Cardiac lesions in sudden infant death syndrome

Sequential morphological changes as found in the hearts of 250 sudden infant death syndrome (SIDS) infants are described. Detailed examination of macroscopic and microscopic lesions reveal that all SIDS infants had identifiable lesions at the time of their death. The lesions can best be described as selective focal anoxic muscle fibre necrosis at chronologically different developmental stages. The extent of these lesions vary markedly from case to case, from a minimal muscle fibre eosinophilia through contraction band formation, myocytolysis, stromal condensation to scar formation. The morphological variations in the lesions amongst individual cases can be interpreted as relating to the time interval of the development of the lesions. The intramural and coronary arteries in some cases are also affected showing intimal hyperplasia. Although these sequential morphological aberrations are not specific and typical to SIDS infants only, they were present in all SIDS infants in this series.     

Spontaneous degeneration of the posticus muscle

The intrinsic muscles of the larynx were prepared in 265 forensic postmortems (death by strangulation: 73; other violent deaths: 93, natural death: 79, others: 20) for a histological examination. Muscle-fiber alterations were found in the (macroscopically normal) PCA muscle in most cases where the persons were of middle age or older. There were abnormalities such as rows or clumps of nuclei (also inside muscle fibers), the accumulation of lipofuscin pigment, focal or total necrosis of muscle fibers with or without predominant histiocytic infiltration, atrophic muscle cells, and fibrosis. The changes were mostly mild (normal muscle cells predominated) but clearly visible. If there had been acute damage to the larynx (for instance, death some time after attempted strangulation), these preexistent alterations must be taken into consideration when interpreting the microscopical findings.     

Heroin dependence as a rare cause of symmetrical globus pallidus necrosis

Long-term survival after carbon monoxide intoxication has been accepted for a long time as pathognomonic for elective cerebral tissue damage, especially in cases of isolated symmetrical necrosis of the globus pallidus. The results of old bilateral necrosis in the globus pallidus are described in a case of an acute heroin death after long-term drug abuse. The evaluation of such cerebral changes is discussed as they have to be interpreted as hypoxic or oligemic tissue damage. The different causes of symmetrical necrosis of the globus pallidus that are relevant for legal medicine are compiled and discussed.     

Blood carbon monoxide and hydrogen cyanide concentrations in the fatalities of fire and non-fire associated civil aviation accidents, 1991-1998

To evaluate pathophysiological significance of post-mortem urinary myoglobin levels in determining the cause of death, we investigated 210 forensic autopsy cases, partially in comparison with serum levels. Post-mortem serum myoglobin levels were extraordinary high in most cases possibly due to post-mortem change. Urinary myoglobin levels did not correlate with the serum levels, showing possible post-mortem elevation in cases of a prolonged post-mortem period over 48h. A high (>1000 ng/ml), moderate (100-1000 ng/ml), slight (50-100 ng/ml) and not significant (<50 ng/ml) elevation of urinary myoglobin were observed in 26, 43, 31 and 110 cases, respectively. Half the highly elevated cases were those with a survival time over 24h. In cases of minor muscle injury such as head trauma, elevation of urinary myoglobin level was closely related to longer survival. In acute/subacute deaths with a post-mortem interval within 48h, a significant difference was observed in relation to the blood carboxyhemoglobin (COHb) levels of fire victims: myoglobinuria over 100 ng/ml was more frequently and markedly observed in cases with COHb below 60% than over 60%, suggesting muscle damage in fatal burns. Similar elevation was observed in heat stroke victims, and also in some cases of acute and subacute death from polytrauma, asphyxiation, drowning, electricity and spontaneous cerebral bleeding, but not in myocardial infarction. Thus, it was suggested that high post-mortem urinary myoglobin levels in acute and subacute death cases may be a possible indicator of antemortem massive skeletal muscle damage as well as exertional muscle hyperactivity or convulsive disorders associated with hypoxia.     

Penile strangulation: report of a fatal case

Penile strangulation or entrapment is an unusual entity that requires urgent treatment due to its potential complications. Several cases have been reported in the medical literature, some of them describing serious injuries such as necrosis, gangrene, and amputation of the penis. However, as far as we know, no fatal cases have been described before. We present the death of an adult male secondary to the complications due to penile strangulation with a plastic bottle neck. The time of incarceration was unknown, but according to a witness it could be about 10 to 14 days. The findings of autopsy were penile strangulation, necrosis of the penis, acute pyelonephritis, and bronchopneumonia. The subject's refusal to ask for medical help was the cause of this atypical evolution.     

