Henry J. Carson

A fatality involving an unusual route of fentanyl delivery: Chewing and aspirating the transdermal patch

We recently encountered a subject who died from an uncommon misuse of a fentanyl transdermal patch, chewing, followed by complications of aspiration of the patch. We report this case to alert medical examiners to the troubling trend of increased fentanyl patch abuse and its expanding range of misuses and associated morbidities. The decedent was a 28-year-old white male with a past medical history of prescription drug abuse who was pronounced dead in the emergency department shortly after arrival. An autopsy was completed and a tough but stretchy beige foreign body was identified lodged in a mainstem bronchus. Toxicological analysis of femoral blood showed methamphetamine, fentanyl and norfentanyl concentrations of 1456, 8.6 and 1.4 ng/mL, respectively. Individuals who abuse prescription medications often modify the route of administration of the drug from the intended method. As this case demonstrates, this choice can be fatal. The novel findings include a chewed patch, aspiration of a drug patch, and combination with an illicit drug at potentially lethal blood levels for both methamphetamine and fentanyl in a novice user.

Mast cell tryptase in a case of anaphylaxis due to repeat antibiotic exposure

Mast cell tryptase can be an indicator of type I hypersensitivity reaction and thus may serve as a surrogate marker of anaphylaxis. A 34-year-old white male patient presented with a history of systemic lupus erythematosus. Shortly after administration of cefazolin for dialysis, he developed pruritus and shortness of breath. He expired an hour later. Autopsy excluded anatomic causes of death. There was an elevated postmortem mast cell tryptase level, 29.2 ng/mL. For mast cell tryptase level to be useful, the patient must survive long enough after exposure to an allergen for mast cells to release this enzyme. A credible allergen must be identified. In this case such, mast cell tryptase could establish anaphylaxis as the cause of death. The case suggests that in a patient with autoimmune disease, it may be prudent to test for immune reaction to a drug before administering it a second time via pinprick or other method.

Brain trauma in head injuries presenting with and without concurrent skull fractures.

Head injuries and skull fractures may be problematic in cause and manner of death. Over a 10-year period, 54 cases showing head injuries were studied. Of these, 34 had skull fractures and 20 had no skull fractures. Virtually all decedents with skull fractures had brain injuries. The most common injury in both groups was motor vehicle accidents (MVA), in which 50% had skull fractures. In cases of skull fracture, brain lacerations, hemorrhages, and cerebral edema were common. Of 20 decedents with head injury but no skull fracture, most were accidents, and all but 3 cases had brain injury, although often relatively minor, except for atlanto-occiptital dislocation. There were significant differences between the two groups. Decedents with skull fractures tended to by younger (mean 35 years) compared to those with head injury only (mean 52 years) (p=0.0021). The use of drugs or alcohol was more likely in decedents with skull fractures than in those with head trauma only (p=0.0431). Mean abbreviated injury scale scores were higher for the face and head/neck of decedents with skull fractures, while significantly lower for chest and extremities, compared to decedents without skull fractures. Brain injury of some kind occurred in 90% of cases of head trauma, so a high level of suspicion should be placed in seeking skull fractures or brain injury.

