External examination in cases of oral drug abuse (i.e., pills or liquid medications) is generally not rewarding unless actual medication or medication residue is observed in the mouth or on the hands. However, as noted earlier, multiple parallel scars on the wrists or neck suggest prior suicide attempts and a subsequent suicidal drug overdose. Bite marks (contusions and lacerations) of the tongue and lower lip should be specifically sought because these frequently accompany terminal convulsions which may be the result of cocaine or tricyclic antidepressant toxicity.
The prevalence of cocaine requires careful inspection of the nasal septum (preferably with a nasal speculum) to detect inflammation, necrosis, or perforation (Figure 18.104.22.168 a and b) from the chronic nasal insufflation (snorting) of cocaine hydrochloride. Also, it should be noted that crystals of cocaine may occasionally be observed in the nasal hairs or attached to the bristles of a mustache.
Stigmata of intravenous drug abuse are, naturally, the identification of fresh, recent, and old injection sites (Figure 22.214.171.124). Sometimes these may not be evident if the user makes a conscious attempt to conceal such marks by using very small gauge needles, rotating injection sites, and by injecting in areas normally concealed even by warm weather clothing. This is especially likely to occur among those in the health professions or in occupations where inspections are frequent (e.g., police, military personnel). These abusers may inject into the ankle or foot, beneath a watch band, in the axillary region or even directly through the abdominal wall and into the peritoneal cavity. If the suspicion is high, "blind" incisions into these areas as well as more likely areas (e.g., antecubital fossae) may reveal extravasated blood in the subcutaneous tissue and around a vein, which is typical for a fresh or recent injection (Figure 126.96.36.199). Mostly, however, fresh and recent injection sites appear as small subcutaneous ecchymoses surrounding a cutaneous puncture. With cocaine, the needle puncture may be surrounded by a clear halo which in turn is surrounded by an extensive ecchymosis; recent injection sites appear as poorly demarcated ecchymoses. Intravenous cocaine users may have little or no perivenous scarring even after years of intravenous injections.4
Repeated intravenous injections of narcotics generally leave characteristic hyperpigmented or hypopigmented zones of perivenous scarring commonly referred to as "tracks". These arise because narcotic addicts frequently mix heroin with oral medication containing starch or talc fillers.1 These act like myriads of microscopic splinters to elicit inflammatory (particularly granulomatous) reactions which eventually form scar tissue. This process, plus venous thrombosis, may eventually occlude the vein. Externally, these tracks appear as irregular subcutaneous "ropes" that follow the veins of the hands and forearms.
Round atrophic scars clustered predominantly on the arms and legs are frequently seen in intravenous drug abusers,4 particularly cocaine abusers. These may represent healed abscesses or healed ischemic ulcers due to the vasoconstrictive effect of cocaine (which is also directly toxic to capillary endothelium). More rarely encountered are dramatic instances of necrotizing fasciitis (Figure 188.8.131.52) whch may involve an entire extremity and be accompanied by a severe lymphedema, multiple surrounding ovoid scars, and cellulitis. In extreme cases, auto-amputation of the extremity may occur. The etiology of the fasciitis and the lymphedema is unknown.
Internally, some drugs (e.g., alcohol, ethchlorvynol) may impart a characteristic odor, and some medications contain dyes that may impart a red, green, or blue discoloration to the
Figure 184.108.40.206 "Blind" incision reveals extravasated blood in the subcutaneous tissue and around a vein. This is typical for a fresh or recent injection.
gastrointestinal tract. In situ changes typical of intravenous narcotic abuse include hepatosplenomegaly, enlargement of lymph nodes about the celiac axis and/or porta hepatis, and fecal impaction (from the pharma-cologic property of opiates that inhibits intestinal motility).
Toxicologic analysis requires specimens to be obtained for drug screening, confirmation, and quantitation as well as tissue distribution and evaluation of drug metabolites. Thus, samples for alcohol determination should be obtained from peripheral blood (e.g., femoral vein), vitreous fluid, and central blood (e.g., aorta or pulmonary trunk); brain alcohol determinations are often useful as well. Urine is ideal for qualitative drug screening. Drugs such as tricyclic an-tidepressants and propoxyphene are best evaluated by analyzing liver for concentrations of the parent drug and its major metabolites.
This is also important for drugs that give spuriously elevated levels in postmortem blood because of leaching from tissue (tricyclic antidepressants and digitalis are particularly well known to leach from tissues and cause spurious increases in postmortem blood samples). Other drugs, such as cocaine, not only readily hydrolyze in the postmortem state but may leach from tissues as well, rendering interpretation of postmortem drug concentrations in blood even more difficult. For cocaine, the brain is the best substance for toxicologic analysis. For routine toxicologic evaluation, samples from the following sites are recommended: peripheral (femoral) blood, blood from aorta and pulmonary trunk, vitreous fluid, bile, liver, brain, and gastric content. In addition, one sample of blood should be centrifuged for postmortem serum (preserved by freezing) and one preserved with sodium fluoride and refrigerated for long term storage. Injection sites, the contents of the entire small intestine, hair, and other samples should be obtained as the case dictates.
Figure 220.127.116.11 Necrotizing fasciitis.
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