Forensic medicine aspects of fatal coronary insufficiency with normal coronary arteries

Clinical experiences give examples for the existence of various courses of anginal symptomatology even with cases of sudden heart death demonstrating angiographically normal coronary arteries. Pathogenetically may be considered spasms of regular or little changed coronary arteries, coronary muscle bridges and acute arrhythmias. In cases of recurrent myocardial ischemias an interstitial fibrosis and endocardial fibrosis can be proved histologically in the myocardial supply area. However an acute coronary insufficiency based on rheological and metabolic etiology cannot be found with morphological methods. The results are discussed, considering forensic aspects in cases of competitive causes of death.     

Cerebral hypoxia and ischemia: the forensic point of view: a review

In cases with suspected brain anoxia/ischemia and hypoxia/hypoxemia a neuropathological investigation should give additional information to elucidate the cause of death and its pathophysiological mechanisms. Primary ischemic brain damage is associated with morphological and biochemical alterations. While acute ischemic neuronal injury reveals axon sparing and selective neuronal lesions due to the release of large quantities of glutamate, late neuronal death is associated with antiapoptotic growth factors, and decreased expression of microtubule-associated proteins and tubulin. On the morphological level ischemia can be detected by necrosis of neurons, proliferation of microglia, and astrocytes in vulnerable regions of the brain. In cases of permanent ischemia the so-called pale nervous cell injury is observed, in cases of partial perfusion the so-called dark nerve cell injury and apoptosis are detectable. In spite of the considerable advantages of recent research, presently there is no reliable qualitative marker to ascertain death due to acute hypoxic or ischemic events.     

致心律不齐性右室心肌病的研究进展

致心律不齐性右室心肌病是以右室心肌被纤维脂肪取代为特征的一种原因不明的心肌病,通常表现为局限性右室病变。亦可弥漫性进展,侵犯左室,最终导致左心功能不全。近年来,致心律不齐性右室心肌病导致心源性猝死已越来越引起人们的注意。在法医实际工作中,相关研究报道较少。本文综述了致心律不齐性右室心肌病的发病病因、发病机理、病理变化、临床特点和鉴别诊断等方面的研究进展。     

Sudden death of an alcoholic elderly man with acute esophageal necrosis (black esophagus)

We report a fatal case of acute esophageal necrosis (black esophagus) in an elderly male with alcohol abuse who was found dead with coffee-ground vomiting. A postmortem examination revealed severe anemia and marked black coloring of the esophagus from the upper to the bottom end. This was accompanied by histologic evidence of extensive mucosal necrosis. Alcohol abuse and esophagitis-related vomiting were both considered to be factors that led to the acute fatal esophageal necrosis. The cause of death was undetermined. We discuss the possible role of acute esophageal necrosis in the cause of sudden death.     

多发性软组织挫伤后成人呼吸窘迫综合征──组织学及免疫组织化学研究

本研究应用组织学Ｈ·Ｅ、Ｍａｌｌｏｒｙ、ＰＴＡＨ以及免疫组织化学染色方法对６例多发性软组织挫伤后成人呼吸窘迫综合征者肺组织改变进行了深入探讨。结果表明，所有外伤性呼吸窘迫综合征者肺组织均呈急性充血、出血及水肿改变，且免疫组织化学染色证明，水肿液中含有纤维蛋白（原）成份。在６例中２例可见肺组织局灶性出血坏死，３例有散在性血管内纤维蛋白柱形成及肺泡内透明膜形成。这些改变均属成人呼呼吸窘迫综合征的早期肺损伤。对多发软组织挫伤后呼吸窘迫综合征的形成机理进行阐述。     

Fatal amphetamine-associated cardiotoxicity and its medicolegal implications

Amphetamines are popular drugs of abuse, particularly among youngsters and at dance scenes. Cardiotoxicity (manifested as cardiomyopathy, acute myocardial infarction/necrosis, heart failure, or arrhythmia) after the recreational (mis)use of amphetamine and its synthetic derivatives has been documented but is rather rare. Amphetamine-related cardiac fatalities are even more rare. We present 6 cases of young persons who died unexpected after the chronic abuse of amphetamines. Death was not attributed to a lethal intoxication but to an acute myocardial necrosis, a right ventricle rupture, a cardiomyopathy, or an arrhythmia. Two of the deceased persons presented prior to their death to the emergency department, but their complaints were not considered (probably due to their young age) to be of cardiac origin. One case was a sport-related fatality where medical screening failed to identify the underlying cardiac pathology or the amphetamine abuse, and 1 case was a so-called idiopathic dilated cardiomyopathy where substance abuse was not considered by the treating physician. We think that amphetamine-associated cardiotoxicity is a rare but probably genuine entity that should be considered both in forensic and clinical/emergency medicine because of its potential medicolegal implications.     

