Autopsy Report of Jim McDougal

Office of Chief Medical Examiner Tarrant County Medical Examiner's District Tarrant County, Texas 200 Feliks Gwozdz Place, Fort Worth, Texas 76104-4919 (817) 923-4999 FAX (817) 927-0902

AUTOPSY REPORT NAME: JAMES MCDOUGAL

Case No: 981110T Approximate Age: 57 years Height: 70 inches Weight: 210.8 pounds Sex: Male

We hereby certify that on the ninth day of March 1998, pursuant to Statute 49.25 of Texas Criminal Code, an autopsy on the body of James McDougal was performed at the Tarrant County Medical Examiner's Office in Fort Worth, Texas and upon investigation of the essential facts concerning the circumstances of the death and history of the case, we are of the opinion that the cause of death was as follows:

FINDINGS: I. Sudden death associated with: 1. Severe hypertensive atherosclerotic cardiovascular disease with: a. Cardiomegaly (weight = 546 gms) b. Concentric left ventricular hypertrophy, moderate

(LV thickness = 1.9 cm) c. Multi-focal occlusive coronary atherosclerosis, moderate, with 50-60% stenosis d. Moderate narrowing of intramural stenosis of coronary artery branches (small vessel disease) e. Absence cardiac conductive system lesions f. Arteriolonephrosclerosis, bilateral, mild g. Generalized atherosclerosis, moderate-severe h. Scars of carotid endarterectomy, bilateral i. Status-post aorto-femoral bypass graft (remote) j. 2. Elevated blood levels (above therapeutic levels) of fluoxetine (Prozac) (See comment)

II. Chronic obstructive pulmonary disease with: 1. Centrilobular pulmonary emphysema, bilateral, mild 2. Bronchiectasis, bilateral, mild-to-moderate 3. Pulmonary anthracosis, moderate

Ill. Hepatomegaly (weight = 1695 gms) with mild fatty metamorphosis IV. Prostatic hyperplasia, mild VI. No evidence of dehydration or electrolyte imbalance: 1. Postmortem vitreous chemistry non-contributory 2. Blood furosemide (Lasix) negative

VII. Postmortem toxicology: 1. Cardiac blood fluoxetine = 2.72 ug/mL 2. Femoral vein blood fluoxetine = 0.778 ug/mL 3. Gastric fluoxetine = 4.2 ug/mL 4. Liver fluoxetine = 61.4 ug/mL

VIII. Postmortem blood 20 heavy metal screen negative

IX. Postmortem blood mercury negative (below detection level)

COMMENT: Mr. James McDougal was 57 years of age at the time of his death. He was an inmate at the Federal Medical Facility in Fort Worth, where he was apparently discovered unresponsive, in his segregated cell. The exact downtime is unknown but could be as much as 20 minutes or more before he was discovered unresponsive. At the Federal Medical Facility, immediate advanced cardiac life support protocols were instituted. The MedStar ambulance arrived at 11:08 a.m. and he was transported to John Peter Smith Hospital in Fort Worth, where he pronounced [sic] dead at 12:01 p.m. Records obtained from Federal Medical Facility in Fort Worth indicate that Mr. Dougal [sic] had clinical history of hypertension, hyperlipidemia as well as severe peripheral vascular disease for which he had undergone both carotid endarterectomy 98111 OT James McDougal Page 3 of 13 as well as femoral-popliteal bypass grafts. In addition, he was (+) PPD (Tuberculous skin test) for which he had received a course of INH ending on December 27, 1998. Autopsy confirmed clinical history of both hypertension as well as severe peripheral vascular disease. Most significant findings at autopsy included an enlarged heart with left ventricular hypertrophy and dilatation, and occlusive coronary atherosclerosis. Postmortem toxicology was positive for fluoxetine (Prozac) and its metabollite norfluoxetine. Fluoxetine is a selective serotonin uptake- inhibitor antidepressant. Because it is highly selective, fluoxetine has fewer side-effects than the older tricyclic antidepressants including dry mouth, blurred vision, memory impairment, constipation, urinary retention and sinus tachycardia, all which are primarily due to anticholinergic effects. Fluoxetine is well absorbed after oral administration and is not affected by food. In the body, fluoxetine is metabolized to norfluoxetine. Both the parent compound (fluoxetine) and the metabolite (norfluoxetine) are active compounds. The half-life of fluoxetine is 1 to 3 days after acute administration and with chronic usage, the half-life of the drug is elevated to 4 to 16 days. Fluoxetine is available in capsules containing 20 mg for oral administration and the recommended initial dose is 20 mg/day which may be augmented to 100 mg/day. The steady state serum concentration ranges from 0.025 ug/mL to 0.473 ug/mL (mean = 0.109 ug/mL)

