Roger W. Byard

An 80-year-old man who presented with hemoptysis died from ischemic heart disease and emphysema with cor pulmonale. He had a past history of ischemic heart disease with previous myocardial infarction, chronic obstructive pulmonary disease with endobronchial valve insertion and squamous cell carcinoma of the lung with lobe resection. On the day of death he had coughed up approximately one tablespoon of blood. While causes of hemoptysis usually include entities such as bronchitis, pneumonia, bronchiectasis, tumors, adjacent aneurysms, inflammatory/infective processes or septic emboli, occasionally there may be an iatrogenic etiology. The present case demonstrates a rare cause of hemoptysis associated with medical treatment - endobronchial valve insertion with surrounding granulation tissue formation and resultant hemorrhage. Hemoptysis in decedents with COPD may, therefore, be due to treatment rather than to underlying inflammatory or neoplastic lesions.

Black oesophagus, or acute necrotising oesophagitis, is characterised by diffuse circumferential black discolouration of the distal oesophagus associated with mucosal necrosis. A consistent feature is a very sharp line of demarcation at the gastro-oesophageal junction. Two cases are reported to demonstrate differences in the lower margin. Case 1: a 63-year-old man who died of gastrointestinal haemorrhage complicating black oesophagus was noted to have an irregular lower border located approximately 5 cm from the gastro-oesophageal junction. This was associated with columnar mucosa typical of Barrett oesophagus. Case 2: a 79-year-old man who aspirated gastric contents following gastrointestinal haemorrhage due to black oesophagus had diffuse black discolouration of the oesophageal mucosa with the more usual sharply demarcated inferior margin at the gastro-oesophageal junction. Sparing of the distal oesophagus in case 1 was most likely due to the protective effect of metaplastic columnar epithelium, a finding that may, therefore, be a potential macroscopic marker for Barrett oesophagus in individuals with black oesophagus.

Thrombosis of the deep veins of the legs is a relatively common occurrence initiated by venous stasis, endothelial damage or hypercoagulable states. Prolonged sitting has also been associated with thrombotic events. A case is reported where immobility caused by drug overdose resulted in lethal pulmonary thromboembolism. Case report: A 50-year-old male was found sitting in the driver's seat of his car slumped forward. A suicide note was present. At autopsy finely granular tablet residue was found in the stomach. Deep venous thrombosis was present in both calves with bilateral pulmonary thromboembolism. Toxicological examination of blood revealed elevated levels of amitriptyline (0.92 mg/L), nortriptyline (0.41 mg/L) and oxycodone (0.17 mg/L). Death was due to pulmonary thromboembolism arising from bilateral deep venous thromboses complicating mixed drug toxicity. Prolonged immobility should be considered a possible mechanism for venous thrombosis in drug takers.

COVID-associated acute mesenteric ischaemia is a rare event that has a high mortality rate, particularly in the elderly. Despite gastrointestinal symptoms being relatively common in COVID-19 infections, however, lethal gut complications are often not considered. Two cases with fatal COVID-associated acute mesenteric ischaemia are therefore reported. Case 1: A 74-year-old woman who died following a presentation with diarrhoea and abdominal pain was found at autopsy to have extensive ischaemic changes of her small and large intestines. The superior mesenteric artery and its major branches were widely patent. Histologically acute inflammation and necrosis of the mucosa and intramucosal haemorrhage were found with fibrin thrombi in intramucosal and submucosal vessels. Respiratory viral nucleic acid testing performed on a retronasal swab obtained at autopsy was positive for COVID-19 (SARS-CoV-2). Death was due to multi-organ failure complicating mesenteric ischaemia associated with COVID-19 infection. Case 2: A 94-year-old woman with COVID-19 infection died after developing abdominal pain with melaena and bright red rectal bleeding. At autopsy there was focal transmural acute inflammation of the small intestine with multiple fibrin microthrombi. Death was also due to multi-organ failure complicating mesenteric ischaemia associated with COVID-19 infection. In the absence of obstructive vascular lesions at autopsy in cases of intestinal ischaemia, COVID-19 should be considered with appropriate swabbing and careful histological sampling of the intestine and mesentery to check for microvascular fibrin thrombi.

Both obesity and opioid abuse are increasing in numbers globally. As these entities may be associated with significant respiratory compromise, it was hypothesized that synergism may occur and that as a result of this obese individuals may be more sensitive to the effects of opiates, that is, that deaths may occur at lower blood levels. To investigate this possibility, case files at Forensic Science SA, Adelaide Australia, were reviewed for all cases that occurred between 2000 and 2019 where deaths had been attributed to heroin or morphine toxicity. There were 259 cases (66 females, 193 males; age range: 18-91; average: 41.5). The average body mass index (BMI) was 26.8 (females, 26.1; males, 27.0). The total number of obese (BMI ≥ 30 < 40) decedents was 50, and the total number of morbidly obese (BMI ≥ 40) decedents was 17. No significant association was found in the obese or morbidly obese between BMI and postmortem drug levels of <0.01, ≥0.1 < 0.3, ≥0.3, <0.4, or ≥0.4 mg/L (P = 0.30, Fisher exact test). The lack of association between fatal postmortem opiate levels and BMI suggests that the negative respiratory effects of opioids and a high BMI may in some way be compensated for by as yet unidentified metabolic/pharmacokinetic factors in obesity.