Thrombotic thrombocytopenic purpura causing sudden, unexpected death--a series of eight patients

Eight patients were presented to the medical examiner after dying suddenly and unexpectedly from thrombotic thrombocytopenic purpura. Compared with patients who die after prolonged hospitalization and treatment, these patients showed fewer neurologic symptoms and correspondingly fewer or no microthrombi within the brain. Only four of eight subjects developed fever, which further contributed to misdiagnosis. The differences in clinical presentation between our cases and most published series is striking and may be explained by shorter duration and no treatment. Each case contained the characteristic histology of thrombotic thrombocytopenic purpura. Ischemic injury to the heart and conduction system was the most likely mechanism of sudden death. Included in this series is a patient with acquired immunodeficiency syndrome (AIDS) diagnosed at autopsy, a concurrence that is now appearing more frequently in the medical literature.     

Death due to thrombotic thrombocytopenic purpura in pregnancy: case report with review of thrombotic microangiopathies of pregnancy.

Maternal death during pregnancy, although uncommon, may result from a broad range of conditions. In this paper, a case of thrombotic thrombocytopenic purpura diagnosed by postmortem examination is presented. Thrombotic thrombocytopenic purpura is one of a subset of diseases that result in the formation of microthrombi within the vasculature, either as a primary or secondary manifestation. Other conditions included in the differential diagnosis during pregnancy are hemolytic uremic syndrome, systemic lupus erythematosus, preeclampsia-eclampsia and the HELLP syndrome, acute fatty liver of pregnancy, antiphospholipid antibody syndrome, and disseminated intravascular coagulation. The histologic manifestations of these diseases can be similar and in most cases do not provide adequate information to accurately differentiate these diseases in the postmortem period. This paper addresses the need for clinical history (i.e., symptomatology, trimester of onset) and antemortem laboratory testing in addition to a thorough autopsy to accurately differentiate among the conditions named previously. In the absence of an adequate clinical history and antemortem laboratory testing, the more general diagnosis of "thrombotic microangiopathy of pregnancy" is acceptable.     

Sudden death due to thrombotic thrombocytopenic purpura

This case studies the clinical, laboratory, and pathologic findings observed in thrombotic thrombocytopenic purpura (TTP). Although TTP is a well-recognized syndrome, it is frequently undetected antemortem and represents a rare cause of sudden death. We recently were involved in a case of TTP in which an 18-year-old woman with no previous history died suddenly. The case was referred to our office for consultation because of a recent history of methamphetamine abuse. We report herewith our approach to the diagnostic workup of TTP and review relevant literature.     

Fluidity of cadaveric blood after sudden death: Part I. Postmortem fibrinolysis and plasma catecholamine level

In rats, fibrinolytic activity and plasma catecholamine levels increased rapidly after death. Postmortem fibrinolysis was affected by the method of sacrifice, but catecholamine level was not always affected. Immediately after death, the plasma adrenalin level was higher than the noradrenalin level, but then adrenalin remained unchanged or tended to decrease while noradrenalin tended to increase gradually with time. In human subjects after rapid death, the plasma catecholamine and fibrinolytic activity levels were high. However, in cases after slow death they were low.     

白血病死亡的法医学鉴定

材料和方法回顾性研究我所2003～2005年间检案实践中4例白血病死亡的法医学鉴定案件。结果4例死者生前均无明显的血液病症状,其中1例死亡前经临床确诊为急性颗粒增多型早幼粒细胞性白血病（M3）,另外3例均无血液病相应的临床资料。尸体解剖主要所见：（1）多器官（尤其是脑）白血病细胞浸润;（2）肝、脾肿大;（3）凝血功能障碍引起的出血倾向,如：皮肤紫癜、创口渗血或迁延不愈等;（4）可排除暴力死亡。结论白血病细胞脑浸润引起的脑内血肿和血液病的并发症弥漫性血管内凝血（DIC）是导致死亡的常见原因;在白血病患者突发死亡的案例中,死者生前往往缺乏典型的血液病症状,或仅有轻微的症状未引起注意;此类案件的法医学鉴定应注意收集临床资料,必须进行系统的尸体解剖检验,在有检验条件的情况下应进行骨髓细胞学病理检验。     

Extensive Necrotic Purpura in Levamisole‐Adulterated Cocaine Abuse – A Case Report

