As part of a review of substance abuse deaths in Dutchess County, New York, the Dutchess County Medical Examiner's Office identified 3 cases of angiocentric systemic foreign-body granulomatosis discovered at autopsy. Our investigation disclosed that in all 3 cases patients surreptitiously injected crushed oral prescription medication. Of the patients, 2 obtained intravenous access through central venous lines, the other patient was found to have injected herself intramuscularly. Autopsy demonstrated lung abnormalities due to diffuse deposits of foreign material within and around vessels, associated with foreign-body granulomatous reaction. We also identified a systemic distribution of this foreign material deposited beyond the lungs in the brain, heart, kidneys, and spleen. We present these cases along with a review of the literature of systemic embolization of foreign material in previously documented cases of deaths due to parenteral abuse of oral medications.
To compare the efficacy of patient-controlled lumbar and thoracic epidural sufentanil, 22 patients scheduled for elective thoracotomy were assigned randomly to receive sufentanil via either a lumbar or a thoracic epidural catheter. For 24 h postoperatively, the patients received analgesia only by patient-controlled epidural sufentanil. There were no significant differences in the visual analog scale (VAS) for pain between the two groups at 8 and 24 h postoperatively. Nausea and pruritus were minimum, requiring treatment less than once per 24-h period in either group. The forced vital capacity (FVC) measured at 24 h (as a percentage of baseline FVC) showed no significant difference between the lumbar and thoracic groups (44.7 +/- 3.8 and 41.7 +/- 5.5; P = 0.68). The total sufentanil used by the lumbar and thoracic groups was not significantly different (196 +/- 25.2 micrograms and 157 +/- 28.6 micrograms; P = 0.32). We conclude that there is no clinical advantage of thoracic over lumbar epidural sufentanil in the thoracotomy patient with respect to quality of analgesia, amount of sufentanil used, severity of side effects, or postoperative pulmonary function.
We report the case of postmortem animal depredation that produced initial confusion for investigators who responded to the scene. A decomposing elderly woman was found in her presumed home with bilateral upper extremity amputations and craniocerebral trauma. This raised suspicion of foul play. Subsequent investigations together with autopsy led the medical examiner to conclude that the cause of death was natural disease and that those injuries found on her body were produced by at least one of the dogs who shared the premises. We linked the canine culprit to the postmortem trauma and positively identified the remains by collecting material defecated by the animal and by using radiologic and dental comparison techniques.
We report a case of sudden death due to a catastrophic spontaneous rupture of a urinary bladder associated with megacolon due to a fecal impaction (fecaloma). The massively distended rectum and sigmoid colon filled the pelvic cavity and pressed up against the posterior aspects of the uterus, vagina, and urinary bladder. This produced bladder outlet obstruction, followed by massive dilatation and rupture of the urinary bladder, bilateral hydronephrosis, and a 3.5 liter collection of urinary fluid within the abdominal cavity. Complications of chronic constipation, fecalomas, and rupture of the urinary bladder are reviewed.
Migrating bullets are rare sequelae of penetrating gunshot wounds. Such cases have been described in the neurosurgical literature because they can produce complications in the management of patients such as decline in neurologic status, delays in rehabilitation, and difficulties in bullet removal. In contrast, few postmortem reports have described this phenomenon. We report a case of a gunshot wound in which the projectile entered the left side of the head and traversed to the right frontal area as documented by CT scan on hospital admission. At autopsy, the bullet was noted to have migrated back to the left side of the head from where it was recovered. Medical examiners need to be aware of this unusual phenomenon of retained intracranial projectiles.
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