Post mortem determination of bromureides (author's transl)]

Concentrations of carbromal, carbromide and bromisoval are determined in blood, urine, brain, kidney and muscle taken at autopsy from 41 fatal cases after overdosage of bromureides. In addition values of total bromine in blood are presented. Contents of total bromine can only lead to the deduction that a chronical abuse of bromureides is existent or not. Concentrations of bromureides and carbromide show a wide range according to the different time between taking the drug and death particularly in cases of pure carbromal intoxications which sometimes cause death after several days. In such cases quantitative determination of carbromide, a pharmacologically active metabolite of carbromal, is the only way to prove an acute carbromal intoxication. Especially in cases of additional foreign substances death may occur in early the phase of poisoning. Bromureides decompose post mortem by putrefaction a high degree so that the condition of the cadaver is important. Brain tissue is the most usable material for examination but other organs, particularly muscle and kidney, can be analysed with success. For differential diagnosis fatal cases are presented which were not caused by drug intake.     

A comparison of efficiency of manual and automatic fibres search with the Maxcan fibre finder

The aim of this work was to study the efficiency of automatic fibre searching with the Maxcan fibre finder (Cox Analytical Systems, Sweden) in comparison to manual searching. The influence of some parameters (color, thickness, background noise) on the results of a fibre search was considered. Eighteen experimental tapes with different target fibres and different background noises were prepared in the laboratory. Searching of fibres was performed manually and with the Maxcan fibre finder by different operators from four European laboratories. Two laboratories have the Maxcan fibre finder system and the two instruments were used and compared in this study. The results show that searching with the Maxcan is generally as efficient as manual searching, except for very pale or very dark fibres. Note that the tapes used for these experiments were prepared in laboratory, and are not completely representative of the tape that could be obtained in real cases. To generalize the results obtained, further research on real case samples would be necessary.     

A comparison of efficiency of manual and automatic fibres search with the Maxcan fibre finder

The aim of this work was to study the efficiency of automatic fibre searching with the Maxcan fibre finder (Cox Analytical Systems, Sweden) in comparison to manual searching. The influence of some parameters (color, thickness, background noise) on the results of a fibre search was considered. Eighteen experimental tapes with different target fibres and different background noises were prepared in the laboratory. Searching of fibres was performed manually and with the Maxcan fibre finder by different operators from four European laboratories. Two laboratories have the Maxcan fibre finder system and the two instruments were used and compared in this study. The results show that searching with the Maxcan is generally as efficient as manual searching, except for very pale or very dark fibres. Note that the tapes used for these experiments were prepared in laboratory, and are not completely representative of the tape that could be obtained in real cases. To generalize the results obtained, further research on real case samples would be necessary.     

Can Renal Acute Tubular Necrosis Be Differentiated from Autolysis at Autopsy?*

Abstract: We investigate the morphological characteristics that may differentiate between ischemic acute tubular necrosis (ATN) and autolysis in postmortem samples. Renal tissue from 57 postmortem cases with an antemortem diagnosis of ATN and 57 age-/sex-matched control cases were examined for 10 morphological characteristics: epithelial proliferation (Ki-67 immunoperoxidase positivity), fibrin thrombi, tubular epithelial whorls, mitoses, casts, autolysis, tubulorrhexis, epithelial flattening, interstitial inflammation, and interstitial expansion. Tubular epithelial whorls were found in 16 ATN cases and were absent in controls. These findings suggest that specific morphological criteria may distinguish ischemic ATN from autolysis. Diagnoses of ATN may be confirmed using these combined criteria as contributing to cause of death and/or to ascertain previously undiagnosed cases of ATN postmortem.     