Mr. McDougal was prescribed 60 mg of fluoxetine/day. His postmortem cardiac blood concentration was 2.72 ug/mL, while femoral blood concentration was 0.778 ug/mL. Fluoxetine is a weakly basic drug with a high apparent volume of distribution (26 L/Kg body weight). In such a setting, the femoral vein drug concentration is more reflective of the antemortem drug concentration. The known lethal range for combined fluoxetine and norfluoxetine has been reported to be 1.93 to 4.57 ug/mL. The values reflected in Mr. McDougal's femoral blood indicate that the combined amount of fluoxetine and norfluoxetine were in the toxic range but not lethal range. In addition to the above studies, a comprehensive heavy metal screen as well as screen for mercury poisoning were carried out, all of which were reported negative. Postmortem vitreous chemistry did not indicate electrolyte imbalance and postmortem blood furosemide was negative. In conclusion, Mr. James McDougal's death is attributed primarily to hypertensive atherosclerotic cardiovascular disease. Many clinical and pathological studies have indicated that hearts over 550 gms in total weight with left ventricular enlargement are associated with significant incidence of sudden death irrespective of the presence or absence of coronary atherosclerosis. Mr. McDougal did not only have an enlarged heart but also significant occlusive coronary artery disease especially small vessel disease. Finally, although the amount of fluoxetine was in the toxic range, it did not directly contribute to his death. The manner of death is therefore ruled as natural. CAUSE OF DEATH: SUDDEN CARDIAC DEATH DUE TO HYPERTENSIVE ATHEROSCLEROTIC CARDIOVASCULAR DISEASE MANNER OF DEATH: NATURAL Signature Marc A. Krouse, M.D. Signature Nizam Peerwani, M.D. A CERTIFIED COPY ATTEST JUNE 22, 1998 NIZAM PEERWANI, M.D. CHIEF MEDICAL EXAMINER TARRANT COUNTY, TEXAS BY [signature] NOVELLA YOUNG 981110T James McDougal Page 5 of 13 GROSS ANATOMICAL DESCRIPTION Photo 1: Identification I. CLOTHING AND PERSONAL EFFECTS: The body is presented to the Morgue secured in a body bag and clad in: 1. White T-shirt 2. Red coveralls (cut) 3. Pair of white socks

II.THERAPEUTIC INTERVENTION: 1. Oral Endotracheal tube

2. Left nasogastric tube

98111OT James McDougal Page 6 of 13 3. IV lines localized to left external jugular vein, dorsal right hand and lower left forearm 4. Venipunctures over the right antecubital fossa, radial right wrist and left antecubital fossa are present as well as single puncture site is found in the right femoral triangle 5. Cardiac thumper marks on the anterior chest 6. Eight (8) electrocardiographic monitor pads on the torso