Severe Leptospirosis Similar to Pandemic (H1N1) 2009, Florida and Missouri, USA

To the Editor: Leptospirosis is caused by pathogenic spirochetes of the genus Leptospira and transmitted through direct contact of skin or mucous membranes with urine or tissues of Leptospira-infected animals or through indirect contact with contaminated freshwater or soil. Leptospirosis shares common clinical signs with influenza, including fever, headache, myalgia, and sometimes cough and gastrointestinal symptoms. During 2009, acute complicated influenza-like illness (ILI) and rapid progressive pneumonia were often attributed to pandemic (H1N1) 2009; however, alternative final diagnoses were reported to be common (1). We report 3 cases of severe leptospirosis in Florida and Missouri with clinical signs similar to those of pandemic (H1N1) 2009. Patient 1 was a 40-year-old Florida man who sought treatment at an emergency department after a 4-day history of fever, myalgia, calf pain, malaise, and headache in July 2009. ILI was diagnosed. Laboratory testing was not performed, and the patient was instructed to take ibuprofen. Three days later, jaundice developed. He was admitted to an intensive-care unit with a diagnosis of hepatitis and acute renal failure. The man raised horses, goats, and chickens on his farm and was frequently employed to control rat infestations at an auto parts store and warehouse. Leptospirosis was suspected. Doxycycline was administered, and the man recovered and was discharged on the eighth day of hospitalization. Leptospira-specific immunoglobulin M antibodies were detected by dot blot (ARUP Laboratories, Salt Lake City, Utah, USA) on the second of paired consecutive blood specimens. Patient 2 was a 17-year-old Missouri woman with a history of obesity. She was hospitalized in August 2009 with a 5-day history of fever, myalgia, calf pain, malaise, headache, nausea, vomiting, dyspnea, and cough, complicated by acute renal failure. The diagnosis on admission was viral infection. On the third day of hospitalization, severe pneumonia and respiratory failure developed, and she was administered vancomycin, piperacillin/tazobactam, levofloxacin, and doxycycline. She died the same day. Ten days before illness onset, she had swum in a creek near her residence. Patient 3 was a 59-year-old Florida man with a history of obesity and diabetes mellitus. He sought treatment at a clinic in September 2009 and reported a 5-day history of fever, myalgia, malaise, nausea, abdominal pain, and dyspnea. He was treated for gastritis. Two days later, he came to an emergency department and was admitted to the hospital with severe pneumonia and multiorgan failure; he died the next day. The man had frequently engaged in activities to control rat infestations on the farm where he raised chickens, pigs, and goats. Although patients 2 and 3 were neither tested nor treated for influenza before they died, their clinical signs and rapidity of death prompted postmortem suspicion of pandemic (H1N1) 2009. Autopsies were performed and formalin-fixed tissues were submitted to the Centers for Disease Control and Prevention (Atlanta, GA, USA). Histopathologic evaluation of both patients demonstrated extensive pulmonary hemorrhage and interstitial nephritis (Figure, panels A and B), features consistent with leptospirosis. Immunohistochemical tests for leptospirosis, spotted fever group rickettsiae, and influenza A were performed on multiple tissues obtained from patients 2 and 3. Immunohistochemical evidence of leptospiral infection was identified in lung, liver, kidney, heart, and spleen tissue in both patients (Figure, panels C and D). Figure Photomicrographs of lung, liver, and kidney sections from patient 2 during study, Missouri and Florida, USA, 2009. Hematoxylin and eosin stain showed pulmonary hemorrhage (A) (original magnification ×10) and interstitial nephritis (B) (original ... These cases of severe leptospirosis were reported during the 2009 influenza pandemic. Although pulmonary hemorrhage (experienced by patients 2 and 3) is increasingly recognized as a severe manifestation of leptospirosis (2), it is also a known complication of influenza (3). ILI was initially diagnosed in patient 1, but symptom progression and clinical complications, combined with a history of animal exposure, prompted the physician to consider leptospirosis and to initiate appropriate antimicrobial drug therapy. Autopsies are critical in determining the reasons for death after undiagnosed illness. Pulmonary involvement in cases of leptospirosis is characterized by congestion and hemorrhage, usually without prominent inflammatory infiltrates (4); pulmonary involvement in cases of severe pandemic (H1N1) 2009 typically manifests as diffuse alveolar damage (5). Postmortem diagnosis of leptospirosis was supported by characteristic histopathologic findings, including pulmonary hemorrhage and interstitial nephritis, and was confirmed by immunohistochemical tests. Our report illustrates the need for autopsies in unexpected deaths, even if the cause appears obvious in a specific clinical and epidemic setting. Leptospirosis ceased being nationally notifiable in the United States in 1994 and is likely underdiagnosed because it is not routinely considered in differential diagnoses. However, outbreaks with exposures similar to the case-patients we studied have been periodically reported in the United States (6–8). Because leptospirosis commonly manifests as acute febrile illness, cases can be underrecognized during infectious-disease epidemics (e.g., dengue) (9). Leptospirosis should be included in the differential diagnosis of acute febrile illness in the United States and other industrialized countries. Epidemiologic clues include recreational or occupational water exposure; animal exposure (including rodents) in the home or the workplace, travel to tropical areas, and water exposure during travel. These risk factors for leptospirosis are increasing in industrialized countries (10). Thorough patient-history reviews and consideration of alternative diagnoses are needed for cases of respiratory illness during an influenza pandemic.

