COBB COUNTY 150 North Marietta Parkway OFFICE OF THE MEDICAL EXAMINER (710) ssizaie Fox (77) 528-2207 Christopher Gulledge, M:D., M.S. Cassie Boggs, M.D. Abraham Philip, M.D. Chief Medical Examiner Deputy Chief Medical Examiner Medical Examiner Decedent: Kevil Wingo Case Number: 19C-1177 County: Cobb Pronouncement date: 09/29/2019 Date of Birth: 12/18/1982 (36) Sex: Male Race: Black Procedure: Complete Autopsy Date: 09/30/2019 Time: 0930 hours Pathologist: Abraham T. Philip, M.D. Investigator: Autumn Quinn ‘A complete autopsy was performed on the above-named decedent as pursuant to the Georgia Death nvestigationAct Pathological Diagnoses: 1, Perforated gastric ulcer with secondary peritonitis a. Large ulcer on anterior surface of the stomach near pylorus b. 1300 ml of purulent looking yellow fluid within the abdominal cavity €. Up to 400 ml of similar fluid within the scrotal sac 4. Past medical history significant for peptic ulcer disease 2. Medical history also significant for myalgia 3. History of cocaine and heroin abuse a. Reportedly was undergoing detoxification protocol while incarcerated ‘ology positive for hydroxyzine, methocarbamol, phenytoin and promethazine a, These compounds were medications prescribed to the decedent b. The concentrations of these compounds are not within the ranges reported in fatal cases; Baselt RC: Disposition of Toxic drugs and chemicals in man; (11" Edition) ¢. Toxicology tests negative for alcohol and the commonly abused illicit drugs and medications CAUSE OF DEATH: Complications of perforated gastric ulcer with peritonitis MANNER OF DEATH: Natural ‘The fats stated herein are correct tothe best of my knowledge and belief ‘Abraham Philip, M.D. Medical ExaminerEXTERNAL EXAMINATION: Received per protocol is the body of a man whose appearance is consistent with the stated age of 36 years. Length: 74 inches Weight: 172 pounds Body Condition: Intact Rigor mortis: 3+ Livor mortis: Could not be evaluated ‘Temperature: Refrigerated Hair: Short, dark and curly Facial Hair: Mustache and beard, more prominent at the chin Teeth: Natural- upper and lower Cornea: Clear Irides: Brown Conjunctivae: Injected The body is received without clothes. There is no personal property received with the body. Identifying characteristics include multiple tattoos and scars as indicated on the attached body diagram. Medications are not received with the body. The medical and therapeutic devices affixed to the body include: Endotracheal tube with Velero straps ‘Automated electrical defibrillator electro pads Electrocardiogram electrode pads Intravascular lines established in both antecubital regions Pulse oximeter affixed to the left index finger Incised wounds, extending into the chest cavity, for insertion of intercostal intra thoracic chest drain tubes, bilateral ay aene The head is normally formed. There is small amount of white material adherent to the nostrils. There are no fluids accumulated within the ears, nose, or mouth. The eyes, ears, nose, mouth, and lips ate unremarkable, The chest is with normal contours. The abdomen appears mildly distended, There is a dark discoloration to the skin of the anterior abdominal wall extending from a horizontal level at the umbilicus to the pelvic brim. ‘The scrotum is distended. There is no trauma to the external genitalia, ‘The posterior torso is unremarkable, The anus is without lesion. ‘The upper extremities are symmetrical. There are well healed needle track marks on the anterior aspect of the right forearm, ‘There is a partial amputation with a well healed sear on the little finger of the left hand. The hands are otherwise remarkable. The lower extremities are symmetrical and appropriately hair bearing. The feet are clean, and the tocnails are intact. Aqh a\iolure Page |2 19C-1177EVIDENCE OF TRAUMA: ‘There are no recent physical injuries to the body. INTERNAL EXAMINATION: Body cavities: ‘The scalp is reflected by the usual ear-to-ear incision over the top of the head. The chest and the abdominal cavities are opened by the usual “Y” shaped incision. The internal organs are in their normal anatomic locations and with the usual relationships. The volume of fluid in the abdominal cavity measures 1300 ml. There is 400 ml of