Fatal malignant hyperthermia--delayed onset and atypical course

A case of malignant hyperthermia (mh) in a 27-year-old man is described. In a first anaesthesia using isoflurane and succinylcholine, the end-tidal CO(2) rose from 39 to 49 mmHg 2.75 h post-intubation and the body temperature rose to 39.8 degrees C 14 h post-intubation but was normal again the next day. In a second anaesthesia using the same medication, the maximal end-tidal CO(2) was 44 mmHg and the body temperature rose to 39 degrees C after 9 h. After 4 days, the fever rose to 40 degrees C, and to 42 degrees C when death occurred 10 days after the second anaesthesia. Masseter spasms or muscle rigidity were never present. According to the death certificate, death was due to multi-organ failure from sepsis. At autopsy, the skeletal muscles were pale and oedematous. Histology demonstrated focal necroses in the skeletal muscles, shock kidneys with myoglobin excretion and myoglobin clots in small blood vessels of the lungs. Hence, the postmortem diagnosis "malignant hyperthermia" was established but accusations of medical maltreatment were rejected because of the atypical and protracted clinical course and because uncharacteristic signs of malignant hyperthermia were attributable to the clinically suspected sepsis.     

Sudden death due to malignant hyperthermia

A case of sudden death in a young athlete, most likely the result of malignant hyperthermia, is reported. This diagnosis was entertained at autopsy and later confirmed by muscle biopsy on the father of the deceased, who was proven to be susceptible to malignant hyperthermia. The condition should be strongly suspected at autopsy in unexplained sudden deaths of young adults occurring during exercise or under stress.     

Is it a modacrylic fibre?

This study describes the characteristics of modacrylic fibres and includes over 80 samples (previous and current) representing 15 trade names. Fibre morphology was examined using brightfield microscopy. Signs of elongation were determined using polarised light microscopy. Fibre cross sections were also examined. The generic class of fibre was divided into sub groups using polymer composition as determined by FTIR-microscopy. Microscopically, some modacrylic fibres cannot be distinguished from acrylic fibres. Others display unusual optical and morphological features which are a strong indication of their generic class. The infrared spectra provide information about the co-monomer, termonomers added to produced dye sites, the presence of solvent residue, dyes, and additives, e.g. flame retardant material. The infrared spectra should always be recorded before and after any thin layer chromatographic examination of the dye, otherwise peaks attributable to dyes, which may be a valuable comparative feature in casework will be lost.     

An autopsy case of malignant hyperthermia

A report is made of a 44-year-old female who died of malignant hyperthermia during general anesthesia for an operation of left subtrochanteric femoral fracture. Symptoms began with increases in heart rate and blood pressure after the introduction of anesthesia with halothane and were accelerated by the administration of succinylcholine, followed by muscle rigidity and high temperature. The typical wine red urine was observed. The oral temperature of 42 degrees C was recorded within 1 h after succinylcholine. The rectal temperature was 30 degrees C 22 h after death. Severe pulmonary edema and tubular necrosis of the kidney were found by postmortem examination. No latent myopathy was observed. The creatine phosphokinase levels in plasma obtained after the onset of malignant hyperthermia and at the time of autopsy were abnormally high and were 5632 and 34,854 mU/ml, respectively. Plasma myoglobin levels were 130,000 and 2.8 X 10(6) ng/ml, respectively.     

The population of coloured textile fibres in domestic washing machines.

A population survey was carried out to analyse examples of the coloured fibre population that may be expected to exist in both front- and top-loading domestic washing machines during Spring, in Sydney, Australia. White cotton T-shirts were washed both individually, and with a normal household wash load, then taped to recover extraneous fibres transferred during the wash cycle. Twelve thousand one hundred and seventy-eight fibres were classified according to length, colour and generic class. Cotton fibres were most prevalent (69.4%), followed by man-made fibres (24.2%). The most common colour/generic class combinations were black/grey cotton (27%), blue cotton (20%) and red cotton (15.6%). Other combinations generally represented under 2% of the total fibre population. Two thirds (65.9%) of the recovered fibres were under 2 mm in length, the proportion of fibres decreasing with increasing fibre length. Variations in machine type did not affect the distribution of fibres with respect to fibre type, colour or length.     