The Medium, Not the Message How Tattoos Correlate With Early Mortality

OBJECTIVES At autopsy, tattoos are recorded as part of the external examination. An investigation was undertaken to determine whether negative messages that are tattooed on a decedent may indicate a predisposition to certain fatal outcomes. METHODS Tattooed and nontattooed persons were classified by demography and forensics. Tattoos with negative or ominous messages were reviewed. Statistical comparisons were made. RESULTS The mean age of death for tattooed persons was 39 years, compared with 53 years for nontattooed persons (P = .0001). There was a significant contribution of negative messages in tattoos associated with nonnatural death (P = .0088) but not with natural death. However, the presence of any tattoo was more significant than the content of the tattoo. CONCLUSIONS Persons with tattoos appear to die earlier than those without. There may be an epiphenomenon between having tattoos and risk-taking behavior such as drug or alcohol use. A negative tattoo may suggest a predisposition to violent death but is eclipsed by the presence of any tattoo.

Massive internal injury in the absence of significant external injury after collisions of passenger vehicles with much larger vehicles.

We have encountered cases of motor vehicle collisions in which there was relatively little external trauma, but there were massive internal injuries that were much more extensive than might be expected from the external examination. Two cases were collisions between trains and pickup trucks, the third a collision between a semi trailer and a van. In all three cases, the external examination showed minor abrasions and lacerations. Internally, however, there were massive injuries which were fatal. While the significant injuries in our cases were not surprising given the force of the collisions involved, it is interesting that the external examination showed relatively little injury. We speculate that collisions between passenger vehicles and very large vehicles generate massive internal injuries by transmission of force through the victims.

Identification at autopsy of pulverized pills in lungs of a first-time methadone user

We recently encountered a 25-year-old white man who died of substance abuse including methadone. The route of administration of the drug(s) appears to have been insufflation. He was found dead at home. There were bottles of prescribed medications and an empty bottle of non-prescribed methadone. There was a grinding device nearby. At autopsy, no needle tracts were identified. Microscopically, the bronchi had desquamated ciliated respiratory epithelium admixed with red-brown pigment, which was found under plane-polarized light to be comprised of birefringent finely-granular material consistent with pulverized pills. Blood toxicology was positive for tetrahydrocannabinol, sertraline, nicotine, and methadone. The cause of death was ruled drug interactions with cerebral and pulmonary edema, the manner of death accidental. The decedent fit a profile of a victim of prescription drug abuse, for whom the mode of administration of drugs may be altered from intended use in as many as 80% of cases.

Optic nerve trauma with unilateral edema as a result of head injury

We encountered a patient who suffered a head injury that translated to the optic nerves, leading to dramatic unilateral right optic nerve edema. The decedent was a 20-year-old unsecured passenger in a convertible. The car collided with a pickup truck. The patient survived for 8 h. At autopsy, a comminuted skull fracture involving the right frontal bone including the right orbital plate was found. The right optic nerve measured 1.2 cm in diameter, compared to only 0.4 cm for the left optic nerve. Microscopically, the right optic nerve was markedly edematous, but the nerve fibers and nuclei were viable and intact. The dramatic difference in size between the right and left optic nerves can be attributed to several mechanisms. The survival interval was essential for the asymmetrical swelling to take place. Optic nerve trauma is relatively rare in head injuries, reported to be present in 0.5% of automobile accidents and assaults. Other causes of optic nerve trauma and edema include tumors, osteopetrosis, or reaction to a peripheral hemodialysis shunt.