Levamisole, which is used as an adulterated compound of cocaine, is currently being seen year after year in cocaine intoxication. For a few cases in the last decade, necrotic purpura and neutropenia after levamisole/cocaine intoxication have been described in the medical community. Herein, we present an original case of levamisole intoxication of a 40‐year‐old woman who smoked heroin and cocaine few during a month. She rapidly presented an extensive necrotic purpura of the nose, cheeks and extremities (lower and upper), and immunologic reactions (positive anti‐MPO and anti‐HNE). Levamisole was detected on hairs with ultra‐high performance liquid chromatography and tandem mass spectrometry. The case reports also a probable cocaine supplier deceit, which bring pure drug for hospital investigation after the intoxication of his client. The intoxicated woman had survived with several skin and chronic pain complications. That case recalls the knowledge about levamisole with a short review of the forensic literature.     

Histamine, cortisol and organ changes in fatal anaphylactic shock in guinea-pigs

Anaphylactic shock was produced in guinea-pigs by sensitizing them with oval albumin and challenging them with an intracardial dose (rapid shock) or intraperitoneal dose (slow shock) of the same protein 4 weeks later. The animals died within 5 min or 30 min, respectively. Blood for biochemical assays was taken by cardiac puncture and tissue samples were excised for histamine assay and histological studies. High concentrations of histamine (4-5 times the control values) were measured in the animals which died rapidly, but not in the others, whereas the histamine content of the stomach wall and lungs was decreased both in rapid and slow shock. Plasma cortisol was low in the rapid shock group. Plasma free fatty acids were high in both groups, but glucose only in the slow shock group. The lungs were distended, indicating bronchial obstruction. Occasional platelet agglutinations were seen in the lung veins. The most promising signs regarding the diagnosis of death from anaphylaxis were the high plasma histamine values and acute emphysema.     

Postmortem stability of DNA

High-molecular-weight DNA was recovered postmortem in sufficient quantities from various human organ tissues as well as from blood, although not all organs were equally well suitable. Good DNA stability was found in brain cortex, lymph nodes and psoas muscle over a period of three weeks postmortem. Spleen and kidney showed good DNA stability up to five days postmortem but after longer periods, rapid degradation was observed. Yields of DNA from blood were not consistent because of the non homogeneity of samples. Blood clots were rich with DNA. Generally, the amount of degraded DNA correlated directly with the duration of the postmortem period. However in some cases, DNA degradation was already prominent after a short period. However in some cases, DNA degradation was already prominent after a short period. Case histories showed that high environmental temperature at the site of death and/or infectious diseases prior to death were the main factors for rapid autolysis. Gradual disappearance to complete loss of the long fragments (15-23 kb) was observed in DNA fingerprinting using the minisatellite probe 33.15. No extra-bands were noted, thus excluding erroneous conclusions. However, evidentiary value of older samples was lower.     

Fournier Gangrene and Unexpected Death

Abstract: Fournier gangrene represents a rare but progressive perineal infection that may result in rapid death. A 70‐year‐old man with poorly controlled diabetes mellitus and alcohol abuse is reported who was found unexpectedly dead. He had last been contacted the night before his death. At autopsy, the most striking finding was deep necrotic ulceration of the scrotum with exposure of underlying deep muscles and testicles, with blood cultures positive for Escherichia coli. Death was, therefore, attributed to necrotic ulceration/gangrene of the perineum (Fournier gangrene) that was due to E. coli sepsis with underlying contributing factors of diabetes mellitus and alcoholism. In addition there was morbid obesity (body mass index 46.9), cirrhosis of the liver, and marked focal coronary artery atherosclerosis with significant cardiomegaly. Fournier gangrene may be an extremely aggressive condition that can result in rapid death, as was demonstrated by the rapid progression in the reported case.     

论脑死亡标准中的法律问题

随着医学科学的迅速发展 ,传统的死亡标准已不能适应现实的需要 ,更阻碍了有关医学的进一步发展。有学者提出脑死亡概念 ,国外也有相关立法 ,我国脑死亡立法也已进入实质性程序。本文对脑死亡的概念、意义、标准及国外的规定作了初步的阐述 ,并对我国的立法提出建议。     

Anaphylactic death: the effect of aminoguanidine and heparin on histamine and stress hormones in guinea pigs

