Influenza A virus infection complicated by fatal myocarditis

Influenza virus typically causes a febrile respiratory illness, but it can present with a variety of other clinical manifestations. We report a fatal case of myocarditis associated with influenza A infection. A previously healthy 11-year-old girl had malaise and fever for approximately 1 week before a sudden, witnessed fatal collapse at home. Autopsy revealed a pericardial effusion, a mixed lymphocytic and neutrophilic myocarditis, a mild lymphocytic interstitial pneumonia, focal bronchial/bronchiolar mucosal necrosis, and histologic changes consistent with asthma. Infection with influenza A (H3N2) was confirmed by virus isolation from a postmortem nasopharyngeal swab. Attempts to isolate virus from heart and lung tissue were unsuccessful. Immunohistochemical tests directed against influenza A antigens and in situ hybridization for influenza A genetic material demonstrated positive staining in bronchial epithelial cells, whereas heart sections were negative. Sudden death is a rare complication of influenza and may be caused by myocarditis. Forensic pathologists should be aware that postmortem nasopharyngeal swabs for viral culture and immunohistochemical or in situ hybridization procedures on lung tissue might be necessary to achieve a diagnosis. Because neither culturable virus nor influenza viral antigen could be identified in heart tissue, the pathogenesis of influenza myocarditis in this case is unlikely to be the result of direct infection of myocardium by the virus. The risk factors for developing myocarditis during an influenza infection are unknown.     

Axonal injury – a diagnostic tool in forensic neuropathology?: A review

We used β-amyloid precursor protein (β-APP) to investigate our own forensic neuropathological case material (n=252) in light of the current literature on the phenomenon “axonal injury” (AI) to determine the incidence, specificity and biomechanical significance of AI and its significance for determining vitality and survival time. The case material consisted of cases of fatal nonmissile closed-head injury (n=119), gunshot injury (n=30), fatal cerebral ischemia/hypoxia (n=51), brain death caused by mechanical trauma (n=14) or nonmechanical injury (n=18), and acute hemorrhagic shock (n=20). AI was observed in 65% to 100% of cases of closed-head injury, fatal cerebral ischemia/hypoxia, and brain death with a survival time of more than 3 h; AI could not be detected in the cases of acute hemorrhagic shock. A statistically significant difference between traumatically and nontraumatically induced (nondisruptive) AI was not found. There was no statistical evidence of a correlation between AI and the different types of external force, since AI could be demonstrated after both acceleration/deceleration injuries and traumatic impact. Therefore, biomechanical inferences for reconstruction purposes are not possible. On the other hand, β-APP was found to be a definite marker of vitality. In our material, cases with a posttraumatic interval of under 180 min did not express β-APP. Moreover, the literature shows that the posttraumatic interval can be determined by other methods for demonstration of AI such as by ubiquitin immunostaining (360 min), silver staining (15–18 h), hematoxylin and eosin staining (about 24 h), or by demonstration of a microglial reaction (about 4 to 10 days) or of a few remaining isolated bulbs, without accompanying fibers, which can be detected after a survival time of up to 17 months.     

A fatal poisoning involving Bromo-Dragonfly

This paper reports a fatal overdose case involving the potent hallucinogenic drug Bromo-Dragonfly (1-(8-bromobenzo[1,2-b; 4,5-b′]difuran-4-yl)-2-aminopropane). In the present case, an 18-year-old woman was found dead after ingestion of a hallucinogenic liquid. A medico-legal autopsy was performed on the deceased, during which liver, blood, urine and vitreous humour were submitted for toxicological examination. Bromo-Dragonfly was identified in the liver blood using UPLC–TOFMS, and was subsequently quantified in femoral blood (0.0047 mg/kg), urine (0.033 mg/kg) and vitreous humour (0.0005 mg/kg) using LC–MS/MS. Calibration standards were prepared from Bromo-Dragonfly isolated from a bottle found next to the deceased. The structure and purity of the isolated compound were unambiguously determined from analysis of UPLC–TOFMS, GC–MS, HPLC–DAD, ¹H and ¹³C NMR data and by comparison to literature data.The autopsy findings were non-specific for acute poisoning. However, based on the toxicological findings, the cause of death was determined to be a fatal overdose of Bromo-Dragonfly, as no ethanol and no therapeutics or other drugs of abuse besides Bromo-Dragonfly were detected in the liver, blood or urine samples from the deceased. To our knowledge, this is the first report of quantification of Bromo-Dragonfly in a biological specimen from a deceased person. This case caused the drug to be classified as an illegal drug in Denmark on 5th December 2007.     