A study in relation to the random distribution of four fibre types on clothing (incorporating a review of previous target fibre studies).

A new target fibre study was undertaken building upon eight previous published studies, which are reviewed here. Fifty-eight items of outer clothing, obtained from households across England, were taped and searched for three types of commonly occurring fibres and one less common fibre type. The tapes were examined using a combination of automatic and manual searching. Any fibres similar to the target fibres were removed and examined using microspectrophotometry, comparison microscopy, thin layer chromatography (TLC) and fourier transform infrared spectroscopy (FTIR) where applicable. One polyester fibre, four acrylic fibres and eleven wool fibres were found that matched the three commonly occurring target fibre samples. None of the less common polyester fibres were found. One item had six matching wool fibres and another had the polyester fibre and an acrylic fibre recovered from it. The remaining eight fibres were each recovered from individual items. The results suggest that finding a large number of fibres that match a control is unlikely to happen by chance, which supports the findings of the previous target fibre studies.     

Damage caused to fibres by vapour cloud explosions

Research on the very specific damage to single textile fibres caused by vapour cloud explosions is presented. Vapour cloud explosion experiments were carried out using a selection of 41 garments differing in colour, fibre composition and textile construction. Fibres subjected to a vapour cloud explosion become wider at the end, often taking the form of a ball, bulb or shovel, while the morphological structure of the remaining part of the fibre remains almost unchanged. The presented results can clearly indicate that an explosion took place at the scene of the crime. The authors would like to be able to provide investigators with specific information on how to link clothes (and thus people) to a specific type of crime.     

Fatal neurotoxic response to neuroleptic medications: case report and review of the literature

Neuroleptic malignant syndrome (NMS) is a diagnosis of exclusion difficult to make due to a lack of pathognomonic features. Diagnosing NMS by postmortem examination becomes increasingly challenging when possible underlying brain pathology is obscured. The diagnosis is based on clinical history and laboratory findings. Autopsy and histologic findings, if any, usually are reflective of hyperthermia or complications (eg, aspiration pneumonia) of NMS. The authors describe a case of a 36-year-old Hispanic woman with a presumptive diagnosis of pseudoseizures, treated with various combinations of neuroleptic medications over a 6-week period prior to her sudden, unexpected, in-hospital death. Neuroleptic malignant syndrome is likely to have contributed to this patient's death. Confounding factors and medicolegal issues of a postmortem diagnosis of NMS are discussed.     

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.     

Further insights into the persistence of transferred fibres on outdoor clothes.

This study was conducted to assess persistence of fibres on items of outdoor clothes in normal wear situations. The persistence of acrylic and wool fibres transferred on 23 recipient garments was examined in relation to: time of wear; features of the recipient garment (fibre composition, surface structure and texture); conditions of wear (public transport used or not), and; their location on the recipient. After 8 hours of wear more than 75% of transferred fibres were lost during 8-10 hours of wear. After 16 hours of wear no more than 10%, most often up to 5%, of fibres remained. Fibres were lost at higher rate when public transport was used. The persistence of fibres depended more on the surface structure and texture of the recipient garment and the location of donor fibres rather than on the type of fibre.     

Urinary catecholamines in hyperthermia-related deaths

A group of five hyperthermia-related deaths is presented in which urinary noradrenaline (NA) concentrations were elevated (172.1 +/- 119.4 ng/ml) compared with a control group of rapid violent deaths (43.7 +/- 26.1 ng/ml). Urinary adrenaline (A) concentrations were not elevated in the hyperthermia cases, nor were there any significant differences in urinary dopamine (DA) concentrations between the two groups. All except one of the hyperthermia victims were under the influence of ethanol. It is suggested that a combination of heat stress and ethanol consumption was responsible for the elevated urinary NA in the hyperthermia cases, reflecting increased sympathetic nervous system activity. A combination of high urinary NA with low A seems to be characteristic of hyperthermia fatalities, in contrast to hypothermia deaths, where both NA and A are usually elevated.     