The modifying effect of aminoguanidine (a histaminase inhibitor) and heparin (a histaminase liberator) on anaphylactic shock in guinea pigs was studied using ovalbumin as an antigen and trigger. The animals died of the shock, the time to death remaining unaltered by the drugs. Serum histamine and cortisol values were high after shock, but were reduced by heparin. Both noradrenaline and adrenaline in plasma were also elevated after shock, the final concentration of the latter being lowered by heparin. The lungs were dilated, indicating bronchoconstriction. The results confirm the role of histamine in anaphylactic shock and its potential value for the diagnosis in this kind of rapid death, in which morphological signs are scarce or lacking. Its diagnostic value still requires confirmation, however, which only autopsy studies can supply. It also appears that pretreatment of the animals with heparin affected the blood cortisol and catecholamines, which are involved in the shock mechanism as countermeasures, although aminoguanidine did not have any effect.     

Sudden death after a cold drink: case report

We report a case of sudden cardiac death in a 12-year-old boy after rapid ingestion of a frozen slurry drink. The cause of death was determined to be a cardiac arrhythmia secondary to a previously undiagnosed cardiac rhabdomyoma with associated myocardial scarring. Ingestion of cold liquids has been associated with syncope, but not sudden cardiac death. In this case, bradycardia induced by cold-induced vasovagal reflex may have precipitated the terminal arrhythmia. Ingestion of cold liquids should be considered a potential trigger for fatal cardiac arrhythmias in patients with underlying heart disease.     

Homicide by intravenous injection of naphtha

A case of homicide by the intravenous injection of Energine, a petroleum distillate spot remover, is presented. This case is the only known homicide committed with naphtha. This elderly man had severe natural disease in addition to chest trauma sustained in the assault leading to death; however, the rapid injection of approximately 25 mL of Energine was the overwhelming cause of death.     

Sudden, unexpected death due to "pineal apoplexy"

A 20-year-old woman had a minute vascular malformation in the wall of a glial cyst of the pineal body. Bleeding into the cyst lumen caused rapid expansion of the pineal body, resulting in compression of the midbrain and her sudden, unexpected death.     

家兔死后体内2-氨基噻唑啉-4-羧酸分布研究

目的建立家兔氰化钾灌胃给药致死动物模型,研究氰化物代谢物2-氨基噻唑啉-4-羧酸(ATCA)在家兔体内的死后分布规律。方法雄性家兔7只(体重约2.0kg~2.5kg)经口灌胃2LD50(10mg/kg)氰化钾水溶液,观察家兔反应,待家兔呼吸、心跳和反射全部消失后立即对家兔进行解剖取心、肝、脾、肺、肾、脑、睾丸、胃壁、肌肉等组织检材以及心血、玻璃体液、尿液等体液检材置于-80℃冷冻保存待检。液相色谱-串联质谱联用法测定生物检材中氰化物代谢物ATCA的含量,对其在各个组织的分布进行比较并寻找规律。结果氰化钾灌胃后家兔出现呼吸频率加快,走路乏力,癫痫大发作样抽搐,后瞳孔散大,肌肉松弛,各种反射消失,似"电击样"死亡。死亡后测得心血中氰基(CN-)平均浓度为11.81μg/ml。死后0h氰化物代谢物ATCA在家兔体内的分布如下:脾>肺>肾>肝、脑>睾丸>心血>心、胃壁>玻璃体液>右下肢肌肉>尿。结论大剂量氰化物中毒致死后其代谢物ATCA在家兔体内分布不均匀,在脾中最高,尿中最低。在疑似氰化物中毒致死案件的法医学鉴定中,除采取心血外,还应全面正确采集分布量较高的脾、肺、肾和肝组织进行氰化物代谢物ATCA的定性定量分析。     

A rapid postmortem cardiac troponin T assay: laboratory evidence of sudden cardiac death

