Over-the-counter (OTC) medications are not typically considered “drugs of abuse” by the public, yet they are implicated in a portion of overdose cases. Although the toxicity of some OTC medications (such as acetaminophen, aspirin, and diphenhydramine [DPH]) has been extensively reported in the medical literature, the lethality of other substances (including melatonin) has not been well established. We report the case of a 21-year-old woman who was found deceased within her secure residence. Scene investigation revealed the presence of 5 empty containers of DPH and a partially empty container of melatonin, as well as a handwritten note of apparent suicidal nature. Upon autopsy examination, the gastric mucosa was notable for a green-blue discoloration, and the gastric contents were consisted of a green-tan viscous material with admixed blue particulate material. Further analysis revealed elevated concentrations of both DPH and melatonin within the blood and gastric contents. The death was certified as a suicide by acute combined DPH and melatonin toxicity. This paper will review the pharmacology of OTC sleep aid medications and provide a brief outline of their documented toxicity, in addition to reinforcing the role of death scene investigation and its correlation with autopsy findings.
Follicular thyroid carcinoma (FTC) is the second most common cancer of the thyroid after papillary thyroid carcinoma (PTC). However, FTC is considered more aggressive than PTC because of a greater tendency to invade blood vessels and spread to distant organs, such as lung and bone. FTC commonly presents as a solitary thyroid nodule, which is diagnosed by thorough examination of thyroidectomy/lobectomy specimens for capsular and vascular invasions. First diagnosis of FTC from femoral metastasis is very rare. Herein we report such a case in an 84-year-old woman who presented with increasing pain in her left thigh. A bone scan revealed multiple lesions in the femur. Biopsy showed solid nests of cells with round to oval nuclei and abundant eosionophilic/granular cytoplasm. On high power, the nuclei contained 1 or more small nucleoli and granular chromatin. Only rare nuclear grooves are found. Four years ago, the patient had a right humeral pathologic fracture. The biopsy was positive for TTF-1 and was interpreted as "metastatic non-small cell carcinoma consistent with lung primary." However, subsequent bronchial washing and lung biopsy were negative for malignancy. Immunostains for thyroglobulin, TTF-1, HBME-1, CK19, CD56, and CK7 were performed. Detailed medical history was investigated. Tumor cells from femur are positive for thyroglobulin and TTF-1, consistent with metastatic tumor from thyroid primary. HBME-1 and CK19 immunostains only mark scattered cells, not supporting differential diagnosis of metastatic PTC. CD56 and CK7 stains are both positive. On further communication, patient's remote history of thyroid nodule status post right lobectomy was obtained. Based on the overall morphologic and immunohistochemical features and the history, the final diagnosis of metastatic FTC was made. We would like to raise the awareness that metastatic FTC should be included in the differential diagnoses for tumors metastasized to bone to avoid misdiagnosis.
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