The United Nations Office on Drugs and Crime had released their 2019 World Drug Report, in which they found that there had been a global increase in the trend of use of controlled and novel psychoactive substances. Between 1998 and 2017 alone saw a tenfold increase in global seizures of amphetamine-type stimulants (ATS), which include methamphetamine and MDMA or ‘ecstasy’. Southeast Asia alone has seen a worrying fivefold rise in methamphetamine seizure within a short span of 2013 to 2018 (World Drug Report 2019: Pre-release to Member States 2019).
The surge in traffic for ATS could only mean that there is a global demand for their use. It was estimated that about 3.5 to 20.9 million people use ATS in East Asia and Southeast Asia alone (Dargan and Wood 2012). Crackdowns on trafficking and drug control legislation on plant-based narcotics such as opioids, cocaine and marijuana were postulated to have caused an increase in the production of synthetic-based psychostimulants such as ATS, which can be produced anywhere (Stoneberg et al. 2018). While snorting, smoking and ingestion remained as popular routes of administration for these drugs, injectable forms were found on intravenous drug users (Chomchai and Chomchai 2015).
With the increasing trends in ATS use, there had been a growing clinical report with regard to its adverse effects. A study on an inner-city hospital in Australia found that 1.2% of Emergency Department presentations was due to amphetamine-related illnesses, with its burden on clinicians expected to rise in the future (Gray et al. 2007). A wide range of clinical manifestations associated with amphetamine toxicity had been reported (Greene et al. 2008). These primarily affect the cardiovascular and central nervous systems, owing to its sympathomimetic actions.
Besides being associated with amphetamine-type stimulants, ExDS had also been implicated in certain psychiatric illnesses and its pharmacological treatment, as well as other stimulant drug abuse such as cocaine, phencyclidine (PCP) and lysergic acid diethylamide (LSD) (ACEP Excited Delirium Task Force 2009). These drugs may cause ExDS at levels lower than the expected toxic threshold (ACEP Excited Delirium Task Force 2009).
The lack of specific aetiology and anatomical features made defining excited delirium a great challenge. Therefore, the White Paper Report on ExDS (2009) suggests identifying the syndrome based on its epidemiology, clinical presentations and course of illness. A prerequisite for the consideration of the syndrome is the presence of both deliriums with psychomotor and physiological excitation (ACEP Excited Delirium Task Force 2009).
The effects of the drugs on central dopamine activity have been widely postulated to be the cause of features seen in the syndrome (Mash et al. 2009). Fatal hyperthermia, arrythmia and acidosis have been implicated as the cause of sudden cardiac arrest in ExDS (ACEP Excited Delirium Task Force 2009). Unlike methamphetamine poisoning for which similar fatal arrythmias may be seen (Inoue et al. 2006), the levels associated with excited delirium were described to be lower than the expected toxic thresholds (ACEP Excited Delirium Task Force 2009).
Nevertheless, diagnosing ExDS solely based on the autopsy findings may present a challenge to pathologists. Like other syndromes of forensic significance, such as the San Diego protocol for sudden infantile death syndrome (Bajanowski et al. 2007), the diagnosis of ExDS requires a review of the history, findings from the scene, features upon contact, features of clinical assessment, features at death and features at autopsy (ACEP Excited Delirium Task Force 2009). There is also a need to exclude other causes of altered mental status, psychomotor agitation and physiological excitation for the diagnosis of ExDS to be considered.
A conundrum faced by clinicians and pathologists are the legal implications associated with ExDS. Many reported cases involve the legal issues of excessive restraint by law enforcement officials, especially when the victim is impervious to pain stimuli (O’Halloran and Lewman 1993), as well as the relationship between electronic control (TASER®) devices and ExDS (Jauchem 2010). However, no cases have been reported that showed traumatic injuries were possibly the result of excited delirium.
In the present case, it was imperative to determine whether the injuries found had caused death and what caused those injuries. Assessment of all wounds was consistent with blunt and sharp superficial trauma sustained during an episode of erratic behaviour, with none being fatal or fitted the pattern of homicide. No clinical features suggest immediate complications from the injuries, such as embolism and traumatic rhabdomyolysis. At autopsy, it was important to rule out other natural diseases that may cause sudden death, as well as conditions that may cause altered mental status.
With a review of the toxicology and the circumstances using the White Paper Report on diagnosing ExDS, the cause of death was finalized. Features from the history and scene of this case that suggested ExDS include the following: male gender, age of 25 that is close to the mean age of 30, sudden onset, history of psychostimulant abuse, psychomotor agitation and excitation, violent and belligerent, not responding to verbal commands, psychosis, yelling and guttural sounds, disrobing, destruction of inanimate objects, superhuman strengths, impervious to pain, profuse sweating, hyperthermia, drug screen positive for psychostimulants, drug levels lower than anticipated and no anatomic correlate for death.