Homicidal Snake Bite in Children

Snake bites are common in many regions of the world. Snake envenomation is relatively uncommon in Egypt; such unfortunate events usually attract much publicity. Snake bite is almost only accidental, occurring in urban areas and desert. Few cases were reported to commit suicide by snake. Homicidal snake poisoning is so rare. It was known in ancient world by executing capital punishment by throwing the victim into a pit full of snakes. Another way was to ask the victim to put his hand inside a small basket harboring a deadly snake. Killing a victim by direct snake bite is so rare. There was one reported case where an old couple was killed by snake bite. Here is the first reported case of killing three children by snake bite. It appeared that the diagnosis of such cases is so difficult and depended mainly on the circumstantial evidences.     

Animal-related fatalities--part I: characteristic autopsy findings and variable causes of death associated with blunt and sharp trauma

Animals may be responsible for an array of potentially lethal injuries. Blunt force injuries characteristically involve larger animals such as cattle or horses that may kick, crush, or trample a victim causing head and facial injuries. Farm workers in particular are at high risk of lethal injuries involving the head and torso. Significant blunt trauma may be found in vehicle occupants after collisions with large animals such as camels or moose. Rarely, zookeepers may be crushed by particularly massive animals such as elephants. Sharp force injuries usually involve carnivore bites, most often from dogs with a "hole and tear" pattern of wounding. Injuries from animals such as alligators and sharks may have a significant component of crushing. Incised wounds may result in death from exsanguination and air embolism. On occasion, blunt or sharp trauma from animal activity may be confused with postmortem damage or with inflicted injury from an assault.     

Utilization of serum tryptase and immunoglobulin e assay in the postmortem diagnosis of anaphylaxis

The postmortem diagnosis of anaphylaxis is difficult. Serum concentrations of tryptase (a mast cell product released during anaphylaxis) have been used after death as an indicator of possible antemortem anaphylaxis. However, studies have indicated that tryptase may be elevated with increasing postmortem interval (PMI), or in nonanaphylactic deaths with significant atherosclerosis or chest trauma. Serum total IgE has been used by some to confirm anaphylaxis when tryptase is elevated. Serum levels of tryptase from 57 decedents with varying PMI, all dying of presumed nonanaphylactic causes, were determined. In cases with elevated levels (>11.4 ng/mL), an assay of total serum IgE was also performed. Both tryptase and IgE demonstrated significant elevations with increasing PMI. Decedents were categorized according to presence of cardiovascular disease, chest trauma, or both; many demonstrated elevation of 1 or both markers, without statistically significant differences between categories. Postulated mechanisms for nonanaphylactic elevations of these markers are reviewed. The possible utility of allergen-specific IgE or allergen panels is discussed.     

Seven hundred seventy eight bite marks: analysis by anatomic location, victim and biter demographics, type of crime, and legal disposition