The persistence of fibres on skin in an outdoor deposition crime scene scenario

Textile fibres were transferred to a pig skin carcass and their persistence determined at daily intervals for up to a 12 day period during which time the carcass was left outdoors exposed to the prevailing weather conditions and animal activity. In the absence of strong winds and precipitation, the loss of fibres was found to be exponential. Stronger winds and heavier precipitation caused an increase in the rate of loss of fibres. The results of this study showed that the majority of fibres transferred to a body deposited outdoors, can be expected to be lost after the first 2 days, however, none of the experiments performed resulted in a complete loss of fibres, even after 12 days exposure. These persistence characteristics differed from those observed in a similar study using small sections of skin, rather than carcasses.The implications of the results of the present study in relation to the examination of fibre evidence in cases of homicide are discussed.     

The use of linear dichroism in forensic fibre examinations — Part 6. Validation and practical aspects of MSP-PPL

This paper summarizes the results of previous work on the microscopic observation of linear dichroism found in dyed fibres (polyesters, polyamides, wool, silk, cotton, viscose, acrylics and acetates) and in pigmented fibres as well as the measurements on these fibre classes using microspectrophotometry with plane polarized light (MSP-PPL). The validation of this method is discussed and a practical tool is proposed for comparing fibre traces with control fibres. The limitations and strengths of this method are also revised.     

The individuality of fibres used to provide forensic evidence--not all blue polyesters are the same.

Fibres used in forensic casework suffer from a disadvantage common to other forms of trace evidence--it is not possible to state with absolute certainty that they originate from a specific source. Target fibre studies, population studies and research on 'blocks of colour' have effectively demonstrated the polymorphism of textile fibres (particularly man-made ones) and have shown that when a fibre is believed to have a specific putative source, the chance that it has originated from a different source purely by coincidence is extremely remote. A study by Houck MM (Houck MM, Inter-comparison of unrelated fibre evidence. Forensic Science International 2003; 135: 146-149) has shown that no coincidental matching fibres were recovered from items of clothing examined in 20 unrelated crimes. The study involved over two million comparisons. This work goes a step further, and using the example of blue polyester fibres shows that even within a very narrow segment of the whole general fibre population, many examples of a specific colour/type of man-made fibre taken from random sources can be compared and the chance of any two being the same is very low. These studies should help to show the specificity and value of transferred fibres in providing forensic evidence.     

The influence of hypnotics on the development of morphological and biochemical wound reaction (author's transl)]

The influence of hypnotics (barbital and carbromal) on the development of the early wound reactions in mechanically injured skin of guinea pigs was investigated: 1) The cellular reactions in incised wounds were retarded after moderate intoxication by hypnotics (300 mg/kg barbital; 3 g/kg carbromal). The histomorphological changes in wounds were inhibited by carbromal twice as much as by barbital. The hitherto published investigations had not shown any retardation of the early cellular inflammation by weakening influences such as loss of blood or alcohol without symptoms of shock (Berg et al., 1977) or local disturbances by acids and bases (Kampmann et al., 1978). 2). A moderate delay of the activity of structure bound enzymes was found in barbital intoxication, a stronger restriction under the influence of carbromal. 3) After barbital intoxication significant elevation of histamine or serotonin in wounds was not seen. Under the influence of carbromal there was also no increase of histamine but an increase of serotonin. Thus, although the cellular reactions seem to be the most reliable indicator among the methods for the determinations of wound age under devitalizing influences, their value is reduced in cases of intoxications by hypnotics needing treatment. Possible pathophysiological connections of the alterations of morphological and biochemical wound reaction with shock are discussed.     