股骨颈骨折法医学鉴定的回顾性研究

目的 探讨股骨颈骨折后股骨头坏死的相关因素。方法 对69例股骨颈骨折的鉴定资料进行回顾性研究。结果69例股骨颈骨折的伤者,伤后4年内发生股骨头缺血坏死的21例,其中1～3年内发生缺血坏死者18例。根据股骨颈骨折的Garden分型,Ⅲ型股骨颈骨折后发生股骨头缺血坏死者9例,Ⅳ型11例,Ⅱ型1例。根据复位后的Garden指数分组,B组股骨颈骨折后发生股骨头缺血坏死者11例,A、C组各5例。结论 股骨颈骨折后股骨头坏死与股骨颈骨折的原始移位程度和骨折的复位质量(对位、对线情况)有关。     

Black Esophagus: Acute Esophageal Necrosis in Fatal Haloperidol Intoxication

Herein, we present a case of 53‐year‐old psychotic woman with acute esophageal necrosis (black esophagus), who was found lying on the floor in the living room of her flat. Pillboxes of antipsychotic drugs were located in the bin. External examination of the body was unremarkable. On internal examination, we found acute esophageal necrosis. Histologically, there was complete epithelial necrosis with focal involvement of muscularis mucosae, dense infiltrate of leukocytes, and ulcerations without any viable cells. There was no evidence of underlying organic diseases or trauma. Toxicological analysis revealed a fatal blood level of antipsychotics (haloperidol, zotepine, and chlorprothixene). Death of the deceased was attributed to fatal intoxication with three various types of antipsychotics. As far we know, this is the first described association between so‐called black esophagus and fatal blood level of neuroleptics.     

Postmortem serum uric acid and creatinine levels in relation to the causes of death

Serum uric acid (UA) and creatinine (Cr) mainly derive from skeletal muscle tissues. Although, remarkable postmortem stability of the serum levels has been reported, there appears to be very poor knowledge of the diagnostic value in investigation of death, except for uremia. The aim of the present study was to evaluate postmortem serum UA and Cr levels using 395 forensic autopsy cases, in comparison with blood urea nitrogen (BUN), for investigation of the pathophysiology of death with special regard to the causes of death involving possible skeletal muscle damage, e.g. due to hypoxia, heat or agonal convulsions. Cr and BUN showed relatively good topographic stability in the cadaveric blood, whereas, UA was often much higher in the right heart blood than in the left heart and peripheral blood, independent of postmortem intervals. Moderate to marked elevation of Cr and BUN accompanied with hyperuricemia was observed in delayed death. In the acute death cases (survival time <30 min), UA, especially in the right heart blood, showed a considerable elevation in mechanical asphyxiation and drowning. The Cr level in fire victims with a lower carboxyhemoglobin (COHb) level (<60%) was significantly higher than in those with the possible fatal level (>60%). A similar elevation of Cr was observed in fatalities from heat stroke and methamphetamine (MA) poisoning. The observations suggested that hyperuricemia in acute death may be indicative of advanced hypoxia and that elevated Cr level may reflect the skeletal muscle damage, especially due to thermal influence.     

Delayed death following strangulation (hanging)

6 cases of suicide by hanging with delayed death are presented in tables laying out the circumstances and the findings. All the persons involved remained continuously unconscious after initially successful reanimation; two were at this time already dead. The survival times lay between 18 hours and 4 days. In two cases intravital vertebral death occurred. In the other cases death was due indirectly to hypoxial brain-damage which had led to a greater or lesser extent to elective parenchymal necrosis. In 3 of 4 histologically investigated cases there was evidence of extensive cell destruction in the PCA muscle which was, however, not specifically related to the process of hanging since lesions of this nature also occur with other cases of delayed death after reanimation. In 7th case the problems encountered in compiling an expert opinion are discussed in cases where there are no corresponding procedural details. A 44 year old man died 3 weeks after having been submitted to bondage in a brothel at his own request (including binding of the neck). Compression of the throat with emphasis on one side was evident resulting in extensive ganglial cell damage in one half of the cerebral cortex.     

急性坏死性胰腺炎与死后胰腺自溶病理形态学变化

目的比较大鼠急性坏死性胰腺炎（acute necrotizing pancreatitis,ANP）与各种急性死亡大鼠死后48h胰腺的病理形态学变化,探讨两者的鉴别点。方法参照文献制作ANP和电击、机械性窒息（勒死）、急性毒鼠强中毒动物模型,采用半定量评分和图像分析定量分析,观察死后48h胰腺大体和光镜下组织病理变化。结果ANP组炎细胞浸润、脂肪坏死、钙沉积3项与其他组相比有显著意义（P〈0．05）。结论炎细胞浸润、脂肪坏死、钙沉积是ANP在普通光学显微镜下最重要的特异性形态学病理变化,对区别其他急性死亡和死后自溶胰腺有特别重要意义．