A study of the etiology, anatomic location, victim demographics and legal disposition of bite mark cases was made with the purpose of updating and augmenting previous research in the field. The information may be of interest to a myriad of professional disciplines including Forensic Odontologists, Medical Examiners, Detectives, Profilers, Emergency Room Personnel, Coroners, Psychologists, and Family Service Counselors, as bite marks provide both physical and biological data. While bite marks were found on all anatomic regions of the body some sites are significantly more likely to receive bites, and the frequency that an area is bitten may vary with the type of crime. Sex and age of the victim may also impact the resulting location and frequency of bites. A survey form for bite mark cases was created and mailed to all Diplomates of the American Board of Forensic Odontology. The survey form was also included in the American Society of Forensic Odontology newsletter. The survey requested that the recipient fill out a separate form for each case for which the recipient was the primary investigator of a patterned injury. The data from the resulting surveys were entered into a Microsoft Excel spreadsheet. The responses detailed two hundred thirty two (259) bite mark cases that included seven hundred (778) individual bite marks. Harvey (1976) and Sweet and Pretty (2000) published studies finding the highest percentage of bites to the breasts. In 1983 Vale and Noguchi published the paper indicating that the most frequently bitten area was the upper extremities. The survey forms were sent to approximately 1100 forensic dentist in 26 countries. The forensic experience level of the dentists varied from neophyte to very experienced. The data were analyzed and the results reported and organized in the following categories; Victim Distribution by Gender, Victim Distribution by Age, Child Abuse Distribution by Age and Gender, Sexual Assault Distribution by age and Gender, Homicide Distribution by Age and Gender, Bite Mark Distribution by Gender and Location, Number of Bite Marks per Victim, Bite mark Distribution Comparison to Previous Research, Child Abuse Suspect Age Distribution by Age and Sex, Homicide Suspect Age Distribution by Age and Sex, Sexual Crimes Suspect Age Distribution by Age and Sex, and Bite Mark Incidence by Anatomical Area and Type of Crime. Fifty-two forensic odontologists from seven countries responded. Nineteen responders were Diplomates of the American Board of Forensic Odontology. The number of cases reported by each responder ranged from one to thirty-three and the average number of cases reported was 4.5. In this broad based study, females were bitten more often than males. The average male victim was younger than the average female victim. Males that were victims tended to be either very young or very old. The youngest victim was a two-month-old boy and the oldest victim a 95-year-old woman. Perpetrators were male more often than female and there was an average of 1.4 suspects per case. The results show that most bites occurred on the arm, followed by the breast. If broken down by gender, males were bitten on the arm more than females, and females were bitten on the breast more often than males. The data show patterns in location and number of bites that seem related to both the type of crime and the age of the victim.     

A Review of the Forensic Implications of Pica

Pica is characterized by the persistent eating of non‐nutritive substances over some time that is inappropriate for the maturation stage of the individual and is not culturally sanctioned. A 9‐year‐old boy with Goldenhar syndrome, significant developmental delay and pica, collapsed and died after a short history of diarrhea and vomiting. Death was due to a sigmoid volvulus resulting from filling of the distal colon with feces containing dirt, stones, and rice with evidence of ischemic intestinal necrosis. Lethal complications of pica include intestinal obstruction and perforation with peritonitis and generalized sepsis. Other findings at autopsy may include airway obstruction, heavy metal poisoning, and parasitic infestation. Presenting symptoms and signs of such complications may be subtle or masked given the nature of underlying conditions, and so careful evaluation of the medical histories of individuals with pica may be necessary to provide pertinent details of associated medical and psychiatric conditions.     

Fatal brodifacoum rodenticide poisoning: autopsy and toxicologic findings.

This report details the pathologic and toxicologic findings in the case of a 15-year-old girl who deliberately and fatally ingested brodifacoum, a commonly used rodenticide. The mechanism of death, massive pulmonary hemorrhage, has not been previously reported. Brodifacoum was quantitated in liver, spleen, lung, brain, bile, vitreous humor, heart blood, and femoral blood using HPLC with fluorescence detection. The highest brodifacoum concentrations were detected in bile (4276 ng/mL) and femoral blood (3919 ng/mL). No brodifacoum was detected in brain or vitreous humor. A brodifacoum concentration of 50 ng/g was observed in frozen liver while formalin fixed liver exhibited a concentration of 820 ng/g. A very high blood:liver brodifacoum concentration ratio suggested acute poisoning but the historical and pathologic findings suggested a longer period of anticoagulation. Though most cases of brodifacoum poisoning in humans are non-fatal, this compound can be deadly because of its very long half-life. Forensic pathologists and toxicologists should suspect superwarfarin rodenticides when confronted with cases of unexplained bleeding. Anticoagulant poisoning can mimic fatal leukemia or infectious diseases such as bacterial sepsis, rickettsioses, plague, and leptospirosis. A thorough death scene investigation may provide clues that a person has ingested these substances.     