Fatal Myocarditis Following Treatment with the PD‐1 Inhibitor Nivolumab

Therapeutic antibodies targeting the programmed cell death protein 1 (PD‐1) pathway function as immune checkpoint inhibitors, allowing the immune system to recognize tumors which otherwise escape immune surveillance. However, these agents can also elicit an autoimmune response by inhibiting the ability of non‐neoplastic tissues and regulatory cells to suppress the immune system. Here we present a fatal case of active myocarditis in a 55‐year‐old man with non‐small‐cell lung cancer which occurred following monotherapy with the PD‐1 inhibitor nivolumab (Opdivo). He presented with acute right‐sided heart failure and died 1 day after admission. Postmortem examination revealed multiple gelatinous lesions in the myocardium of the interventricular septum and the bilateral atria and ventricles which had microscopic features diagnostic of myocarditis. Subsequent studies failed to identify an infectious cause. Immune checkpoint inhibitors are an increasingly common addition to anticancer regimens and they should be considered in the evaluation of acute myocarditis.     

Giant cell myocarditis with cardiac tamponade: a rare combination

Giant cell myocarditis (GCM) is a rare but fatal disease of idiopathic origin. It results in focal necrosis of myocardium. This is a case report of middle aged Malaysian Indian female who died due to cardiac tamponade due to rupture myocardium and tear in the root of aorta. On naked eye examination, it simply resembled as recent as well as old fibrotic areas of myocardial infarction. She was clinically diagnosed as a case of obstructive cardiomyopathy with atrioventricular block, and was on pace maker. There was subendocardial fibrosis and left ventricular transmural infarction in the left ventricle. On histopathology, this was diagnosed as GCM, there were widespread areas of inflammatory cellular infiltration within the myocardium with multinucleated giant cells and granulomas interspersed with lymphocytes. Microscopic field showed up to 10 multinucleated giant cells. In this case, there were focal areas at multiple locations and caused uneven thickness in the left ventricle wall. Idiopathic GCM is very rare and causation of hemopericardium is the unique feature of this case. In this case the direct link of GCM with aortitis and rupture of left ventricle wall resulting in hemopericardium is shown. This case is documented through macroscopic as well as microscopic photographs in H&E, Ziel-Nelson, and GMS staining.     

Tumours and sudden death

A series of 27 sudden deaths caused by tumours, amounting to 1.2‰ of all deaths in the 5-year period studied, is found to include 9 cases where the death had also been unexpected, since the fatal tumour had gone undiagnosed. Four of these cases had had no preceding symptoms. Males were predominant (19 males vs. 8 females), and all the sudden unexpected deaths were males. The age range was 24 – 86 years for the males and 45 – 83 years for the females.The most common tumour was bronchial epidermoid carcinoma, which caused sudden death by massive haemorrhage into the lungs or externally. In the latter case the scene of death at home resembled a violent death. Other tumours found were mostly gastric or oesophageal epidermoid carcinomas and adenocarcinomas of the kidney, pancreas, ovary and colon.     

Immunohistochemical techniques improve the diagnosis of myocarditis in cases of suspected sudden infant death syndrome (SIDS)

Immunohistochemical techniques have improved the diagnosis of myocarditis. In a post mortem study, eight specimens in each case of the formalin-fixed and paraffin-embedded hearts of 20 suspected cases of sudden infant death syndrome (SIDS) were investigated with traditional hematoxylin-eosin staining and immunohistochemical methods. The hematoxylin-eosin stained specimens were examined for myocarditis according to the Dallas criteria; only in one case was a myocarditis diagnosed. The subsequent definition of the major histocompatibility complex class II antigens (HLA-DP,DQ,DR and HLA-DR), known to be enhanced in cases of myocarditis, the quantification of leucocytes with leucocyte common antigen (LCA) and characterization and quantification of T-lymphocytes using a specific marker (CD-3) allowed the definite diagnosis of myocarditis in three additional cases, six cases were found with moderate changes and ten cases without signs of inflammation.     

