Biomedical subjects
Publications and source records attributed to C V Wetli.
Two cases of aortoesophageal fistula are presented. The etiology, symptoms, and diagnosis of aortoesophageal fistula are reviewed. Signs and symptoms of gastrointestinal hemorrhage followed by sudden collapse hours to days later should prompt consideration of an aortoesophageal fistula. Accidental ingestion of foreign bodies, particularly by children, is a frequent etiology.
Conjunctival petechiae were mentioned in 227 (4.5%) of 5,000 consecutive autopsy reports of the Dade County Medical Examiner Department. They were most frequently observed in those who had died natural deaths (particularly due to cardiovascular disease), followed by those who had died from asphyxia, head injury, and central nervous system disorders. The incidence of conjunctival petechiae in victims of homicidal asphyxiation was 78%. These data suggest that conjunctival petechiae most often are the result of hypoxia coupled with an acute increase in cephalic vascular pressure. The latter factor may be the consequence of mechanical vascular obstruction or acute right heart failure.
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The cardiovascular effects of cocaine may culminate in clinical episodes of angina pectoris, myocardial infarction, arrhythmias, and intracranial hemorrhage. To clarify whether or not cocaine causes fatalities by these mechanisms, we studied 24 cases of sudden, apparently natural deaths as a result of coronary arteriosclerosis (15 cases), hypertensive cardiovascular disease (4 cases), and intracranial hemorrhage (5 cases) associated with cocaine use. In 11 cases, cocaine was found in the blood (average concentration: 0.57 mg/L, range: 0.05 to 1.45 mg/L), whereas in the remainder, cocaine or its major metabolite was found in the urine or other tissues. In the majority of decedents, autopsy disclosed the existence of severe natural disease which could have been exacerbated by the administration of stimulant drugs, including cocaine. These data, and a review of the current medical literature, indicate that cocaine may precipitate the sudden death of an individual with undiagnosed cardiovascular disease. A contributory role of cocaine should be considered in any apparently natural death occurring in a population where cocaine abuse is prevalent.
A retrospective analysis of the plain abdominal films of 53 "body packer" drug smugglers was performed to ascertain the importance of radiographic studies in the diagnosis and management of these patients. Eighty-nine percent had studies diagnostic for foreign body ingestion. Multiple, well-defined, homogeneous oval or oblong densities, especially if surrounded by a crescent of air (double-condom sign), are key findings. If these densities were found in the proximal ascending colon or upper gastrointestinal tract, the diagnosis was almost assured. Six percent of patients exhibited complications suggested on serial radiographs, proving the necessity for follow-up studies until complete expulsion or removal of the foreign body. Radiologic evaluation is essential in the diagnosis and management of the cocaine smuggler.
Two intravenous amphetamine abusers had fatal, rapidly progressive cerebral mucormycosis with abscess formation in the presence of absolute lymphopenia. Postmortem examination confirmed the primary nature of the fungal cerebritis, documented by postmortem culture and histology. The clinical and pathologic features of these cases are compared to previously reported occurrences of primary fungal cerebritis (and abscess) among intravenous drug abusers, including cocaine users. Primary fungal cerebritis associated with intravenous abuse of stimulant drugs is discussed as a possible variant of the acquired immunodeficiency syndrome.
Fatal cocaine intoxication presenting as an excited delirium is described in seven recreational cocaine users. Symptoms began with the acute onset of an intense paranoia, followed by bizarre and violent behavior necessitating forcible restraint. The symptoms were frequently accompanied by unexpected strength and hyperthermia. Fatal respiratory collapse occurred suddenly and without warning, generally within a few minutes to an hour after the victim was restrained. Five of the seven died while in police custody. Blood concentration of cocaine averaged 0.6 mg/L, about ten times lower than that seen in fatal cocaine overdoses. Police, rescue personnel, and emergency room physicians should be aware that excited delirium may be the result of a potentially fatal cocaine intoxication; its appearance should prompt immediate transport of the victim to a medical facility. Continuous monitoring, administration of appropriate cocaine antagonists, and respiratory support will hopefully avert a fatal outcome.