Potentially lethal complications of tracheostomy: autopsy considerations

Tracheostomy is widely used to facilitate respiration by protecting the airways. It may be performed to relieve upper airway obstruction from congenital stenoses or from acquired conditions such as foreign body impaction, swelling from neck trauma or anaphylaxis, benign or malignant tumors, and infection. Tracheostomy may also be performed in individuals with respiratory impairment who require suctioning for accumulated mucoid secretions and in those with obstructive sleep apnea. Review of autopsy files and the literature was undertaken to demonstrate the range of lethal circumstances that may involve tracheostomy. Unexpected death may result from incorrect positioning of an endotracheal tube with failure of oxygenation, tracheal perforation with pneumothorax, mucus plugging, accidental extubation, and hemorrhage from tracheovascular fistulas. Lethal tracheovascular fistulas usually involve the innominate artery and result from mural perforation by the tip of a tracheostomy tube, mural necrosis from a high-pressure cuff, prolonged intubation, radiotherapy, and low tracheal incisions. Increased movement of tubes in patients with impaired consciousness and excessive head movements may also increase the chances of hemorrhage, as may infiltrating tumors. Given the wide range of potential fatal mechanisms that may be found in such cases, careful autopsy evaluation and dissection will be required to demonstrate the exact nature and site of the lethal lesion in individuals who underwent tracheostomy and die unexpectedly.     

Sudden death associated with food and exercise

Exercised-induced anaphylaxis occurs in conjunction with significant physical exertion. Anaphylaxis occurring when an individual exercise within a few hours of ingesting a particular food is an unusual variant. Cardiovascular symptoms can be the sole manifestation of exercise-induced food allergies, in which case death may mimic sudden cardiac death during physical exertion due to other pathologic causes. We report the sudden and unexpected death of an individual following the ingestion of hazelnuts and almonds, to which the individual was not previously known to be allergic. The decedent collapsed during vigorous dancing. The death was not associated with cutaneous or laryngeal manifestations of anaphylaxis. Awareness of the variable manifestations of food-precipitated anaphylaxis is necessary to correctly establish the diagnosis. An elevated serum tryptase level may be indicative of an allergic reaction, and allergen-specific IgE levels may be used to confirm the particular antigen.     

Human bites and the risk of human immunodeficiency virus transmission.

The risk of human immunodeficiency virus (HIV) transmission following a bite injury is important to many groups of people. The first are those who are likely to be bitten as an occupational risk, such as police officers and institutional staff. Another group are represented by the victims and perpetrators of crimes involving biting, both in attack and defense situations. The possibility of these bites transmitting a potentially fatal disease is of interest to the physicians who treat such patients and the legal system which may have to deal with the repercussions of such a transmission. Bite injuries represent 1% of all emergency department admissions in the United States, and human bites are the third most common following those of dogs and cats. The worldwide epidemic of HIV and acquired immunodeficiency syndrome (AIDS) continues, with >5 million new cases last year and affecting 1 in 100 sexually active adults. A review of the literature concerning human bites, HIV and AIDS, HIV in saliva, and case examples was performed to examine the current opinion regarding the transmission of HIV via this route. A bite from an HIV-seropositive individual that breaks the skin or is associated with a previous injury carries a risk of infection for the bitten individual.     

The use of serial measurement of plasma cholinesterase in the management of acute poisoning with organophosphates and carbamates

OBJECTIVE: To evaluate the benefits of using serial measurements of plasma cholinesterase (butyrylcholinesterase, BuChE) activity in the management of cholinesterase inhibitor insecticidal poisoning. METHOD: After establishing and validating BuChE activity test, and making it available for clinical service in the toxicology laboratory at Jordan University Hospital. Serial measurements of BuChE were performed on samples taken from 10 symptomatic patients presented with the manifestations of poisoning due to acetylcholinesterase inhibitor insecticides during the year 2001. The number of serial repeats of BuChE activity tests ranged from 2 to 4 and from 8 to 11 for patients with carbamates and organophosphates (OPs) poisoning, respectively. The results of serial measurement of BuChE obtained from each patient's samples were used to draw a curve; three different types of curves were obtained from all patients samples. RESULT: The obtained curves were found to follow our three proposed curves, which support our point view regarding the importance of the proposed curves in the differential diagnosis and treatment of cholinesterase inhibitor pesticides poisoning. CONCLUSION: This study pointed out the importance of utilizing serial measurements of BuChE activity in the diagnosis and the management of organophosphates and carbamates poisoning. The BuChE activity results were used to support diagnostic and prognostic criteria that guided patient management and follow up. Applying those curves to large number of patients' samples will enhance its credibility. The study also demonstrated the importance of direct contract between toxicologist and physician in treatment of the pesticides poisoned patients.     

