Hydrocephalus: a fatal late consequence of mumps encephalitis

Common and usually self-limited diseases may occasionally have fatal consequences. Hydrocephalus is a very rare complication of mumps, with just a few cases reported in the literature. Here we report a fatal case of hydrocephalus presenting 19 years after mumps encephalitis. The long latency period between encephalitis and hydrocephalus-associated symptoms makes this case particularly interesting.     

Fatal Drowning Accident and Undiagnosed Hydrocephalus

Abstract: Bodies found in water present several diagnostic challenges for the forensic examiner, such as the identification of the time and mechanism of death, the postmortem submersion time, and above all the circumstances of drowning. We report the case of a 33‐year‐old security guard found dead in Venice, in the water of the lagoon, who at autopsy presented a previously undiagnosed hydrocephalus with macrocephaly. The victim remained asymptomatic until 2 months before death and had never undergone a neurological or radiological examination. In the article, we emphasize the need to perform a thorough autopsy in all suspected drownings, discuss the etiopathogenesis of the neurological disease and hypothesize a possible relationship between the hydrocephalus and the drowning accident. Finally, we discuss the major clinical and forensic implications of macrocephaly and hydrocephalus in adults.     

Fatal intraoperative hemorrhage during spinal fusion surgery for osteogenesis imperfecta

Osteogenesis imperfecta (OI) is an uncommon inherited systemic disorder of the connective tissues characterized primarily by varying degrees of bony fragility. Consequently, individuals affected by this condition frequently suffer severe skeletal injuries from otherwise innocuous traumatic events. This syndrome has other associated abnormalities, including hydrocephalus and brain stem compression on the basis of cranial developmental defects (platybasia), cardiac and vascular problems, respiratory disease from spinal deformities, vascular fragility, a bleeding disorder caused by an apparent platelet function abnormality, and anesthesia-related hyperpyrexia. A case is presented here of a young girl with advanced OI in whom intraoperative death occurred as a consequence of inadvertent rib fractures, with subsequent uncontrollable hemorrhage. OI may also potentially be mistaken for child abuse by an inexperienced examiner.     

Enucleation in psychosis associated with aqueductal stenosis

Reports of self-enucleation are frequent in medical literature, but cases of enucleation towards another are rare. We report the case of a man, 20 years of age, who suffered from psychosis with hydrocephalus and aqueductal stenosis that required a forensic psychiatric investigation to ascertain whether he was of unsound mind when he assaulted and enucleated the right eye of an officer and led to the surgical enucleation of the victim's left eye. Based on his clinical interviews and hospitalization record, we conclude that at the time of the assault, he was suffering from a delusional disorder with religious and demonic content, visual and auditory hallucinations, illusion phenomena, delusional interpretations, imaginative elements, a feeling of terror, and command hallucinations that compelled him to perform the act of aggression.     

Carbofuran poisoning of pregnant woman and fetus per ingestion

A case of carbamate pesticide poisoning of a pregnant woman by carbofuran ingestion is presented. The mother recovered from the poisoning in the hospital but necrosis of the fetus was found. Toxicological findings of the liver, brain, and kidney of the fetus revealed carbofuran in concentrations comparable with the mother's blood. Our findings in the case contribute to the research on permeation of the placental barrier by chemical substances.     

Sarcoidosis and mechanisms of unexpected death

Sarcoidosis is a multisystem disease of uncertain etiology characterized by multifocal areas of discrete and confluent granulomatous inflammation that may rarely be responsible for sudden and unexpected death. Two cases are reported to demonstrate disparate pathological features in fatal cases, one involving cardiac sarcoidosis, and the other neurosarcoidosis with hypothalamic infiltration. Sarcoidosis in individuals dying suddenly may be completely unrelated to the death, contributory or causal. Cardiovascular causes of sudden death in sarcoidosis include arrhythmias associated with cardiomyopathy and ischemia, ventricular rupture, and cor pulmonale due to pulmonary hypertension; respiratory causes include hemorrhage and upper airway obstruction; central nervous system causes include arrhythmias from infiltration of autonomic centers, epilepsy, and obstructive hydrocephalus from brainstem involvement; and gastrointestinal deaths may be due to hemorrhage from esophageal varices associated with portal hypertension. The diagnosis relies on the demonstration of typical noncaseating granulomas and the exclusion of other infective and environmental diseases with similar histopathological findings.     

DETERMINING THE EFFECTIVE REPRESENTATION OF A CHILD IN OUR LEGAL SYSTEM

This note addresses the process by which lawyers must determine their role and responsibilities with regard to a child-client. The authors engage in an analysis of current standards, such as AAML, ABA, Fordham Conference. and Jean Koh Peters, by employing a case study.which was modeled after an actual case that was being handled by the Hofstra University School of Law Child Advocacy Clinic. The case study is then applied to the four current standards and to the ethical standards proposed by The Model Rules of Professional Conduct and the Quebec Bar Association's findings.     

