Death due to neurogenic shock following gastric rupture in an anorexia nervosa patient

We report a case of fatal gastric rupture discovered after death, which developed due to a bulimic attack of a 19-year-old woman suffering from anorexia nervosa. An autopsy revealed an acute gastric dilatation and rupture without commonly observed ischemic damage of gastric wall structures. However, it may be difficult to determine the cause of death despite the marked findings. The death as a consequence of neurogenic shock accounts for all the results of gross examination and histologic analysis. This case is the first reported case of fatal gastric rupture of an anorectic patient discovered after death.     

Postmortem transport of gastric contents?

For the determination of the time since death, the distribution of the last meal in the stomach and small bowel may be of great importance. It may be even more difficult to estimate the time if there is a possibility that postmortem peristaltic emptying of the gastric content occurs, as has been claimed. Radiological control immediately after death by means of applying barium sulfate to the stomach, however, revealed no evidence of peristaltic emptying of the gastric content after death.     

Mechanisms of unexpected and/or sudden death in Lafora disease

A 23-year-old male was found dead wedged between two chairs at his home address. His past history included a diagnosis of Lafora disease (a type of heritable progressive myoclonic epilepsy) at the age of 16 years. This had been characterised by the development of epilepsy and progressive motor impairment and mental deterioration. Diagnosis had been confirmed by demonstration of mutation in the EPM2A gene on chromosome 6q24. At autopsy, petechial haemorrhages were noted of the face and conjunctivae bilaterally. There were no other significant findings apart from gastric contents within the airways. Death was attributed to positional asphyxia complicated by aspiration of gastric contents. Although death in Lafora disease is usually predictable and often protracted, sudden and/or unexpected death may occur and involve status epilepticus, sudden unexpected epileptic death, choking, aspiration of gastric contents, and cardiac arrhythmias. In addition, the possibility exists of unnatural causes of death, such as accidents, provoked by epilepsy or physical inability of the victims to extricate themselves from dangerous situations, or homicides, provoked by difficulties in caring for individuals with significant and progressive disabilities.     

胃内容物排空延缓5例分析

根据胃排空的情况进行死亡时间的推断是法医学常用方法,但有时会出现一定的误差,本文对5例胃排空显著延缓的案例进行分析,探讨提高其准确性的方法。     

The trials of Steven Truscott.

Determination of time of death (postmortem interval) is one of the most difficult problems confronting forensic pathologists. One noteworthy such case is that of Steven Truscott, a 14-year-old Canadian youth who was convicted of the June 1959 rape-murder of 12-year-old Lynne Harper in rural southwestern Ontario. The two had been seen together on the evening when Lynne was last seen alive. At her autopsy approximately 48 h later, the prosecutor, relying almost entirely on examination of the gastric contents, placed the time of death during the period in which the two were apparently in each other's company. Truscott's defense was unable to refute this opinion, and Truscott was sentenced first to death, then to life imprisonment. Isabel LeBourdais, a Canadian journalist, published a book defending Truscott that eventually led to a judicial rehearing, but his conviction was upheld. The examination of gastric contents is only one measure employed in the often difficult determination of time of death. It has not been made inherently more reliable in this regard since 1959. It is crucial, therefore, to use all available evidence in determining time of death.     

Sudden death from hyponatremia and hypokalemia in a woman with Gardner syndrome.

The authors present the case of a 39-year-old woman with Gardner syndrome who died from marked hyponatremia and hypokalemia. Gardner syndrome is a rare variant of the familial adenomatous polyposis syndrome in which the affected individual develops thousands of polyps within the gastrointestinal tract, with a 100% risk of eventual malignant change. Individuals with Gardner syndrome also develop a variety of extra gastrointestinal abnormalities. In the case presented, a woman with a clinical history of Gardner syndrome who had previously undergone a total colectomy with ileorectal anastomosis presented to the hospital with a recent history of sore throat, fever, diarrhea, and abdominal pain. The symptoms were considered clinically to be due to a viral gastroenteritis. She was admitted to the hospital, where she had episodes of collapse believed to be vasovagal in origin. She suffered a cardiorespiratory arrest and died 24 hours after admission. After her death, electrolyte estimation performed on blood taken shortly before death revealed severe hyponatremia and hypokalemia. Postmortem examination showed the gastric mucosa to be virtually covered by innumerable adenomatous and hyperplastic polyps. Fewer polyps were seen within the small bowel. There was no evidence of malignancy. The features were consistent with Gardner syndrome. Hyponatremia and hypokalemia have been described in patients with villous adenomas and in familial adenomatous polyposis syndromes associated with numerous colonic polyps. The cause of death in this case was considered to be hyponatremia and hypokalemia associated with florid gastric polyps in a woman with Gardner syndrome. Viral gastroenteritis contributed to the death by causing further electrolyte depletion. To the best of the authors' knowledge, death in Gardner syndrome has not been described as attributable to such metabolic disturbance, in particular in those who have only gastric, small bowel, and rectal polyps remaining after total colectomy.     