Gunshot wound with asphalt related pseudo-soot, pseudo-tattooing, and pseudo-scorching

Artifacts which mimic the tattooing and soot deposition of close range gunshot wounds have been described as "pseudo-soot" and "pseudo-tattooing." The origin of such findings includes glass, intermediate targets, insect bites, medical manipulation, graphite, and sutures. The authors present a case of pseudo-soot and pseudo-tattooing as a result of asphalt pavement, and describe the associated entity of pseudo-scorching.     

Sudden death due to asphyxia by esophageal polyp: two case reports and review of asphyxial deaths

Asphyxia, not an uncommon cause of sudden death, may result from numerous etiologies. Foreign-body aspiration and strangulation are 2 extrinsic causes. Airway obstruction may also be caused by laryngeal edema, asthma, infection, or anaphylaxis. Chronic causes of asphyxia include musculoskeletal diseases (eg, muscular dystrophy, amyotrophic lateral sclerosis), neurologic disorders (eg, myasthenia gravis, multiple sclerosis), respiratory disease (eg, emphysema, chronic bronchitis), or tumors. The manner of death in cases of asphyxiation may be natural, accidental, homicide, or suicide. For the death investigator, determining the cause and manner of death can often be quite challenging.We report here 2 cases of an esophageal fibrovascular polyp causing sudden asphyxial death, review of the literature, and discussion of other differential diagnoses in the case of asphyxial death.     

A study on house fire victims: age, carboxyhemoglobin, hydrogen cyanide and hemolysis.

Correlation among age, concentrations of carboxyhemoglobin and hydrogen cyanide, oxygen density and hemolysis were studied in 120 house fire victims. Victims aged over 60 years comprised approximately 50% of the pooled subjects. Blood samples were mainly collected from the left ventricle, but sometimes from both the right and left ventricles. The concentration of carboxyhemoglobin ranged from 1-95%, of which 71 persons (59.7%) died with carboxyhemoglobin concentrations below 60%. Carboxyhemoglobin concentrations below 10% were found in 9 persons (7.5%). Most of these cases involved the elderly persons. In this paper, we report on the death of elderly victims as a result of low carboxyhemoglobin concentrations. A significant correlation of blood carboxyhemoglobin concentrations existed between the right and left ventricles. The concentration of carboxyhemoglobin in the left ventricle was significantly higher than that in the right. Two out of 31 victims whose hydrogen cyanide concentrations were determined, succumbed to hydrogen cyanide poisoning, having a high concentration of hydrogen cyanide and a low concentration of carboxyhemoglobin. On analysis, oxygen density was found to be low in 13 persons. A negative correlation was shown between carboxyhemoglobin concentration and hemolysis. Inasmuch as hemolysis may indicate the extent of heat dissociation, hemolysis should provide an index of carbon monoxide dissociation from carboxyhemoglobin. In the present study of victims, possible causes of death i.e., carbon monoxide gas poisoning, hydrogen cyanide poisoning, oxygen deprivation, burning, shock due to burns and others were estimated. The survival time for elderly victims was considered to be short.     

