Fatalities case studies

Musshoff, F., Schmidt, P., Daltrup, T., Madea, B. (2002). Cyanide fatalities case studies of four suicides and one homicide. Am. J. Forensic Med. Pathol. 23 315-20. 

Renal Effects. Hemorrhage of the medullary layer of the kidneys was observed in an early report of three fatal cases of acute oral poisoning with endosulfan (Terziev et al. 1974). More recent studies have reported acute renal failure after ingestion of endosulfan as a major contributing cause of death in two individuals in both cases, postmortem examination showed extensive tubular necrosis (Blanco-Coronado et al. 1992 Lo et al. 1995). Neither case discussed the possible mechanism of endosulfan-induced acute renal failure, but in one case, the authors of the report indicate that the renal lesions may relate to sepsis and shock (Blanco-Coronado et al. 1992). Ingested doses were not determined in any of these cases, and it is not totally clear that the effects observed at autopsy were a direct result of endosulfan exposure, although based on results from acute animal studies, it seems likely. 

Sullivan et al. (1998) USA Nested case-control of oesophageal cancer 53 fatal cases 971 controls (study base Eisen et al., 1992 cohort) 1941-84 Cumulative exposure to the three types of metalworking fluid durafion of exposure to metalworking fluid and ofher components, inch nitrosamines. 

Death. No case studies of human fatalities have been reported following exposure to chlorobenzene by inhalation, ingestion, or dermal contact. Death has been reported in animals at high doses for brief periods of exposure. Rabbits died within 2 weeks after removal from exposure at approximately 537 ppm (Rozenbaum et al. 1947). The cause of death has been attributed to central nervous system depression resulting in respiratory failure. Animal data suggest that lethality may not be a concern for humans unless the exposure level is very high. 

Adams JH, Haller L, Boa FY et al (1986) Human African trypanosomiasis (T.b. gambiense) a study of 16 fatal cases of sleeping sickness with some observations on acute reactive arsenical encephalopathy. Neuropathol Appl Neurobiol 12 81-94... 

Based on case studies, it has been estimated that exposure to a benzene concentration of 20,000 ppm for 5-10 minutes is likely to be rapidly fatal (Flury 1928). Animal studies lend support to human data that indicate that benzene has a relatively low toxicity following acute inhalation exposures. An LC50 of 13,700 ppm has been reported for rats after a 4-hour exposure (Drew and Fouts 1974). Similarly, exposure to 16,000 ppm for 4 hours was lethal for 4 of 6 rats (Smyth et al. 1962). 

Sertindole was associated with 27 deaths (16 cardiac) in 2194 patients who were enrolled in premarketing studies further fatal cases have been collected, and the Committee on Safety of Medicines has described reports of 36 deaths (including some sudden cardiac deaths) and 13 serious but non-fatal dysrhythmias also associated with sertindole (4). 

Fineschi V, Centini F, Mazzeo E, Turillazzi E. Adam (MDMA) and Eve (MDEA) misuse an immunohisto-chemical study on three fatal cases. Forensic Sci Int 1999 104(l) 65-74. 

One of the first major compilations of statistics was produced by H. Thaler in 1964 in 23,382 biopsies, the lethality rate was 0.017% and the complication rate 0.10%. (158) In evaluating 79,381 liver biopsies, H. Lindner (1967) calculated a lethality rate of 0.015% and a morbidity rate of 0.34%. (85) In 19,563 liver biopsies, E. WiLDHiRT registered no fatal cases with a morbidity rate of 0.089%. (176) In a multicentre study carried out by F. PiccioNiNo et af, 68,276 liver biopsies were recorded during the period 1973-1983 with a lethality rate of 0.009% and a morbidity rate of 0.21%. In this study, the Vim-Silverman and Tru-cut needle types proved to have the highest risk rate (0.31% to 0.34%). (121) Severe complications were found in 0.57% of cases by J.F. Cadranel et al. (15) Among 4,124 of our own biopsies (Menghini needle), we registered no cases of death whatsoever from 1961 to 1987 the complication rate was 0.15% (s. tab. 7.7). 

Transient bacteremia was recorded in 11.4% of a series of 175 patients who had undergone barium enema examination it appeared almost at once and lasted up to 15 minutes (16). Although a second study elsewhere failed to confirm these findings, a subsequent fatal case of staphylococcal septicemia in an elderly patient with an immune deficiency suggests that the risks are not merely theoretical (17). 

In a placebo-controlled study of severely anemic patients with low-grade non-Hodgkin s lymphoma, chronic lymphocytic leukemia, or multiple myeloma, a fatal case of pulmonary embolism was thought to have been related to treatment with epoetin beta (95). Thrombotic events, such as vascular access thrombosis, venous thrombosis, and pulmonary embolism, have occurred after treatment with epoetin or darbepoetin alfa (96). It is therefore recommended that a rapid rise in the hemoglobin concentration be avoided and that care should be taken that the hemoglobin concentration does not exceed 12.1 g/dl (7.5 mmol/1) (97). 

Skin reactions to mefloquine have been reviewed, in relation to 74 case reports published between 1983 and 1997 (39). Pruritus and maculopapular rash were the most common skin reactions in some studies, their approximate frequency was 4—10% for pruritus and up to 30% for non-specific maculopapular rashes. Adverse effects less commonly associated with mefloquine included urticaria, facial lesions, and cutaneous vasculitis. There was one case of Stevens-Johnson syndrome and one fatal case of toxic epidermal necrolysis. 

Pancytopenia is a rare but potentially fatal complication, and numerous reports have been published. The characteristics and incidence of pancytopenia have been carefully re-evaluated from case reports and clinical trials published from 1980 to 1995 (38). Of 70 reported cases, 12 patients died (17%). Impaired renal function was the most important contributing factor (54%), particularly in fatal cases (10/12). Other important susceptibility factors included advanced age (over 65 years), hypoalbuminemia, concurrent infection, and/or concomitant multiple medications (particularly co-trimoxazole). The mean cumulative dosage was 675 (10-4800) mg, and the minimal cumulative methotrexate dose leading to fatal pancytopenia was 10 mg. This confirms that pancytopenia can occur at any time during treatment, even in the absence of known susceptibility factors. Bone marrow biopsy showed megaloblastosis and hypocellularity. Eosinophilia and increased mean corpuscular volume were rarely observed. In an overall review of five long-term prospective studies (511 patients), the calculated incidence of methotrexate-induced pancytopenia was 1.4%. Although severe myelo-suppression sometimes required folinic acid, there are as yet no data to determine whether prophylactic folate supplementation can reduce the incidence of pancytopenia. 

---