A distant-range, suicidal shotgun wound of the back

The case being reported is one of a shotgun fatality with a thoracic back wound. A 23-year-old man was shot from a distance with trajectories going from back to front and on a nearly horizontal level. These findings observed in the autopsy could represent homicide, but scene investigation and police records were interpreted and it became clear that the case was suicide. Thus, this case shows that the determination of the manner of death requires a careful forensic investigation including autopsy findings, scene investigation, and reconstruction of the events.     

An Analysis of Possible Mechanisms of Unexpected Death Occurring in Hydatid Disease (Echinococcosis)

Abstract:  Most cases of hydatid disease in human populations are due to Echinococcus granulosus. The hydatid life cycle involves passage between definitive hosts such as dogs and intermediate hosts such as sheep. Humans become accidental intermediate hosts following ingestion of food or water contaminated with eggs or by contact with infected dogs. Although hydatid disease may remain asymptomatic, occasional cases of sudden and unexpected death present to autopsy. Causes of rapid clinical decline involve a wide range of mechanisms including anaphylaxis (with or without cyst rupture), cardiac outflow obstruction or conduction tract disturbance, pulmonary and cerebral embolism, pericarditis, cardiac tamponade, myocardial ischemia, pulmonary hypertension, peritonitis, hollow organ perforation, intracerebral mass effect, obstructive hydrocephalus, seizures, cerebral ischemia/infarction, and pregnancy complications. The autopsy assessment of cases therefore requires careful examination of all organ systems for characteristic cystic lesions, as multiorgan involvement is common, with integration of findings so that possible mechanisms of death can be determined. Measurement of serum tryptase and specific IgE levels should be undertaken for possible anaphylaxis.     

Chloroquine as a poison in murder. Report of fatalities after criminal or suicidal chloroquine administration

Presented is a case of murder by means of chloroquine, committed on a 36-year-old male. The wife of the deceased had confessed to have secretely administered chloroquine-containing tablets to her husband. She was lawfully sentenced to life-imprisonment. The toxicological findings of this case are compared to the results of two chloroquine suicide cases and discussed in the context of the referring literature. An additional case where chloroquine intoxication was doubtful is introduced because of the unusual circumstances under which it occurred.     

Sniffing-associated deaths in Denmark

An account is given of 20 deaths, which occurred in association with sniffing during the period 1959 – 1978. The annual number of deaths was almost constant during the period. Most of the deaths occurred in males. Ether and trichloroethylene were the predominant toxic substances. The material was divided into two groups. Group A, 14 cases, included real sniffing deaths, the cause of death being poisoning by the substance inhaled. In group B, 6 cases, sniffing was a contributory factor to death: 2 cases of suffocation by obstruction, one case of carbon monoxide poisoning during fire, one case of septicemia/severe anemia caused by bone marrow depression, and one case of bleeding to death from stab wounds inflicted by a sniffer against a non-sniffer. The circumstances before and at the time of death are reported, together with the autopsy and toxicological findings when these were performed.     

Fatal intoxication involving 2-methyl AP-237

Novel synthetic opioids contribute considerably to the opioid epidemic, especially with the frequent emergence of structurally similar compounds. This case report describes a fatal intoxication involving 2-methyl AP-237. A 54-year-old Caucasian male was found deceased from an apparent drug overdose. A plastic container labeled “2MAP” and a cut straw were found in the decedent's backpack at the scene. A white substance found in the container tested positive for fentanyl by field testing. According to his medical history, the decedent was treated for a drug overdose 3 years prior to his death. With no diagnostic findings at autopsy, the case was submitted for toxicological analysis. An unknown substance was detected in peripheral blood and urine using gas chromatography with nitrogen phosphorous detection (GC-NPD). Further testing was conducted using gas chromatography–mass spectrometry (GC–MS) and liquid chromatography-quadrupole-time-of-flight mass spectrometry (LC-QTOF-MS) which confirmed the presence of 2-methyl AP-237 and potential metabolites in blood and urine. Quantitation by GC-NPD revealed concentrations of 2-methyl AP-237 in blood and urine at 480 ng/mL and 4200 ng/mL, respectively. The toxicological analysis also identified and quantitated alprazolam in the blood at 55 ng/mL. Additionally, the metabolism of 2-methyl AP-237 was investigated and three hydroxylated metabolites were identified in peripheral blood and urine. Limited literature is available for the detection and quantitation of 2-methyl AP-237 in postmortem specimens. Given the toxicological findings with unremarkable autopsy findings, this case is an example of a fatal intoxication involving 2-methyl AP-237.     