The effect of sodium hydroxide and hydrochloric acid on pig dermis. A light microscopic study

In order to compare the dermal changes after exposure to direct current (d.c.) with changes after influence of acid and base influence, the skin of fully anaesthetized Danish Landrace pigs were exposed to acid and basic solutions. Biopsies were obtained immediately after and up to day 7 after the injury. Collagen fibres with increased affinity for eosin and irregular cross-striation in polarized light together with shrunken cells with dark stained nuclei were found just beneath the epidermis immediately after application of 1 N HCl. Immediately after exposure to 1 N NaOH dispersed collagen fibres showed increased eosinophilia and a fine densely spaced cross-striation in polarized light and vesicular nuclei were present within dermal cells. During the following days a narrow demarcation zone of neutrophilic granulocytes separated the zone containing abnormal collagen fibres from normal tissue below. Calcified collagen fibres were not observed and no other abnormal histochemical reactions were present. It is concluded that the morphology of acid induced lesions and base induced lesions shows resemblance to the morphology of anode and cathode lesions, respectively, but not to heat lesions. The reason for not finding depositions of calcium salts on collagen fibres in skin exposed to basic solutions could be a non-optimal pH in the tissue or that other electrochemical processes than shift in pH are necessary for the calcification process.     

Differentiating cause-of-death terminology for deaths coded as sudden infant death syndrome, accidental suffocation, and unknown cause: an investigation using US death certificates, 2003-2004

We compared written text on infant death certificates for deaths coded as sudden infant death syndrome (R95), unknown cause (R99), and accidental suffocation (W75). Using US mortality files supplemented with the death certifiers' written text for all infant deaths with International Classification of Diseases (ICD)-10 assigned codes R95, R99, and W75, we formed cause-of-death subcategories from common themes identified from the written text. Among all infant deaths in 2003-2004, the underlying cause of death was listed as R99 for 2128 deaths, R95 for 4408 deaths, and W75 for 931 deaths. Among the postneonatal deaths, the differences in subcategories varied between assigned ICD-10 codes: for R99-coded deaths, 45.8% were categorized as "Unknown" and 48.6% as "Pending"; for R95-coded deaths, 67.7% were categorized as "sudden infant death syndrome (SIDS)"; and for W75-coded deaths, 76.4% were categorized as "Suffocation." Examination of the written text on the death certificates demonstrates variability in the assigned ICD-10 codes which could have an important effect on the estimates of SIDS cases in the United States.     

Hyperthermia deaths in Finland in 1970-86

All cases in which hyperthermia had been determined as the basic cause of death during the period 1970-86 were collected from the records of the Central Statistical Office of Finland. Of the total of 230 cases, 228 were included in the present study; the two remaining victims died abroad, and no autopsy was performed in Finland. Most of the hyperthermia deaths occurred while the decedent was taking a sauna bath; most decedents were men aged 42-62 years. An increase in the total number of hyperthermia deaths, and of male victims, was noted from the beginning of the 1970s onward; the number of female victims remained at a relatively steady level throughout, with the exception of a slight rise in 1986. Acute alcohol consumption was detected in most of the victims; in some cases there was also a reference to chronic alcoholism or recent long-term heavy drinking. The findings suggest that in addition to the acute hazardous effect of ethanol on thermoregulatory mechanisms, the long-term consumption of alcohol may have promoted fatal hyperthermia in these subjects.     

A further study of dye batch variation in textile and carpet fibres.

Four sets of acrylic fibre samples were obtained from a company that dyes fabrics for the fashion industry. Between seven and ten different batches of fibres constituted each set. Comparison microscopy, visible and UV range microspectrophotometry and thin layer chromatography (TLC) were used to compare the dyes on each batch of fibres within the sets. Only one of the four sets exhibited variation within the batches. The differences were seen when both microscopical and analytical techniques were used. In addition, two further sets of samples had been obtained from a company that produces carpets for the car industry. The first set consisted of 26 batches of acid dyed orange nylon fibres. The second consisted of 21 batches of acid dyed mustard coloured nylon and direct dyed brown viscose fibres blended together. When the first set was viewed under UV light one batch had more pale orange fibres present and they fluoresced more brightly than the other fibres. This could be due to the blending with a different dye batch of fibre or due to poor dye uptake--the latter being more likely. When tested using visible and UV range microspectrophotometry and TLC, further dye batch variation was not detected. The second set was examined after separating the nylon and viscose fibres from each other. The nylon fibres were indistinguishable when a range of microscopical and analytical techniques were employed; however, the viscose fibres showed dye batch variation when TLC was used.