Ill. EXTERNAL BODY DESCRIPTION: The body is that of a normally developed, well-nourished and well-hydrated, minimally obese adult Caucasian male appearing somewhat older than the given age of 57 years, with a body length is 70 inches and body weight is 210.8 pounds (178 cm, 95.7 kg). The body is well-preserved, unembalmed and cool post refrigeration. Rigor is fully developed. Lividity is developed, posterior, dependent, purple and slightly blanchable. The scalp is covered by short, straight gray and occasional brown hair with frontal, sagittal and slight occipital pattern baldness. The face is shaven. Body hair is male distribution and average. The calvarium is symmetric and intact to palpation and the scalp is intact. The eyes are closed, the corneae are clear and the conjunctivae are slightly congested. There are no bulbar or palpebral conjunctival petechia present The irides are hazel and the pupils are 10 mm and equal. Orbital soft tissues are unremarkable without ecchymosis or edema and the orbits are intact. The nasal cavity is unremarkable with intact septum. Oral cavity is likewise unremarkable without obstructions. The lips and oral mucosa are cyanotic and the jaws are edentulous. There are focal contusions of the upper lip described below. The external auditory canals are clear and there are 2 cm creases in each earlobe. The bony structures of the face, neck, larynx and hyoid are symmetric and intact. The trachea and larynx are midline and mobile. Pale healed scars are found over the right and left anterior sternocleidomastoid borders over the carotid arteries suggestive of previous carotid endarterectomy, the left measuring 4 inches and right 5 inches. The anterior chest is symmetric without barrel configuration. There is mild pectus excavatum and the inferior costal margins are slightly flared. The breasts are male. The abdomen is somewhat protuberant and the pelvis is intact. There is a livid 10 inch midline scar extending from above the umbilicus to the infraumbilical midline and there is a pale healed 2 x 5/8 inch right lower quadrant scar. The penis is circumcised and the testes are descended; there are no palpable testicular masses 98111 OT James McDougal Page 7 of 13

or notable atrophy. The perineum and anal orifice are unremarkable except for a large external hemorrhoidal tag. The back is symmetric and intact. Extremities are symmetric, normally developed and intact. The nailbeds of the hands are cyanotic and slightly clubbed, and those of the feet are pale and clubbed. There is a contusion on the left hand and an abrasion on the right forearm.

IV. INJURIES: Cutaneous injuries are sparse and consists of: 1. A vertical contusion of the upper lip right of midline measuring 1/4 x 1/8 inch with a nearby horizontal 1/8 x 1/16 inch contusion lying under the Endotracheal tube guide. 2. A 3/8 by 1/4 inch rectangular contusion is found on the dorsum of the left hand (overlying skin intact). 3. superficial abrasions on the dorsal right forearm near the elbow ranging from 1/16 inch diameter up to 1/4 x 1/8 inch (no evidence of surrounding cutaneous reaction). In addition, there is a resuscitative fracture of the right fifth costal cartilage without surrounding hemorrhage.

IV. INTERNAL EXAMINATION 1. INTEGUMENT: A Y-shaped thoraco-abdominal incision is made and the organs are examined in situ and eviscerated in the usual fashion. The subcutaneous fat is normally distributed, moist and bright yellow. The musculature of the chest and abdominal area is of normal color and texture. 2. SEROUS CAVITIES: The chest wall is intact without rib, sternal or clavicular fractures except for the resuscitative right fifth costal cartilage as noted above. The pleura and peritoneum are congested, smooth glistening and essentially dry, devoid of adhesions or effusion. There is no scoliosis, kyphosis or lordosis present. The left and right diaphragms are in their normal location and appear grossly unremarkable. Pericardial sac is intact smooth glistening and contains normal amounts of serous fluid. 3. CARDIOVASCULAR SYSTEM: The thoracic and abdominal aorta and major branches are intact. There is moderately severe atheromatous disease of the aorta with multiple ulcerated plaques in the abdominal aorta and accompanying greater than 90 to 95% occlusion of the proximal left femoral artery, and greater than 95% occlusion of the right common carotid artery beginning at a point 2 cm distal to its origin. Remaining major arteries are involved by atheromatous occlusions of less than 20 to 25% except for a focal 50% occlusion of the right femoral artery. An aortofemoral bypass graft is in place and is intact and patent. The superior and inferior vena cava and major branches are intact as are the major pulmonary arteries and veins. The major vessels and heart are engorged with fluid and clofted blood. The heart is moderately enlarged and weighs 546 grams presenting concentric left ventricular hypertrophy with dilatation. The left ventricular wall measures 1.9 cms in thickness and the right 0.5 cms. There is mild sclerosis of all cardiac valves except the pulmonic and there is minimal redundancy of the mitral and tricuspid valve leaflet margins. The cardiac valves are otherwise unremarkable. Coronary ostia are in their normal anatomic locations and posterior circulation is right dominant and diminutive (distal half of right coronary artery approximates 2.5 mm outside diameter). Atheromatous deposits and circumferential sclerosis produce less than 25% occlusion of the left main, circumflex and right coronary arteries and 30 to 40% occlusion of the proximal left anterior descending