Shortcomings of Urine-Preferred Drug Screening on Post-Mortem Specimens

Abstract In counties with limited budgets, in order to save money on toxicology work, the request often comes from local medical examiners that screening for drugs on decedents be performed initially on urine and, if positive, to send blood for confirmation; negative urine results are not further evaluated. A study of known urine and blood drug screens was performed to evaluate the clinical and cost-effectiveness of this practice. Results of 401 autopsies were reviewed. In all, 11 decedents had both urine and blood drug screens performed. There were seven men and four women, mean age for both 39 years. In the urine drug screens, there were nine true positive tests, 17 false positives, 45 true negatives, and five false negatives; sensitivity 64%, specificity 73%. The savings in cost were theoretically 34%, but screening urine for drugs on post-mortem specimens does not appear to be an effective way to determine what drugs were present at the time of death. It is inexpensive, however. Still, in a screening practice for which so many of the results are not reliable, one must decide whether the money saved is worth the misleading results. Considering how many critical decisions about cause and manner of death are based on toxicology, it would seem unreliable to choose a urine-preferred practice.

Letter to the editor--stuffed toy animals as transitional objects in an adult suicide.

Sir, We recently encountered a 33-year-old man who left unusual artifacts at his suicide. He had previously made a hole in the ceiling in the living room of his apartment and suspended a rope from a joist. His father discovered the apparatus and disassembled it. He criticized his son for erecting it, but no other intervention took place. A week later, the decedent restored the ligature and hanged himself from it by the neck. Before he died, he likewise hanged numerous toy stuffed animals that he had collected. He did not leave a suicide note. Stuffed animals serve many roles in the lives of children and adults. In childhood, stuffed animals may be personified as objects of nurturing (1). They are thus considered transitional objects, in that they take the place of the mother–child bond. In adolescence, objects tend to be valued more for their function than for their symbolic value, although stuffed animals and other treasured objects that belong to females may still be valued for interpersonal meaning more than for function (2). In adulthood, stuffed animals may be used as countertransitional objects by parents in the care of high-risk infants, i.e., the objects are used to replace the maternalchild bond for the sake of the parent who is unable to provide direct care to an infant in intensive care (3). Among adult female inpatient psychiatric patients, borderline personality disorder has been found to be prevalent in patients who display stuffed animals in their hospital rooms (4). Thus, the use of stuffed animals in different ways is common, although for a man at this age, such use is atypical. Such involved use of these objects may suggest an underlying personality or affective disorder, although none was explicitly diagnosed or treated. Certainly there were suggestions of a difficult social situation in that no intervention took place when suicidal ideation and intention were discovered. The presence of hanged stuffed animals may also demonstrate regression to an immature or abnormal emotional state, in which the stuffed animals take on meaning beyond their objective or sentimental value. Indeed, the traditional transitional role of the objects may have been repeated, in that ‘‘killing’’ the toys represented loss of maternal ⁄ familial love and nurturing. In addition to personification of the objects, there may have been identification with them, in which the toys became objects that the decedent ‘‘killed’’ so as to complete his suicide. Alternatively, the stuffed animals may have been symbolically ‘‘euthanized’’ so that he need not worry about their ‘‘care’’ after his death, an act that may take place with household pets. As there are no notes or oral history to explain precisely the meaning of his stuffed animals to this man, we cannot be sure what role they played in his suicide. However, he went to such lengths to prepare them for his death, the objects appear to have facilitated his suicide, and left a poignant message of his despair to survivors.