fluid within the scrotal sac. There is the usual amount of fluid within the pericardial sac and the bilateral chest cavities. There are no fibrous adhesions within the thoracoabdominal cavity. Cardiovascular: Heart: 460 grams The epicardium is unremarkable. The coronary arteries have a normal takeoff and distribution. ‘There is no significant coronary artery disease. The cardiac chambers are not dilated. The left ventricular myocardial wall is mildly hypertrophied. The right ventricle is unremarkable. The cardiac valves are unremarkable. On sectioning, the myocardium is firm, red-brown, and without evidence of fibrosis or scarring. The aorta is with mild diffuse atherosclerotic changes. Respirato Right Lung: 470 grams Left Lung: 430 grams The pleural surfaces are smooth and glistening. There is no pulmonary thromboembolus The larynx, trachea, and major bronchi contain no foreign material. On sectioning, the lungs are ‘without significant congestion or edema. The sectioned surfaces are with a mottled appearance of red, brown and black areas consistent with anthracotic pigment deposits. There are no changes of consolidation or tumor. Gastrointestinal: Stomach Contents: 200 ml of yellow fluid with multiple small, firm white particles. The tongue is unremarkable on section, The esophagus is empty, and its mucosa is unremarkable. The stomach is significant for a 5 x 3 om indurated mass with a central almost circular defect, measuring up to | cm. The lesion is located on the anterior gastric wall close to the pylorus. The serosal surfaces of the small and large intestines are with green discoloration, e arkable, TI i rendix is present. otherwise are unremarkable. The vermiform appendix is present. it aller Page |3 19C-1177,Hepatobiliary: Liver: 1750 grams Bile: 20mL The liver capsule is intact, and sectioning reveals a homogenous red-brown parenchyma with no focal abnormalities. The gallbladder contains green-yellow bile and no gallstones. The pancreas has normal size, shape and is at its normal location. Sectioning reveals no abnormalities. Reticuloendothelial: Spleen: 60 grams The spleen has a normal size, shape, and is at its normal location. Sectioning reveals no abnormalities, There are no significantly enlarged lymph nodes. Urinary: Right Kidney; 120 grams Left Kidney: 120 grams Urine: 50 mL ‘The subcapsular surfaces of the kidneys are unremarkable. The sectioned surfaces of the kidneys are similar in appearance with normal renal architecture on sectioning, ‘The bladder mucosa is unremarkable. Reproductive: ‘There is normal internal male reproductive anatomy with an unremarkable prostate and testes on sectioning, Endocrine: The thyroid gland weighs 30 grams and appears mildly enlarged on the right side compared to the left. Sectioning reveals unremarkable thyroid parenchyma. ‘The adrenal glands are unremarkable on sectioning. Neurological: Brain: 1460 grams ‘The scalp and skull are unremarkable, ‘The brain has a normal gyral pattern with thin delicate leptomeninges, The blood vessels at the base of the brain show no abnormalities. Sectioning the cerebrum, cerebellum, and brainstem shows no contusions, hemorthage, or tumor inouin? Page | 4 19C-1177Musculoskeletal: ‘The anterior neck structures are intact. The strap muscles of the neck are without hemorrhage The hyoid bone and the thyroid and cricoid cartilages as well as the upper tracheal wings are without injury, ‘There is no paravertebral hemorrhage or abnormal motility of the cervical veriebrae. The extremities are palpated and manipulated. There are no fractures of the long bones, There are no muscular or skeletal abnormalities. Special Dissection: The skin of the back of the neck, the torso, and the extremities is incised, and the skin is reflected from the underlying muscles and soft tissues. There are no hemorrhages or unusual lesions deep to the skin after reflection. PROCEDURE! Photographs: Photographs are obtained and retained as per protocol, Toxicology (GBI): Iliac Blood: Promethazine: lower than the lowest calibrator of 125 yg/L Hydroxyzine: lower than the lowest calibrator of 50 jig/L Phenytoin: lower than the lowest calibrator of 2.5 g/l. Methocarbamol: Positive Certain amphetamines: Negative Cocaine/cocaine metabolites: Negative Common opioids: Negative Ethyl alcohol: Negative Identification: ‘The decedent was identified by the law enforcement authorities to the emergency medical personnel, who transported Mr. Wingo to the hospital. There are identification tags around the left wrist. Histology: Small sections of vital organs and the significant lesion are submitted in cassettes marked: 1.