coronary. The myocardium is congested and the chambers of the heart are dilated as noted above. Small scars in the posterior left ventricular free wall near the septum range from 2 to 5 mm diameter. There are no acute ischemic cardiac lesions identified. The endocardium is smooth and the epicardium presents slightly increased fat. 4. PULMONARY SYSTEM: The neck presents an intact hyoid bone as well as thyroid and cricoid cartilages. Larynx is comprised of unremarkable vocal cords and folds, appearing widely patent without foreign material, and is lined by smooth, glistening membrane. Epiglottis is a characteristic plate-like structure without edema, trauma or pathological lesions. Both the musculature and the vasculature of the anterior neck are unremarkable. Trachea and spine are in the midline presenting no traumatic injuries or pathological lesions except for scattered tracheal mucosal petechiae above the level of the Endotracheal balloon. The lungs are slightly hyper inflated. The right lung weighs 788 grams and the left 594 grams. Both the lungs appear congested and there is atelectasis and patchy edema of posterior lung fields. Peripheral bronchi contain small amounts of mucoid debris. There is anthracotic pigmentation of the lungs, mild to moderate bronchiectasia and mild emphysema visible in aerated portions of the lung, especially the apices of the upper lobes. There are no mass lesions and there is no gross evidence of pneumonitis or pulmonary embolization. 5. GASTROINTESTINAL SYSTEM: The pharynx and esophagus are intact with unremarkable gastro-esophageal junction. The stomach is intact and there are multiple mucosal petechiae. Some 10 grams of blood tinged mucoid debris are found in the stomach. There are no particles noted. The loops of small and large bowel are unremarkable with intact and unremarkable mesentery. Appendix is absent. The liver is slightly enlarged and weighs 1695 gms and the inferior hepatic borders are slightly blunted. There is irregular hepatic parenchymal congestion and the parenchyma is slightly yellow-tan and oily due to mild fatty metamorphosis. The gallbladder and extrahepatic biliary tree are intact and the gallbladder contains 35 ml of slightly mucoid bile. Cholecystitis or lithiases are not identified. The structures of the hepatic hilus are intact. The pancreas weighs 177 grams. The parenchyma is slightly autolyzed, tan and there is patchy fatty infiltration. The major ducts are patent. 6. GENITOURINARY SYSTEM: The renal cortical surfaces are finely granular and the capsules strip easily. The right kidney weighs 179 grams and the left 196 grams. There are small cortical cysts up to 3 mm diameter in each kidney. The cortices and medullae are congested. The renal columns of Bertin extend between the well demarcated pyramids and appear unremarkable. The medulla presents normal renal pyramids with unremarkable papillae. The pelvis is of normal size and lined by gray glistening mucosa. There are no calculi. Renal arteries and veins are normal. The ureters are of normal caliber lying in their course within the retro peritoneum and draining into an unremarkable urinary bladder containing 150 mL of clear urine. External genitalia present an unremarkable penis without hypospadia, epispadias or phimosis. There are no infectious lesions or tumors noted. The descended testicles are of normal size encased within an intact and unremarkable scrotal sac and on palpation abnormal masses or hernias are not present. The prostate is slightly enlarged due to mild benign prostatic hyperplasia. 7. HEMATOPOIETIC SYSTEM: Thoracic lymph nodes are anthracotic. Hepatic hilar nodes are slightly enlarged and fleshy as are pulmonary hilar nodes. The thymus is involuted. The spleen is intact, weighs 260 grams and is congested and slightly autolyzed. Bone marrow is red and firm. 98111OT James McDougal Page 10 of 13 8. ENDOCRINE SYSTEM: Thyroid gland is of normal size and shape presenting two well-defined lobes with connecting isthmus and a beefy brown cut-surface. There are no goitrous changes or adenomas present. Two grossly identified parathyroids are present. Adrenal glands are of normal size and shape and sectioning present no gross pathological lesions. Pituitary gland is encased within and [sic] intact sella turcica and presents no gross pathological lesions.