Profiles of Child Maltreatment Perpetrators and Risk for Fatal Assault: A Latent Class Analysis

This study examined characteristics and profiles of 196 child maltreatment perpetrators in Florida, including 126 who committed fatal assaults during 1999–2002. Results of logistic regression suggest that being a biologically unrelated caregiver is the strongest predictor of fatal child maltreatment. Latent Class Analysis (LCA) was used to classify perpetrators, and three classes were identified: Biological Mothers with Health Problems, Male Perpetrators with Domestic Violence History, and Multiple-Problem Perpetrators. Results of LCA showed that compared to Biological Mothers with Health Problems, Multiple-Problem Perpetrators were seven times more likely and Male Perpetrators with Domestic Violence History were 12 times more likely to commit a fatal assault. Implications of the findings are discussed.

Hypersensitivity myocarditis and hepatitis associated with imipramine and its metabolite, desipramine

We present two cases of myocarditis and hepatitis with histologic characteristics of hypersensitivity-mediated drug reactions associated with imipramine and its metabolite, desipramine. In one case, death was directly attributed to myocarditis; in the second case, the patient died of an acute myocardial infarct, but myocarditis may have played a contributory role. One patient was taking imipramine, and therapeutic concentrations of imipramine and desipramine were documented in postmortem blood. The other patient was receiving desipramine documented by in-patient hospital medication records. Both cases had liver lesions associated in the medical literature with adverse drug reaction to imipramine. Although myocarditis has been previously associated with amitriptyline, these cases appear to be the first reported in association with imipramine/desipramine. The fact that one patient was taking only desipramine suggests that it may be the offending agent.     

A Case of Sudden Infant Death Due to Incomplete Kawasaki Disease

Although Kawasaki disease (KD) is a self‐limiting disease, it may cause sudden cardiac death. Diagnosis of KD is principally based on clinical signs; however, some infant cases do not meet the criteria. Such cases are identified as incomplete KD. The sudden death risk in incomplete KD cases is similar to conventional KD. In our 5‐month‐old case, he had been admitted to a hospital for a fever and suppuration at the site of Bacille de Calmette et Guerin (BCG) vaccination. However, after discharge from the hospital, his C‐reactive protein (CRP) levels declined, he got indisposed and died suddenly. A medico‐legal autopsy revealed myocarditis, coronaritis, platelet‐aggregated emboli in coronary arteries, and myocardial degeneration, suggesting that the fatal myocardial infarction was due to thrombus emboli in the coronary arteries. Forensic pathologists therefore should pay attention to the cardiac pathology originated from incomplete KD as a potential cause in cases of sudden infant death.     

Law defining the critical level of driver fatigue in terms of hours without sleep: Criminal justice professionals' opinions and fatal accident data

The aims of the present study were to determine the support among criminal justice professionals for a law that defines the critical limit of driver fatigue in terms of 24 consecutive hours of wakefulness; and to determine how many drivers causing fatal accidents would be potentially covered by such a law. The data included an online questionnaire data collected from 325 criminal justice professionals (96 prosecutors, 129 traffic police officers, and 100 local police officers with experience in traffic surveillance and accident investigations) and the national database of fatal road accidents studied in depth (N = 1871; 2002–2008). The support for such a law was quite low among prosecutors while police officers were more in favor than against it. Only a handful of the (survived) drivers who caused a fatal accident were awake for more than 24 consecutive hours. We discuss several challenges and considerations associated with such a law.     

The Next Frontier: Dual Nationality as a Multi-layered Concept

Scholarly debate, legal rules and policy on dual nationality suffer from a fatal flaw: the various situations of dual nationality are conflated in one single category, linked to a single policy. This article argues that the debate would win in clarity if the various situations were untangled. In order to demonstrate the need for more discrimination in situations of multiple citizenship, two cases are discussed: the first one relates to the various situations which may come under the heading of dual nationality. In particular, the argument is made that dual nationality arising out of birthright citizenship should not be confused with situations where a second nationality is voluntarily acquired. The second case where more segregation is in order relates to the treatment of the two nationalities possessed by an individual. The argument goes that the two nationalities should not be treated on equal par, as they rarely have the same value and weight.

