfect storm[ with the end result being aberrant electrical discharges in the heart. Depending on the circumstances of the case and which insult to the body more likely than not led to the dysrhythmia, the manner of death may be deemed homicide, accident, or undetermined. Under the BHow Injury Occurred[ section of the death certificate, Bsudden collapse during police restraint[ may be used. Depending on the philosophy, training, and judgment of the medical examiner, contributory factors (Part II on the death certificate) may include physical restraint (including ECD use if the investigation suggests the dysrhythmia was closely temporally related to its application; pressure applied to torso; hogtieing), intense physical exertion, probable catecholamine surge, recent drug use, acute psychosis, and preexistent cardiac disease. As indicated earlier, if a more specific diagnosis can be identified (eg, Excited Delirium, Asphyxiation due to Yoking, Positional Asphyxia, Acute Cocaine Toxicity) it should supersede CDDR as a cause of death. The use of a standardized term for these challenging cases serves several purposes. First, it will facilitate the identification of such cases for statistical purposes. Second, it helps to satisfy the recommendation of the recent National Academy of Sciences Report BStrengthening Forensic Science in theUnited States: A Path Forward[ which highlighted the need for standardization in the forensic sciences. Finally, it reflects the reality that we often do not know what caused someone to die suddenly during restraint. The opinion section of the autopsy report exists for the medical examiner to justify his or her determination of the cause and manner of death; it should be used in these cases to clearly articulate the thought processes of the medical examiner. Specifically, it provides an opportunity to explain which factor may have predominated in a given case and why a certain manner of death was chosen. Medical examiners strive for accuracy in every case falling under their jurisdiction. The simple fact is that many deaths in custody can only be reduced to 2 simple facts: a person was being restrained when they collapsed, and they suffered a lethal cardiac dysrhythmia. Perhaps we can agree on some term that reflects what we know to be true.