Sandra E. Conradi

A decade of train-pedestrian fatalities: the Charleston experience

Although the cause of death is rarely in doubt in train-pedestrian fatalities, the manner of death is often unclear. The distinction between accident and suicide can only be made after careful evaluation of the history, scene investigation, autopsy findings, and toxicologic data. A retrospective analysis of 25 consecutive train-pedestrian fatalities investigated by our office between 1982 and 1992 is reported. The victims were predominantly healthy, young males. All but one person died at the scene. The cause of death was massive blunt trauma in 88% of the cases. In one case, the sole injury was decapitation. A tissue or blood ethanol level greater than 99 mg/dL was detected in 80% of the cases. A total of 60% of the cases involved persons likely to have been sitting or lying across the railroad tracks; all but one of these victims were intoxicated. The manner of death was determined to be accidental in 92% of our cases. Decapitation by a moving train is an injury highly suggestive of suicide. Massive blunt trauma, especially in the setting of ethanol intoxication, was highly associated with accidental death. Toxicologic analysis is essential in discriminating willful suicide from alcohol-induced incapacitation resulting in accidental death. Homicide, disguised as an accident or suicide, must be ruled out in all cases. Accurate determination of the manner of death is an important issue regarding civil litigation and dispersal of insurance benefits.

Hydrogen peroxide: a source of lethal oxygen embolism. Case report and review of the literature

Hydrogen peroxide is a readily available clear, odorless liquid that is commonly used as an irrigant for superficial wounds. It is not widely thought of as a poison; however, it may rarely be the cause of accidental death. A case of fatal oxygen embolism in a child after ingestion of hydrogen peroxide is reported. A total of five similar cases have been previously described. Morbidity and mortality have also been reported with the use of hydrogen peroxide in hospitals. Gastric catabolism of hydrogen peroxide produces oxygen and water. When the amount of oxygen evolved exceeds its maximal blood solubility, venous embolization occurs. Hydrogen peroxide should not be considered to be innocuous; it should neither be ingested nor used in situations where the evolved oxygen gas cannot dissipate freely. The ubiquitous nature of household peroxide and its erroneous benign reputation suggest that child-resistant containers are in order. A protocol delineating the medicolegal investigation and postmortem examination of fatalities caused by the ingestion of this substance is offered.

Fatal toxic epidermal necrolysis related to lamotrigine administration.

Toxic epidermal necrolysis (TEN) and Stevens‐Johnson syndrome (SJS) are severe life‐threatening dermatologic conditions. To date, eight cases of TEN and one of SJS related to lamotrigine administration have been reported in the literature. Most patients were also taking concomitant valproic acid. It was hypothesized that valproic acid may interfere with glucuronidation of lamotrigine, leading to increased serum lamotrigine levels, or perhaps alter the drugs metabolism, resulting in accumulation of a toxic intermediate metabolite. Ultimately, this may possibly predispose a patient to increased dermatologic reactions, including TEN. A 54‐year‐old man developed TEN 4 weeks after beginning lamotrigine for complex partial seizures related to a glioblastoma multiforme brain tumor. The patient had also been taking concomitant allopurinol and captopril for more than 4 years with no complications, and valproic acid 3 months before the cutaneous event. Despite aggressive intensive care management, the patient died 17 days from the onset of symptoms due to multiple organ failure. Administration of lamotrigine, especially in combination with valproic acid, may lead to the development of TEN.

Sudden death due to metronidazole/ethanol interaction.

Metronidazole (Flagyl), a commonly prescribed antimicrobial agent, can produce a reaction similar to that of disulfiram (Antabuse) when administered to patients drinking ethanol. This drug/chemical interaction results in accumulation of acetaldehyde in the blood. Acetaldehyde is hepatotoxic, cardiotoxic, and arrythmogenic; no lethal serum acetaldehyde level has been established. Sudden death has been reported in patients taking disulfiram while using ethanol; no fatalities have been reported due to ethanol/ metronidazole interactions. Described is a case of a 31-year-old woman who died moments after an assault by a male companion, during which he inflicted minor physical trauma to her upper arm. Toxicologic analysis yielded elevated concentrations of serum ethanol (162 mg/d), acetaldehyde (4.6 mg/d), and metronidazole (0.42 mg/L). The cause of death was reported to be cardiac dysrhythmia due to acetaldehyde toxicity due to an ethanol/ metronidazole interaction. Autonomic stress associated with the assault is likely to have contributed to this womans death. The mechanism of death is examined.