     

Postmortem distribution of dihydrocodeine and metabolites in a fatal case of dihydrocodeine intoxication

A report of a fatal dihydrocodeine ingestion under substitution therapy is given. Quantitation of dihydrocodeine, dihydromorphine, N-nordihydrocodeine, dihydrocodeine-6-, dihydromorphine-6- and dihydromorphine-3-glucuronide was performed simultaneously after solid-phase extraction prior to HPLC analysis, and the analytes were detected using their native fluorescence. Postmortem concentrations of blood samples from different sampling sites as well as from liver, kidney and cerebrum are reported. A hair sample was investigated to prove long-term use of the substitute drug. Site-to-site differences of the analytes from blood samples were very small. The partition behavior of the opioid glucuronides depended on the hematocrit value of the particular blood sample. Most important findings seemed that dihydromorphine and dihydromorphine-6-glucuronide concentrations decisively contributed to the toxicity of dihydrocodeine. This case report outlines that in dihydrocodeine related deaths the concentrations of the pharmacologically active metabolites should additionally be determined for reliable interpretation.     

ECJ rules on acts of “Extraction” that infringe database right

Four years from the European Court of Justice's seminal rulings on database right in the British Horseracing Board and Fixtures Marketing cases, the Court has once again looked at the extent of protection this right affords. The earlier decisions had suggested the right was weak, with many databases not qualifying for protection and the extent of infringement required being difficult to meet. However, the ECJ's recent ruling in the Directmedia case (C-304/07) handed down in late-2008 is more positive for database owners. Adopting the reasoning of the Advocate General, the ECJ has clarified the types of acts which can constitute infringement of database right and confirmed they are broad in scope. The outcome and implications of the ruling are discussed below.     

Fatal verapamil poisoning

A case of fatal verapamil poisoning is reported. The pathologic and toxicologic findings are discussed.     

心肌炎猝死案例的法医病理学研究

从法医尸检案例中取心肌炎猝死17例进行分析及病理学观察，对心肌炎的分关、心肌炎导致猝死机制进行探讨，认为诱发急性心力衰竭是心肌炎猝死的主要原因。     

Mentally ill offenders in prison: the Belgian case

According to the EUPRIS-study on mental health in prisons (2007), available data on mental disorders in prison are scarce. Therefore, this study aims at summarizing and discussing the available knowledge on incarcerated mentally ill offenders concerning: (1) the screening and assessment for detecting mental health; (2) the psychiatric expertise in order to evaluate the mental status; and (3) the development and provision of forensic psychiatric treatment and care. These findings will be applied to the current situation in Belgium, which is a particularly interesting case. Belgium is currently facing difficulties concerning a large population of interned mentally ill offenders residing in correctional establishments.Implications with regard to the penal code, general or mental health legislation, screening, assessment, and treatment could deliver interesting viewpoints on how this problem could be tackled more effectively. Therefore, the findings will be discussed with reference to the international scientific and policy debate, focusing on ethical implications.     

Expert Testimony of the Battered Person Syndrome, Defendant Gender, and Sexual Orientation in a Case of Duress: Evaluating Legal Decisions

The current study examined the utility of expert testimony of the battered person syndrome (BPS) in a case of duress and the extent to which defendant gender, defendant sexual orientation, and participant gender influence mock jury decisions in a case of duress. Participants (N?=?413) read a scenario based on U.S. v. Dixon (2006) and answered questions assessing verdict, guilt, sentence length, duress legal elements, and attributes typically ascribed to victims of abuse. Results showed heterosexual female defendants were assigned the lowest sentences and met more of the legal elements of duress (i.e., were coerced, more likely to be believed, and purchased a gun to prevent harm) and attributes (i.e., experienced severe abuse, learned helplessness) compared to other defendants. When mock jurors received expert testimony, they provided lower rates of guilt and sentencing for defendants. Results also showed the inclusion of BPS expert testimony increased ratings for many of the legal elements of duress and attributes typically associated with intimate partner violence. In addition, results suggested that while heterosexual female defendants are more likely to be believed in a case of duress, expert testimony of BPS is helpful to all defendants. Limitations and future directions for research and practice are discussed.     

Fatal taxine poisoning from yew leaf ingestion

A case of fatal taxine poisoning from the ingestion of yew leaves by a young college man is reported. The toxicity of the plant is discussed, and the limited medical literature is reviewed.     

Cardiac pathological study of sudden death due to myocarditis: analysis of 17 cases

17 cases of sudden death due to myocarditis were presented. The problem of the classification and mechanism of sudden death is discussed. It is concluded that heart function failure is the main reason for the sudden death of myocarditis.