Postmortem examination may be useful in establishing the cause of sudden unexpected death. In many instances, however, limitations of staffing, budget, and time may force the pathologist to triage cases to external examination rather than autopsy. A rapid assay for cardiac troponin T (cTnT) to document suspected cardiac-related deaths may optimize the use of the time and resources of the autopsy pathologist. Peripheral blood was sampled percutaneously before each of 40 autopsies and placed in the well of the Cardiac T Rapid Assay unit in accordance with the included instructions, and the results were read after 15 minutes. The assay result, decedent age, postmortem interval, and evidence of cardiopulmonary resuscitation were tabulated and subsequently correlated with the cause of death. On final sign-out of each of the autopsies, the cause of death was determined to be cardiac-related (n = 20) versus the cause in non-cardiac control subjects (n = 20). This determination was made while the investigators were blinded to the cTnT assay result. Of the 20 cardiac deaths, 17 (85%) showed positive results for cTnT compared with 6 (30%) false-positive results among the 20 control cases; this result was statistically significant according to the chi-square test. In the over-50 age group, the sensitivity of this assay in detecting cardiac-related death was 91%, with a specificity of 86%. Perimortem cardiopulmonary resuscitation did not appear to result in false-positive results. In the appropriate setting, this rapid assay for cTnT can provide valuable data supportive of a cardiac-related death. This inexpensive test may best be used in triaging sudden deaths in persons over 50 to external examination versus complete autopsy.     

Rupture of liver cell adenoma with fatal massive hemoperitoneum resulting from minor road accident

Blunt abdominal trauma can cause rapid death resulting from serious injuries of internal organs. The liver is commonly involved and may show tearing, usually in its upper surface, resulting in hemoperitoneum eventually leading to death. Minor trauma implies serious liver damage only when previous pathologic changes causing enlargement of the organ are present. The case of a 25-year-old woman who died as a consequence of a minor road accident is reported. At autopsy, the body showed no external injuries, the only relevant finding being a massive hemoperitoneum from the rupture of an unusually large liver cell adenoma. Liver cell adenomas carry a serious risk of spontaneous rupture, which may result in the death of the patient. The occurrence of the rupture after a minor blunt abdominal trauma is highly unusual.     

Hyperthermia,Thermal Injuries,and Death from a Forced Convection Heat Source: A Case Report and Experimental Model

Heat‐related deaths of children are most often encountered in the context of enclosed vehicles in summer months. Deviating from this, a 16‐month‐old boy was found unresponsive in a stroller that was placed adjacent to a space heater during mid‐winter. The cause of death was hyperthermia and thermal injuries. Manner of death determination was difficult due to alleged surrounding circumstances. To understand the time‐course of this child's injuries, a child death scene investigation was performed; the stroller and space heater were recovered. In a re‐enactment of the events, a slaughtered pig approximating the child's size was warmed using a water bath and placed in the stroller beside the space heater. Cutaneous temperature measurements showed rapid initial temperature rise with subsequent steady increases. Tanning of the skin was seen on periodic direct observations. Internal temperature monitoring illustrated steady increases. This experiment was essential in classifying the manner of death as homicide.     

Sudden and unexpected death from pituitary tumor apoplexy

Pituitary tumor apoplexy refers to a clinical syndrome precipitated by the expansion of a pituitary adenoma by hemorrhage or infarction. Individuals may present with myriad signs, including sudden onset of severe headache, visual changes, altered mental status, cranial nerve palsies, and hormonal dysfunction. This disorder constitutes a medical emergency and warrants an expedited evaluation, diagnosis, and treatment to prevent the potential sequelae of permanent visual loss, endocrine abnormalities, or death. We report a case of sudden death from undiagnosed pituitary tumor apoplexy. The decedent was evaluated by medical personnel on three occasions in the week prior to her death for severe headache, nausea, vomiting, and photophobia. Postmortem examination demonstrated a hemorrhagic infarction of a pituitary adenoma with necrosis and expansion out of the sella turcica. The recognition of and treatment for a patient with pituitary tumor apoplexy requires a rapid multidisciplinary effort. Failure of prompt diagnosis may be fatal and require a medico-legal death investigation for sudden and unexpected death.     

A Very Unusual Accidental Mechanical Asphyxia of Choking with a Whole Solea Solea

The case here reported involves a schizophrenic 19‐year‐old girl under treatment with clotiapine, which was well tolerated except for a moderate dry mouth. The woman ingested a whole sole (Solea solea), which caused a very rapid death by choking. A complete autopsy was performed 24 h later, as well as histological and toxicological analysis. At autopsy, the sole was wedged in the esophagus causing a choking ab extrinseco. The fish had a length of 18 cm and a maximum width of 6 cm, weighing 188.7 g. Toxicological analysis detected 0.57 mg/L of clotiapine in blood, which falls within the therapeutic range. The peculiarity of this case is represented by two factors: one is the choking by fish and the second was the adverse affect caused by clotiapine, which induced a condition of dry mouth making the act of swallowing even more difficult, thereby contributing to a very rapid mechanical asphyxia and the death of the young woman.