Sudden Death Caused by Coronary Artery Aneurysms: A Late Complication of Kawasaki Disease

The authors describe three cases (two blacks and one Latin American) of sudden death caused by late complications of Kawasaki disease (mucocutaneous lymph node syndrome). At autopsy each heart contained multiple coronary artery aneurysms with luminal stenosis caused by intimal hyperplasia and thrombi. Although virtually all fatal cases of Kawasaki disease occur within six months of the onset of symptoms, there have been other reported deaths up to 14 years after the acute illness. The coronary artery aneurysms of Kawasaki disease may persist and cause death years after the acute illness.

Carbohydrate-Deficient Transferrin and Alcohol Use in Medical Examiner Cases

Carbohydrate-deficient transferrin (CDT) has been studied as an index of heavy alcohol use. The present study evaluates the utility of CDT as a marker for chronic alcohol use in medical examiner cases. Over a 5-month period, serum specimens were collected in consecutive deaths that were referred to the medical examiners office (N = 25). Manner of death was accidental in nine cases, homicide/suicide for eight cases, and natural causes for seven cases. Fifteen of the 17 cases having alcohol abuse had positive CDT levels above threshold, indicating chronic use (sensitivity 88%). Eight cases had no evidence of alcohol abuse but three of these cases had CDT levels also above threshold (specificity 63%). There was no correlation between serum CDT levels and the time of death to blood collection for the total sample, indicating that CDT is stable postmortem for at least 36 h. CDT appears to have value as a marker of ante-mortem alcohol use prior to time of death in medical examiner cases.

Suicide by environmental hypoxia (forced depletion of oxygen).

Suicidal suffocation by forced oxygen depletion (environmental hypoxia) with carbon dioxide (CO2) and with propane is discussed in two cases. No toxicologic proof was available with the former and circumstantial evidence weighed heavily. The latter case demonstrated inhaled propane by an on-scene transthoracic aspirate; all other toxicology specimens, including brain, liver, blood, kidney, fat, and vitreous, did not contain hydrocarbons. This second fatality was complicated by multi-agent overdose, including diphenhydramine, fluoxetine (Prozac), and nordiazepam. The designation of these deaths as due to oxygen depletion involved careful scrutiny of the autopsy, toxicologic, and scene findings. Complete analysis of all factors surrounding these rarely encountered suffocation deaths is stressed.

Dyadic deaths involving Huntington's disease: a case report.

Huntingtons disease is a hereditary neurodegenerative disorder characterized by involuntary choreiform movements and progressive dementia. Although controversy exists regarding the exact risk of suicide in patients with Huntingtons chorea, the literature supports an increased risk of suicide, especially in the early stages of this disease. We describe a case of homicide-suicide involving a father and son. The 60-year-old father, the homicide victim, suffered from advanced Huntingtons disease; his 30-year-old son, the assailant, had a history of depression but had not been diagnosed with Huntingtons disease at the time of his suicide. The psychiatric implications of this dementing disease, including the risk of suicide, are discussed. The gross, histologic, and molecular genetic features of this neurodegenerative disease are also described. The recognition of this autosomal dominantly inherited disorder at autopsy can make a profound impact on the lives of surviving family members.

Battered child syndrome in a four year old with previous diagnosis of Reye's syndrome

A 4-year-old Black child was admitted to hospital in coma and with retinal hemorrhages. He was diagnosed as having Reyes Syndrome and remained hospitalized for 1 month. At discharge, he was neurologically compromised with spasticity of the right arm and leg, and could not walk or sit unsupported. Three weeks later he was again seen in the emergency room with a swollen right arm and leg and was subsequently readmitted. Healing fracture of the right femur and probable healing fracture of the right humerus were diagnosed. These were thought to be due to a fall from a stroller. Almost 4 months later, the child died at his home in the care of his mothers boyfriend. Autopsy findings were consistent with a severely chronically battered child.

Changing a diagnosis: The importance of neonatal autopsy

In this review of a clinical case and the subsequent autopsy findings, the importance of autopsy in determining the cause of death is highlighted. The importance of an autopsy in the neonatal age group is especially important since the yield of unexpected findings is considerably greater than in other groups, and the information may prove invaluable for parents and families in planning other pregnancies.