Criminal poisoning of commuters in Bangladesh: prospective and retrospective study

Travel-related poisoning is an emerging social and public health emergency in Bangladesh but its cause and significance have not been determined. To investigate this syndrome we performed a prospective clinical study and retrospective analysis of hospital records in a general medicine unit of a public tertiary care teaching hospital in Dhaka, Bangladesh, using toxicological analysis by fluorescence polarization immunoassay (FPIA) and liquid chromatography coupled to time-of-flight mass spectrometry (LC-TOF MS). The participants of the prospective study were 130 consecutive patients aged 16-80 years who were admitted with central nervous system depression (Glasgow Coma Score 3-14) after using public transportation, in the absence of other abnormalities, from January through June 2004, and a convenience sample of 15 such patients admitted during 3 days in May 2006. In 2004-2006, travel-related poisoning increased from 6.1 to 9.5% of all admissions (210-309 of 3266-3843 per year), representing 46.6-55.7% of all admitted poisoning cases. Incidents were associated with bus (76%), taxi, train, and air travel, or local markets; 98% of patients remembered buying or accepting food or drinks before losing consciousness. Direct financial damage (missing property) was diverse and frequently existential. Among 94 urine samples analyzed by FPIA, 74% tested positive for benzodiazepines. Among 15 urine samples analyzed by LC-TOF MS, lorazepam was detected in all; five also contained diazepam or metabolites; nitrazepam was present in three. FPIA results obtained for these 15 samples were below the recommended cut-off in eight (53%; lorazepam only). Our findings show that the massive medicosocial emergency of travel-related poisoning in Bangladesh is the result of drug-facilitated organized crime and that benzodiazepine drugs are used to commit these crimes, suggesting modifications to the local emergency management of the victims of this type of poisoning. They also highlight the need for more research in the neglected field of acute poisoning in Bangladesh, and for criminal investigations of the use of benzodiazepine drugs in this country.     

Fatal alcohol poisoning: medico-legal practices and mortality statistics

Compilation of mortality statistics from death certificate data is based on international and national conventions which in certain situations result in the underlying cause-of-death other than that established and reported by the physician. The present study compares all fatal alcohol poisonings in 1997 as registered on forensic toxicological grounds at the accredited central laboratory and as presented in the national cause-of-death statistics, according to the underlying cause-of-death, by applying international statistical rules and principles in ICD-10. Four groups were formed, and case frequencies in each group were obtained from forensic toxicological data, group "T51" for acute poisonings due to alcohol alone, and group "Comb" for acute alcohol poisonings combined with some drug, medicament or other biological substance, and from cause-of-death statistics data, group "X45", for deaths from alcohol poisoning, and group "F102" for those medico-legal fatal alcohol poisoning deaths which at the statistics office were inferred to be due to alcoholism. The study shows that in Finland the officially compiled statistics on fatal alcohol poisonings, when compared with medico-legal statements based on forensic toxicological examinations, were underrepresented by 31.4% in 1997. About two-thirds of this underrepresentation is explained by preferring, as the underlying cause-of-death, alcoholism to acute alcohol poisoning, and about one-third by preferring, in cases of acute combined poisonings, the drug component to the alcohol. From 1998 onwards, more emphasis has been put on the alcohol component when coding medico-legally proven accidental deaths from simultaneous poisoning with alcohol and a medicinal agent. This change in coding practices presumably explains the subsequent decline in the annual underrepresentation rate of alcohol poisoning in mortality statistics to the level of 15-16%. It is concluded that the present ICD rules inevitably lead to underrepresentation of alcohol poisonings in the mortality statistics, and conceptual and practical proposals for future procedures are made.     

Laboratory investigation of deaths due to anaphylaxis.

To establish a useful laboratory protocol to investigate possible cases of fatal anaphylaxis, we measured mast-cell-derived tryptase levels and allergen-specific immunoglobulin E (IgE) antibody levels in sera obtained prior to or within 24 h after death from 19 anaphylaxis victims. Elevated serum tryptase levels (range = 12 ng/mL to 150 micrograms/mL) were found in nine of nine Hymenoptera sting fatalities, six of eight food-induced fatalities, and two of two reactions to diagnostic therapeutic agents. Tryptase levels were normal (less than 10 ng/mL) in 57 sequential sera obtained postmortem from six control patients. Tryptase could not be measured in pleural or pericardial fluids for technical reasons. Serum IgE antibodies were elevated in five of the nine Hymenoptera sting fatalities and in eight of the eight fatal food reactions; assays were unavailable for the two diagnostic/therapeutic agents. If elevated, the victim's serum IgE antibodies to food could be used to identify allergens in uneaten portions of foods consumed shortly before the anaphylactic event. IgE antibodies were moderately stable during storage in a variety of anticoagulants at room temperature for up to 11 weeks. Elevated mast-cell-derived tryptase levels in postmortem sera reflect antemortem mast cell activation and may be used as a marker for fatal anaphylaxis. If assays are available for IgE antibodies to relevant allergens, such assays provide evidence for antemortem sensitization; these assays may be modified to identify allergens in foods consumed by victims of food-induced anaphylaxis.     