9. CENTRAL NERVOUS SYSTEM: A scalp incision, craniotomy and evacuation of the brain is carried out in the usual fashion. Scalp is intact without contusions or lacerations and presents rare subgaleal petechia. Calvarium is likewise intact without bony abnormalities or fractures. The cerebrospinal fluid is clear and the leptomeninges are congested. The arteries of the base of the brain and dural sinuses are intact. There is mild atheromatous disease in arteries over the base of the brain with maximal occlusions of less than 25% in the basilar and internal carotid arteries. The brain weighs 1493 grams. There is mild supratentorial and cerebellar swelling without evidence of herniation. The gray and white matter of the brain are congested and grossly unremarkable. The ventricular and aqueductal systems are patent and contain clear cerebrospinal fluid. The upper cervical spinal cord is unremarkable.

SPECIMENS AND EVIDENCE COLLECTED 1. Heart blood 60 mL, femoral blood 30 mL urine 30 mL, vitreous humor 5 mL bile 30 mL and frozen brain, lung, liver and kidney for toxicology and postmortem chemistry. 2. Samples of the viscera in fixative with sections for microscopic examination. 3. Eight photographs (six frames on roll #039807 and two frames on roll #039808). 4. Blood in a red top tube and a cloth swatch blood sample are reserved along with fingerprints and palmprints.

MICROSCOPIC DESCRIPTION: HEART: Representative cross sections of the left anterior descending coronary artery are notable for an atheromatous plaque producing approximately 50 to 60% cross sectional occlusion. The plaque is partially calcified and there are scattered mononuclear inflammatory cells throughout the plaque and surrounding the artery. Additional sections are remarkable for circumferential sclerosis with subendothelial fibromuscular deposits producing occlusions from 25 to 30 to 40%. There is no evidence of thrombosis or any acute process within the plaque. Representative sections of the anterior free walls of the right and left ventricles, mid intraventricular septum and upper intraventricular septum to include conduction system are examined. There is orderly mild hypertrophy of the left ventricle with delicate interstitial and perivascular fibrosis. Lesser still notable mild hypertrophy is also found in the right ventricle. Scattered subendocardial myocytes are notable for contraction band necrosis. There is no evidence of geographic necrosis or other evidence of acute ischemia. There is no evidence of inflammation or other notable pathology. LUNG: Representative sections of each pulmonary lobe are examined. There is variable centriacinar emphysema with associated, also variable, interstitial fibrosis and patchy mononuclear inflammatory infiltration. Accompanying the emphysematous change and interstitial fibrosis, there is also variable fibromuscular sclerosis of medium sized and small pulmonary arteries. Small airways are generally unremarkable and larger airways are remarkable for increased mass of submucosal smooth muscle, thickening of the basement membrane and patchy mononuclear infiltration. There is no additional notable pathology. STOMACH: Representative section of the gastric wall is notable only for mononuclear infiltration of the mucosa. The superficial mucosa is poorly preserved.

