Kurt B. Nolte

Stroke associated with ephedrine use

Several sympathomimetic agents have been associated with ischemic and hemorrhagic stroke. Ephedrine, a sympathomimetic drug that has a high potential for abuse and can be readily obtained without a prescription in unrestricted quantities, has rarely been associated with stroke. We report ephedrine-related stroke in three patients. One patient developed a thalamic infarct after ingesting known quantities of ephedrine as street-purchased “speed” for weight loss. Two patients had fatal intracranial hemorrhages after ingesting unknown quantities of ephedrine; one of them had a history of drug abuse, and one lacked a history of ephedrine use or drug abuse. Ephedrine appears to predispose to both ischemic and hemorrhagic stroke. The mechanisms responsible for the different cerebrovascular complications remain to be proven. Restriction of ephedrine availability should be considered.

Biosafety considerations for autopsy.

An autopsy may subject prosectors and others to a wide variety of infectious agents, including bloodborne and aerosolized pathogens such as human immunodeficiency virus, hepatitis B and C viruses, and Mycobacterium tuberculosis. Other hazards include toxic chemicals (e.g., formalin, cyanide, and organophosphates) and radiation from radionuclides used for patient therapy and diagnosis. These risks can be substantially mitigated through proper assessment, personal protective equipment, appropriate autopsy procedures, and facility design.

Insect Larvae Used to Detect Cocaine Poisoning in a Decomposed Body

Insect larvae are often found on human remains long after disappearance of the usual toxicologic specimens. It is important for forensic pathologists and toxicologists to recognize the potential of this unique specimen when routine specimens are not available. Cocaine and benzoylecgonine was extracted from Calliphorid larvae found on a badly decomposed body of a man who had been missing 5 months and was also identified in the decomposing skeletal muscle. This toxicologic information combined with the autopsy findings and the circumstances of the death and disappearance was essential in the determination of cocaine poisoning as the cause of death.

Influenza A virus infection complicated by fatal myocarditis.

Influenza virus typically causes a febrile respiratory illness, but it can present with a variety of other clinical manifestations. We report a fatal case of myocarditis associated with influenza A infection. A previously healthy 11-year-old girl had malaise and fever for approximately 1 week before a sudden, witnessed fatal collapse at home. Autopsy revealed a pericardial effusion, a mixed lymphocytic and neutrophilic myocarditis, a mild lymphocytic interstitial pneumonia, focal bronchial/bronchiolar mucosal necrosis, and histologic changes consistent with asthma. Infection with influenza A (H3N2) was confirmed by virus isolation from a postmortem nasopharyngeal swab. Attempts to isolate virus from heart and lung tissue were unsuccessful. Immunohistochemical tests directed against influenza A antigens and in situ hybridization for influenza A genetic material demonstrated positive staining in bronchial epithelial cells, whereas heart sections were negative. Sudden death is a rare complication of influenza and may be caused by myocarditis. Forensic pathologists should be aware that postmortem nasopharyngeal swabs for viral culture and immunohistochemical or in situ hybridization procedures on lung tissue might be necessary to achieve a diagnosis. Because neither culturable virus nor influenza viral antigen could be identified in heart tissue, the pathogenesis of influenza myocarditis in this case is unlikely to be the result of direct infection of myocardium by the virus. The risk factors for developing myocarditis during an influenza infection are unknown.

Rhabdomyolysis associated with cocaine abuse

There have been recent reports of rhabdomyolysis associated with cocaine abuse. The pathologic findings from these cases have not been described. Pathologic abnormalities in two fatalities with cocaine-associated rhabdomyolysis, including one with hyperpyrexia, acute renal failure, and disseminated intravascular coagulation, are discussed in detail. Skeletal muscle in both cases showed necrosis without evidence of vasculitis, polarizable foreign crystals, or other specific lesions. The individual with renal failure showed acute tubular necrosis with granular myoglobin casts in tubules. The mechanism of cocaine-associated rhabdomyolysis is unclear, but potentially includes ischemia due to vasoconstriction, direct toxicity, hyperpyrexia, and increased muscle activity from agitation or seizure. Adulterants may also play a role. In unexplained cases of rhabdomyolysis, toxicologic evidence of cocaine should be sought. In those cases of rhabdomyolysis associated with acute renal failure, the presence of cocaine in blood may be prolonged because of impaired renal clearance.