Review of pathologic findings in remnant hearts following valve donation

The failure of medical examiners/coroners (ME/C) to allow heart valve donation is a major problem encountered by tissue agencies. Even though many ME/C favor tissue donation they remain responsible for determination of cause and manner of death. In 2001, the Jesse E. Edwards Registry of Cardiovascular Disease was approached by one of the nation's largest tissue procurement agencies (The American Red Cross--ARC) for the purpose of performing cardiovascular pathologic examinations following valve donation. The affiliation existed from October 2001 to January 2005. This study was undertaken to review all 593 postvalve recovery heart remnants received during that time period to tabulate the abnormalities identified and to determine whether donation interfered with the determination of cause of death. For each case, a preliminary cause of death was provided by the ARC. The decedent's body height and weight were also provided. Using the preliminary cause of death, the 593 cases were divided into natural and nonnatural manner of death groups. This division of the cases resulted in 106 cases placed in the natural manner of death group and 487 cases in the nonnatural manner of death group. For each case, all cardiac findings including significant conditions, additional findings, incidental findings, and congenital abnormalities were tabulated. Within the natural manner of death group, 15 cases had a noncardiac cause of death and 91 cases had a cause of death suspected to be cardiac related. In the 91 cases, a total of 132 significant cardiac findings were identified and there were six structurally normal hearts including two infants. In the nonnatural manner of death group, 214 significant cardiac findings were identified and 222 cases had a structurally normal heart. In both natural and nonnatural groups, the most common cardiac abnormality was atherosclerotic coronary artery disease. Other frequently encountered conditions were also identified including 11 cases with acute angle of origin of a coronary artery (five cases natural group; six cases nonnatural group). An important feature of this review was the recognition of potentially inheritable conditions that were diagnosed in both natural and nonnatural manner of death groups. There were three cases of hypertrophic cardiomyopathy (one natural; two nonnatural), three cases of arrhythmogenic right ventricular cardiomyopathy (one natural; two nonnatural), and one case of mitral valve prolapse (natural). In reviewing these cases, we did not feel that valve donation severely impaired cardiac pathologic examination. The benefits of cardiovascular pathologic examination by a cardiac pathologist include the identification of significant and incidental findings and recognition of potentially inheritable conditions.     

An Unusual Suicide Inside a Grave with Two Gunshot Wounds to the Head—The Psychological Approach

Abstract: In this report, the authors present a case of suicide committed by a 66-year-old man, inside a grave at the local cemetery, with two gunshot wounds to the head. A multiple-paged, handwritten suicide note was found in an army type bag inside the victim’s car, while a second one was found in his house. Medicolegal examination of the body revealed two typical contact gunshot entrance wounds and one exit wound to the head. Toxicological analysis of the femoral blood was negative for alcohol and drugs. The history, scene and autopsy findings, along with further police investigation, indicated an obvious case of suicide. The literature is reviewed and discussed. We report this case as the place of suicide is extremely uncommon and as there is no mention of a gunshot suicide inside a grave in the current literature.     

A rare suicidal case of a ten-year-old child stabbing himself in the throat

A rare case is reported of a ten-year-old boy who committed suicide by stabbing himself in the throat with a pointed knife. Possibility of an accidental injury was excluded by the autopsy findings; suspicion of a homicide by his father was cleared through the deposition of his sister. The reason of suicide was attributed directly to his father's severe scolding and indirectly to his mother's death two years before.     

Describing the feasibility of using case management in a specialist forensic substance misuse intervention for UK veterans: a case study

Veterans with mental health problems are a high-risk group for substance misuse difficulties and are over-represented in forensic settings. Yet, there are few substance misuse services available for this population. Evidence suggests that case management can provide effective interventions for veterans with substance misuse problems. However, there is little research to show its effectiveness in the UK. The present study reported on the implementation and preliminary outcomes of the Veterans Forensic Substance Misuses Service (VFSMS), piloted within a prison setting, to demonstrate the feasibility of the service. The VFSMS operated in four stages: Assessing needs, developing case management plans, providing bespoke support and developing discharge plans. Case studies were used to demonstrate this process, with measures of alcohol use and recovery showing outcomes for each case. Findings from three case studies suggested that case management was a feasible approach, with a range of interventions being used, including substance misuse and mental health services, plus housing and employment services. Outcome measures suggested that alcohol and substance misuse recovery improved following the VFSMS intervention. While the scope of the findings is limited, they suggested that case management is a feasible substance misuse intervention, with preliminary findings showing improvements in substance misuse outcomes.     

Suicide with two guns represents a special type of combined suicide

Suicide by simultaneous gunshots with two firearms is rare. The case of a 90-year-old man who killed himself with two 6.35 mm pistols fired at the temples at the same time is presented. The victim was found dead on the terrace of his home; two guns and two cartridges were present near the corpse. Cases of suicides with two guns published in the literature are compared, and the Italian cases are illustrated briefly. The authors describe the circumstances and autopsy findings that permitted the assertion that it was a case of suicide and to exclude an homicide and show, by figures, the three-dimensional reconstruction of cranial shooting injuries. The use of two guns is considered a representation of a special type of "combined suicide" or "planned complex suicide."     

A case of fatal rotenone poisoning in a child

A case of a fatal rotenone poisoning in a three-and-a-half-year-old girl is described. The case report and autopsy findings are mentioned. For the extraction of rotenone out of biological samples, a solvent partitioning and silica gel open column chromatographic cleanup procedure has been used. The determination of rotenone was performed by high pressure liquid chromatography.