The epidemiologic, pathological, and toxicological findings of 60 cocaine-related overdose deaths from middle 1978 through 1982 were studied and compared with a previous publication by this office. In addition, 180 deaths where cocaine was an incidental toxicological finding are also discussed. Currently, the average street cocaine fatality victim is 29 years old, and 42% of the victims are female. Blacks comprise 39% of the cases. The blood cocaine concentration in "street cocaine" fatality victims averaged 6.2 mg/L with a wide range, necessitating careful interpretation of the toxicological results in conjunction with terminal events. Although autopsy findings were generally nonspecific, multiple needle-puncture marks with surrounding ecchymoses are typical of IV cocaine abuse. An increase in cocaine-related overdose deaths is anticipated because of its popularity, increasing availability, and, currently, the increased purity of street cocaine.
Drug-related deaths encompass fatal overdoses, the medical derangements from chronic consumption, and violent death from the alteration of normal behavioral patterns. Determining the extent to which a drug contributed to a death necessitates correlation of all aspects of the death investigation; autopsy and toxicologic findings must be interpreted in the light of antecedent events, medical and social history, and thorough scene investigation. The approach to the medicolegal investigation of drug-related deaths is discussed along with some legal ramifications and certain potential problems of death certification.
Three intravenous drug abusers (predominantly cocaine) developed a fulminant fungal cerebritis without any other identifiable predisposing factor. Two died and one survived with a severe neurologic deficit. Zygomycetes (nonseptated fungi) were identified in the brain tissue of two victims and Acremonium alabamensis was cultured from the brain tissue of the third. Fulminant fungal cerebritis in intravenous drug abusers (in the absence of any predisposing illness) may represent a unique variant of the acquired immunodeficiency syndrome (AIDS). Future surviving patients should be evaluated for the possibility of a cellular immune deficiency state in order to confirm this impression.
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A case of maternal death due to Listeria monocytogenes bacteremia, with survival of the prematurely delivered infant, is presented. Lymphopenia and a Haitian origin suggest that the fatal outcome was related to the acquired immunodeficiency syndrome (AIDS). To our knowledge, this is the first recorded instance of a maternal death due to listeriosis.
Of 246 methaqualone-related deaths identified during an 11-year period (1971 through 1981), 76% have occurred since 1977 and 72% have involved fatal trauma. One third of the victims died in vehicular crashes. Sharp increases in methaqualone-related traumatic suicides, nonvehicular accidents, and homicides have occurred since 1978. This report discusses demographic and toxicological findings, particularly in regard to counterfeit methaqualone. The pattern of fatal methaqualone abuse has changed from an overdose phenomenon in the early 1970s to one of traumatic death. Victims frequently have exhibited poor judgment, impulsive behavior, and somnolence while attempting to function in their environment. The socioeconomic impact of recreational methaqualone abuse should be curtailed by appropraite governmental action and restraint in the prescribing of methaqualone.
The case files of 41 female victims of proven fatal sexual assault were reviewed. They averaged 42 years of age, but a bimodal age distribution was evident. Younger victims (averaging 31 years of age) were most often found in canals, fields, or vacant lots, whereas older women (averaging 51 years of age) were found most often in their residences. Death usually resulted from mechanical asphyxiation, and the use of firearms was infrequent. Various instruments used to harm, restrain, or kill the victim were most often obtained at the scene of death and reflected the emotionality and impulsivity of the incident. Alcohol was found in the blood of 40% of the victims and averaged 0.14%. Ligature bindings, torn clothing, varying degrees of disrobing, and bite marks were not infrequent. The average yearly incidence of fatal sexual assaults on females is calculated to be 0.14/100 000 population in Dade County, FL and has not changed appreciably since 1959. Thus, death resulting from sexual assault was found to be distinctly unusual. Black victims were represented more frequently than their racial distribution in this community. The scene and autopsy findings of the average female sexual assault victim form a characteristic profile that should direct further investigation on a particular case.
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Demographic features and predisposing factors to fatal food asphyxiation (cafe coronary) were determined by analyzing 141 such fatalities over a 20-year period. Old age, poor dentition, and alcohol consumption were expected findings. Other predisposing factors included institutionalization in long-term medical care facilities, sedative drugs, and natural diseases, most notably parkinsonism. Since institutionalized patients tended to asphyxiate on soft, friable, or snack-like foods, future improvements in rescue techniques should take this into consideration. The incidence of 0.66 per 100,000 population has remained unchanged over the two decades studied. Observers were present at the time of the fatal incident in 85% of the cases. In only a third, the food was lodged ion a supraglottic location. These data indicate that continued efforts toward greater awareness of the cafe coronary syndrome still are needed. Special attention should be directed to the predisposing role of institutionalization, sedative drugs, and natural diseases.