LIVER: The lobular architecture of the liver is intact. Portal triads are generally expanded by moderate to large numbers (ranging from 50 to more than 250) mononuclear cells. In several triads the inflammatory cells are facing the limiting plate. There is no evidence of hepatocellular necrosis associated with this infiltration. There is also early bridging fibrosis with associated mononuclear inflammation. Occasional areas of hepatocyte entrapment are found in the inflammation and fibrosis, again without evidence of hepatocellular necrosis. There is mild large droplet metamorphosis of hepatocytes in a rather random distribution. Mild pigment is prominent in periportal hepatocytes primarily. PANCREAS: Section of pancreas is notable primarily for postmortem autolysis. In better preserved portions of the gland there is delicate interstitial fibrosis and fatty infiltration with no additional pathology. Islets in these portions of the gland are unremarkable. KIDNEYS: Representative sections of each kidney are examined. The better preserved cortical tubules are unremarkable and deeper portions (from the capsule) are less well preserved. There is a mild increase of mesangial matrix in the glomeruli with variable increase of mesangial cellularity (generally mild). There is no evidence of active glomerular disease. There is patchy interstitial fibrosis and there are also patchy interstitial mononuclear infiltrates. Medium sized and slightly smaller arteries in the renal cortex are notable for subendothelial fibromuscular sclerosis. BLADDER AND PROSTATE: A section of urinary bladder is remarkable only for patchy mononuclear infiltration of the remaining submucosa. The mucosa is lost by postmortem autolysis. A section of prostate is remarkable only for perivascular mononuclear infiltration. There is no evidence of malignancy. SPLEEN: Representative section of spleen is unremarkable. PITUITARY: Section of pituitary is unremarkable. THYROID: Section of thyroid is histologically unremarkable. ADRENALS: Representative sections of each adrenal gland are notable only for postmortem autolysis. BRAIN: Representative sections of cerebral cortex from frontal, parietal and occipital lobes, mesencephalon, pons, cerebellum and medulla are examined. Neurons are uniformly well preserved in all sections. There is vascular congestion and notable edema is found only in the section of medulla. Small vessels in the arachnoid mater are involved by fibromuscular sclerosis consistent with hypertensive vascular disease. In the section of occipital cortex there is localized perivascular mononuclear inflammatory accumulation in at least one vessel and there are accumulations of hematoid and laden macrophages in perivascular spaces of the frontal lobe section. There is no evidence of active neuropathology.

T0XIC0L0GY TESTRESULTS

OFFICE OF CHIEF MEDICAL EXAMINER TOXICOLOGY LABORATORY SERVICE 200 FELIKS GWOZDZ PLACE FORT WORTH, TEXAS 76104

NIZAM PEERWANI, M.D., DABFP CHIEF MEDICAL EXAMINER

ANGELA SPRINGFIELD, PH.D., DABFT CHIEF TOXICOLOGIST

NAME: JAMES MCDOUGAL M.E. CASE NUMBER: 981110T

PRIORITY: 1 M.E. TOX NUMBER: 980204T-00

BLOOD ETHANOL URINE ETHANOL

NEG NEG NEG

URINE CANNABINOIDS ADX URINE COCAINE URINE OPIATES BLOOD CYANIDE URINE CYANIDE GASTRIC CYANIDE BLOOD ABN (HEART) BLOOD ABN (FEMORAL) URINE ABN GASTRIC ABN LIVER FLUOXETINE BLOOD ABN (HEART) BLOOD ABN (FEMORAL) URINE ABN GASTRIC ABN POS POS POS POS ADX ADX

NEG NEG NEG

NEG NEG POS POS FLUOXETINE FLUOXETINE 2.720 UG/ML 0.778 UG/ML

FLUOXETINE FLUOXETINE FLUOXETINE

0.770 UG/ML 4.200 UG/ML 61.410 UG/ML 1.960 UG/ML 0.617 UG/ML

POS POS

NORFLUOXETINE NORFLUOXETINE

POS

NORFLUOXETINE NORFLUOXETINE POS

2.280 UG/ML 1.070 UG/ML 49.810 UG/ML

LIVER NORFLUOXETINE

NORFLUOXETINE

CURTIS W. CLARY

[Autopsy report obtained and converted to text by Wesley Phelan]

Published in the Jun. 29, 1998 issue of The Washington Weekly. Copyright 1998 The Washington Weekly (http://www.federal.com). Reposting permitted with this message intact.