— Kidney and liver; 2. - Lung; 3. — Heart; 4 & 5, — Stomach wall at site of ulceration; 6. ~ Adjacent Duodenal wall. Dal aw Page | 5 19C-1177Microscopie findings: Heart (}# of sections: 1; Slide #: 3.) ‘The myocardium is without overt myonecrosis, acute inflammatory cell infiltrates or hemorrhage. ‘There is a focal area with contraction bands which is more suggestive of processing artifact and not indicative of myocardial ischemia, ‘The available neural elements are unremarkable. Kidney (# of sections: 1; Slide #: 1.) Essentially unremarkable glomeruli, renal tubules and vasculature, Gastric and duodenal wall (# of seetions: 3; Slide #s: 4 - 6) The sections of the gastric wall (Slide #s 4 & 5) are with full to almost full thickness acute inflammatory infiltrates. The inflammatory infiltrates in the sections submitted extend from the mucosal surface to the muscular layer. There are acute inflammatory cell infiltrates within mucosa of the duodenal wall submitted (Slide # 6). There are no changes of malignancy identified. Liver (# of sections: 1; Slide #: 1.) The chronic inflammatory cell infiltrates surrounding the portal triads are mildly increased. There are occasional acute inflammatory cell infiltrates within the hepatic lobules. There are occasional cells with micro and or macro vesicular steatosis. Lungs (# of sections: 1; Slide #: 2.) ‘There is no pulmonary edema, ‘There is dilatation of the alveolar spaces, without peri-bronchial fibrosis and no significant acute inflammatory cell infiltrates within the alveoli. ERPRETATION UMMARY AND. Mr. Kevil Wingo was a 36-year-old man who was incarcerated after an arrest for cocaine possession. He was later transferred to the infirmary for heroin detox treatment. On the 28" of September 2019, he exhibited erratic behavior, including multiple complaints / requests for ‘medical attention, as well as stumbling and falling on other inmates and beds in the infirmary cell allotted to him. He was later removed from the infirmary and transported to a padded isolation cell, where he was later found unresponsive. He was initially treated by the Emergency Medical Services and transported to the hospital where he was pronounced deceased. | g\ 0 ol we v Page | 6 19-1177Mr. Kevil Wingo’s past medical history was significant for myalgia, peptic ulcer disease and opiate and cocaine abuse. ‘The autopsy findings reveal a large, peptie ulcer with significant induration around the margin and a central perforation of the ulcer. There were no significant recent physical injuries to the body. The medical and therapeutic devices affixed to the body were appropriately located The toxicological analyses were positive for hydroxyzine, methocarbamol, phenytoin and promethazine, The tests were negative for alcohol and the other commonly abused medications and illicit drugs. The entire video of Mr. Kevil Wingo’s stay at the infirmary and the incident report and the intemal investigation report was reviewed by the Cobb County Medical Examiner's Office. Based on the medical records and the autopsy examination, it is my opinion that the cause of death in this case is complications of perforated gastric ulcer with peritonitis. The manner of death is certified as natural. COMMENT: Juxtapyloric perforations of gastric ulcers in crack cocaine users has been noted to have an increased incidence. The topic is being studied and a report has been published previously. The speculated mechanism is ischemia of the enteral mucosa and secondary bacterial infection. See Feleiano DV, Ojukwu JC, Rozycki GA et al: The epidemic of cocaine related juxtapyloric perforations; With a comment on the importance of testing for helicobacter pylori.; Annals of surgery; 1999; Vol. 229; No. 6; pages 801-806. wee pana Page| 7 19C-1177COBB COUNTY OFFICE OF THE CHIEF MEDICAL EXAMINER caminedoy,__YO_O\ AY 19C-1177