Esophageal foreign bodies as child abuse. Potential fatal mechanisms

Foreign bodies being forced into the esophagus as a form of fatal child abuse is rare. A 4.5-month-old female infant presented to clinicians with respiratory distress. Several coins were recovered from the esophagus. One month later, she was found dead in her crib. At autopsy, there were three coins in the esophagus. In addition, there were cutaneous contusions of various ages, acute and partially healed fractures of the extremities, old aspirated foreign material in the lungs, and pulmonary fat emboli. Although the fat emboli may have contributed to the death, several potentially fatal mechanisms from the esophageal foreign bodies deserve consideration. These include vagal stimulation from esophageal distention, aspiration of swallowed fluids after esophageal obstruction, compression of the trachea or the heart by the coins, and cardiac compression or airway occlusion by the introducing finger.

Sudden Death Due to Primary Diffuse Leptomeningeal Gliomatosis

Tumors of the central nervous system are an unusual cause of sudden death. This report describes the sudden death of a presumed healthy 28-year-old woman from primary diffuse leptomeningeal gliomatosis. She presented to an emergency room with headache and vomiting, subsequently became unresponsive and was pronounced dead 14 h later. Autopsy revealed a diffuse extensive infiltrate of well-differentiated astrocytoma in the leptomeninges of the brain and spinal cord without an underlying parenchymal tumor. Primary diffuse leptomeningeal gliomatosis is a rare tumor that arises within the leptomeninges from small neuroglial heterotopic rests that undergo neoplastic transformation. Grossly. this tumor can mimic leptomeningeal carcinomatosis, pachymeningitis, tuberculosis, sarcoidosis, and fungal infections. However, the histologic features of primary diffuse leptomeningeal gliomatosis should allow it to be readily distinguished from grossly similar conditions. The mechanism of death in this case is most likely tumor obstruction of cerebrospinal fluid outflow resulting in the usual complications seen with increased intracranial pressure. Although this tumor is aggressive and is associated with a rapidly progressive fatal course, it has not been previously associated with sudden death.

Prevention of Occupational Cyanide Exposure in Autopsy Prosectors

Autopsy prosectors examining individuals with cyanide poisoning are at risk for occupational cyanide exposure. No protective autopsy precautions to mitigate this risk have been published. We report an autopsy on an individual with cyanide poisoning where the procedure was performed in a negatively pressured isolation room and the stomach was opened under a biosafety cabinet hood. None of the three autopsy prosectors had measurable cyanide in pre or post procedure blood specimens. We recommend that similar precautions be taken in all autopsies where cyanide is suspected as a possible cause of death.

Transillumination Enhances Photographs of Retinal Hemorrhages

Light stand photography with direct illumination of the retina is a common method of demonstrating retinal hemorrhages. The lack of contrast between dark hemorrhages and surrounding dark retina, and the difficulty of photographing into the concavity of an eye limit this technique. Transillumination of a bivalved globe with a bright external light source such as a colonoscope or microscope light yields high contrast superior photographs. This technique is useful to document retinal hemorrhages, and provides quality photographs for courtroom demonstrations.

The Tubular “Cookie Cutter” Bullet: A Unique Projectile

Recently marketed PMC (Pan Metal Corporation) Ultramag tubular hollow point ammunition is uniquely constructed with a two-part projectile composed of a tubular copper bullet and a Teflon wad. A fatal gunshot wound with this ammunition is described. A unique radiographic pattern and the results of test firing are also presented.