Implications of trombiculid mite bites: report of a case and submission of evidence in a murder trial

Bites of Trombiculid mites implicated a suspect during a homicide investigation. Clinical documentation of the bites, correlation with entomological studies, and submission of evidence at trial are reported. Insects that have a discrete geographic distribution and leave bites of a characteristic nature may have important forensic science implications.     

Fatal poisoning in childhood, England & Wales 1968-2000

We analysed deaths certified as due to poisoning in England & Wales, 1968-2000, in children aged <10 years by age, sex, circumstances of death, intent, and agents involved. The number of deaths fell from 165 (20.6 per million children) in 1968 to 30 (4.6 per million) in 2000, a decrease of approximately 80%. The age-specific death rates were similar in boys and girls. The rate was initially much higher, and fell more, in those aged <5 years. Most deaths (n=1923) occurred in fires, and had been attributed to inhaling combustion products. A small number (n=104) occurred in fires resulting from motor vehicle and other transport accidents. From 1979 (use of ICD-9) the coding of some of these deaths changed from poisoning with carbon monoxide to poisoning with 'other gases, fumes or vapours'. These 'fire deaths' do not appear as poisonings in mortality statistics based on a single underlying cause of death, and cannot be tabulated as poisoning in many countries. Fire deaths and deaths coded to accidental, deliberate, or undetermined poisoning (n=702) decreased substantially with time, and by 2000 numbered 14 and 10, respectively. Accidental deaths declined from 151 in 1968 to 23 in 2000, but homicides and open verdicts varied from 5 to 20 per year, with no clear trend. Deaths attributed to carbon monoxide and to 'other gases, fumes or vapours' (mostly fire-related) totalled 2431 (84% of all poisoning deaths). Overall, 10% of these deaths were either certified as homicides or open verdicts. However, homicide or open verdict was recorded in half of the 47 fatal opiate poisonings. Opioids have now superseded antidepressants as the commonest agents encountered in fatal poisoning with drugs in children.     

Death scene evaluation in a case of fatal accidental carbon monoxide toxicity

Exposure of humans to high concentrations of carbon monoxide can result in death, due to the formation of carboxyhaemoglobin (COHb), which impairs the oxygen carrying capacity of the haemoglobin. Carbon monoxide is responsible of a great number of accidental domestic poisonings and deaths throughout the world, particularly in homes that have faulty or poorly vented combustion appliances. A case is reported, in which a 21-year-old woman was found dead, due to carbon monoxide poisoning from a gas water heater, despite the puzzling evidence that the heater has been used for more than 10 years without any problem. An evaluation of the exposure to CO was performed, by measuiring the rate of production of CO from the heater, and using the Coburn-Forster-Kane equation to describe the kinetics of the poisoning process. The death was attributed to an accidental poisoning from carbon monoxide due to a sum of unfortunate circumstances.     

Sudden death and sepsis after splenectomy

This paper has reported two deaths occurring in young adults who had undergone splenectomy for trauma several years before developing pneumococcal sepsis. Tissues at autopsy demonstrated a disproportionate autolysis for the postmortem interval. One victim also showed diffuse serosal hemorrhages, presumably as a result of disseminated intravascular coagulation. Both showed evidence of residual splenic implants but such implants clearly did not provide protection against sepsis. The mechanisms whereby the spleen protects from sepsis appear to be that of a mechanical filter and an immunological organ producing antibody or antibody-like substance. How much splenic tissue and what relationships to the system circulation are necessary to provide protection remain undiscovered.