Pregabalin is a gamma-aminobutyric acid analogue; it has been used clinically as an anticonvulsant and analgesic agent. Few documented reports exist of deaths resulting from pregabalin overdose. This report discusses a case of pregabalin intoxication in a 27-year-old male, who was found unconscious in a prison and later pronounced dead at a local hospital. An autopsy and toxicological analysis revealed the presence of pregabalin, alprazolam, diazepam, escitalopram, fluoxetine, lorazepam, bromazepam, flunitrazepam, zolpidem, and piroxicam. The concentrations of pregabalin and alprazolam were 10.3 mg/L and 0.10 mg/L in heart blood, and 11.4 mg/L and 0.08 mg/L in femoral blood, respectively. The other detected drugs were within therapeutic concentrations. Ethyl alcohol was not detected in the blood. Although the pregabalin concentration was within the therapeutic or toxic range, the concomitant use of other drugs, particularly benzodiazepines and zolpidem, likely enhanced its toxicity. Based on the autopsy findings and toxicological results, the cause of death was determined to be multidrug intoxication, including pregabalin. Although pregabalin is generally considered safe and deaths from its use alone are very rare, it can be fatal at relatively low blood concentrations when combined with opioids or other medications. The rising use of pregabalin in Korea increases the risk of overdose deaths, similar to this case. Therefore, in forensic practice, the possibility of such fatalities should be considered when pregabalin is detected.

Positional asphyxia is a type of asphyxia where the position of an individual compromises the ability to breathe. It is commonly caused by accidents due to alcohol or drug intoxication, diseases, and/or being in a confined space. In this study, the authors reviewed autopsy cases at their institute over the past 5 years where positional asphyxia is suspected as a contributing factor or cause of death. The autopsy cases (n=24) were divided into three groups: positional asphyxia was the cause of death (n=15); unknown cause of death but positional asphyxia was considered (n=4); and positional asphyxia was suspected to be a contributing factor (n=5). All cases of group A included postures that could interfere with breathing, but the typical jackknife or head-down postures were seen in approximately half of the cases; “classic signs of asphyxia” were also observed in approximately half of the cases. They shared features such as high blood alcohol concentration, therapeutic levels of drugs, various disease, minor head trauma, and morbid obesity; however, no definite diagnostic criteria have been established for forensic practice. Positional asphyxia is a form of mechanical asphyxia which must be differentiated from traumatic asphyxia. In addition to a complete autopsy, thorough laboratory tests and understanding of the circumstances of the case and the situation at the death scene are required for diagnosis. Special attention is required for the diagnosis of special types of positional asphyxia such as death during institutional restraint or prone restraint.

The growing popularity of cosmetic procedures such as liposuction and fat grafting has been accompanied by a rise in associated side effects. Among these, fat embolism syndrome stands out as a potential complication that sometimes has critical consequences. It is important to recognize that fat embolism affects organs through distinct mechanisms from those involved with other types of embolisms. Early diagnosis is crucial. Unfortunately, no effective treatments have been established for this condition. Therefore, starting with a more detailed categorization of diagnoses, developing new treatment methods for each subtype is essential.

Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a neuroinflammatory disease mediated by autoantibodies against the NMDAR, typically presenting with psychiatric symptoms, cognitive dysfunction, and motor dysfunction. These neuropsychiatric symptoms may be mimicked by drug abuse, and the development of anti-NMDAR encephalitis may be triggered by certain substance use. Here we report a case of anti-NMDAR encephalitis who developed neuropsychiatric symptoms after illicit substance use, the first report in Korea.

Esophageal foreign body impaction may be fatal secondary to occlusion of the glottis or external compression of the membranous portion of the trachea. A 14-year-old adolescent female was admitted to the emergency department for evaluation of sudden dyspnea and cyanosis after she swallowed a food bolus (a part of bachelor radish kimchi) without chewing. Unfortunately, the patient died despite cardiopulmonary resuscitation. Autopsy findings showed an ovoid, firm foreign body (3.5×2.5×2 cm) impacted in the proximal esophagus, with focal narrowing of the tracheal lumen secondary to external compression by esophageal foreign body impaction. Death was attributed to choking caused by an esophageal foreign body.

Pickling salt, also known as curing salt, is a mixture of sodium chloride and sodium nitrite, which is used for color agent and a means to facilitate food preservation. Recently, online purchase of pure sodium nitrite has been restricted, and pickling salts have been used as replacements in cases of suicidal nitrite intoxication. From November 2020 to December 2021, there were four autopsy cases of nitrite poisoning caused by pickling salt, and 10 autopsy cases of nitrite poisoning by pure sodium nitrite. Due to the low nitrite concentration in pickling salts, serum nitrite and nitrate concentration, and methemoglobin levels were relatively low in pickling salts cases. Especially, low methemoglobin levels may cause confusion in the postmortem diagnosis of fatal nitrite intoxication, so caution is required.

Spinal dural arteriovenous fistula (SDAVF) is known for its ambiguous and various clinical presentations. Among these presentations, congestive myelopathy is one of the most common, yet it is challenging to correctly diagnose SDAVF at initial presentation. Several diseases present as myelopathy, including demyelinating diseases. Herein, we present two cases of congestive myelopathy due to SDAVF presenting to the emergency room (ER) with progressive quadriparesis. Even though the patients had a proper magnetic resonance imaging (MRI) examination from the initial presentation, there was a delay in making a final diagnosis. Both patients’ clinical presentation and MRI mimicked central nervous system (CNS) demyelinating disease initially, and a more thorough examination revealed SDAVF. Such a delay in diagnosis can result in more neurological deterioration and may result in more sequelae. Hence, SDAVF should always be considered as a differential diagnosis when examining patients with myelopathy.