Copper toxicity following massive ingestion of coins

Two hundred seventy-five United States coins were discovered in the stomach of a mentally disturbed individual at autopsy. Many coins containing copper were corroded by prolonged contact with gastric juice, with subsequent absorption and deposition of copper in the liver and kidneys. The patient died from complications related to the acute toxic phase of chronic copper poisoning. A discussion of the case, foreign-body ingestion, gastric bezoars and the mechanism of copper toxicity is presented. To our knowledge, this is the first death due to copper intoxication following a massive ingestion of coins.     

马钱子中毒生物检材的毛细管电泳法分析

测定马钱子蓄积中毒死者胃内容和肝组织中马钱子碱成分含量。以标准马钱子碱和送检马钱子药材粉末作对照 ,采用毛细管电泳仪在 190～ 6 0 0nm波长 ,扫描分析检材中马钱子碱成分含量。结果表明 :马钱子碱成分在检材中的含量分别为 5 83mg/ 10 0ml、 4 92mg/ 10 0 g和 3 0 7% (w/w )。确认死者的胃内容、肝组织中的高含量马钱子碱而引起的中毒死亡。     

Pathogenesis of Vishnevskiĭ's spots in death from excessive cooling

Histochemical successions of the gastric mucosa reaction are described, their role and the impact of the kallikrein-kinin system are evaluated, and pathophysiological aspects of development of Vishnevsky's spots as a pathognomonic sign of death from excessive cooling are described. Analysis of 34 deaths from excessive cooling helped determine the correlation between the size, volume, and depth of the gastric mucosa involvement, on the one hand, and duration of periods of cooling and freezing, on the other. The technique of expert evaluation of Vishnevsky's spots is described.     

Suicide by multidrug ingestion: hypothesis on the role played by the self-administration of activated charcoal

A fatal suicidal ingestion of drugs, together with activated charcoal, is reported. The death occurred 31 hours after the self-administration. The autopsy revealed a large amount of gastric content that appeared to be a compact mass of black color. Toxicologic analyses showed the presence of toxic levels of desalkylflurazepam and trazodone; metamizole and pridinol were also detected. The obtained results supported the hypothesis of a death due to acute intoxication delayed by the self-administration of activated charcoal, which elimination was probably hindered by the action of pridinol.     

Peri-mortem skin lesions caused by regurgitation of gastric juice. 2 case reports and differential diagnostic considerations

Two cases of regurgitation of gastric juice peri mortem are reported which resulted in lesions of the thoracic skin and led to the suspicion of being caused by another possibly dangerous chemical agent. In both cases, however, other causes of death could be established. Neither could any foreign chemical substances be detected by extensive toxicological investigations nor were any alterations of esophagus and gastric mucosa revealed in the course of the autopsy. Histological investigations demonstrated a circumscribed recent necrosis of the epidermis and dermis. Therefore, regurgitation of the acidic gastric content as the agent impairing the skin was most likely. The impressive histological appearance of the peri mortem regurgitation skin lesions lesions may be due to the circulatory arrest as well as stagnation of vital cellular reactions and repair mechanisms, dehydration of the altered tissue and postmortem permanence of the impairing agent.     

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.     

Pesticide poisoning initially suspected as a natural death

A pesticide poisoning victim suspected initially as having died a natural death was autopsied. The victim was a 47-year-old male. Macroscopically, signs of acute death and, in particular, general erosion in the mucosa of the airways and esophagus were observed. In the gastric contents, which had a pungent smell and a greenish-brown color, 5.00 g/L of propanil, 1.27 g/L of carbaryl, 0.38 g/L of ethylbenzene, and 0.32 g/L of xylene were detected. In the blood (serum), 21.6 mg/L of propanil, 8.1 mg/L of carbaryl, 1.7 mg/L of ethylbenzene, and 4.0 mg/L of xylene were identified. Postmortem methemoglobinemia (45%) was recognized. The cause of death was considered to have been pesticide poisoning; propanil was probably most responsible for his death. The police considered the case to be "death with illness as the suspected cause." By performing an autopsy, however, we were able to clarify that the cause of death was pesticide poisoning.     

Toxicological findings in a fatal overdose of verapamil

Presented is a case where the death was attributed to the deliberate ingestion of an overdose of verapamil (V). Blood, urine, and gastric concentrations of the drug were determined by gas chromatography with nitrogen phosphorus detection (GC-NPD). Identification of norverapamil (NV) was made. A presumptive identification of o-demethylnorverapamil (DNV) was also made.     

吗啡及其代谢物在藏毒致死者体内分布初探

目的采用固相萃取、液相色谱一串联质谱（LC-MS／MS）检验方法,考察吗啡和葡萄糖醛酸吗啡（M3G）在一例体内藏毒致急性死亡者体内分布情况。方法提取死者心血、尿、胃内容物、肝、肾、脑等15种检材,经Waters HLB小柱固相萃取后,C18色谱柱分离,采用电喷雾电离（ESI）、多反应监测模式（MRM）检测目标化合物。结果所建方法在0．0l～101μg／mL浓度范围内线性关系良好,提取回收率大于75％。结果显示总吗啡含量（游离态＋结合态）在胃内容物中最高,其次是尿、‘肾,在心血、胃组织、肺和腺体中居中,脑组织和心脏含量最低。结论本例检验结果验证了胃内容物、尿液和肾脏等是该类中毒案件的理想检材,其分布规律也可作为体内毒品分析实验依据。     

Death of a 6-year-old boy with mental retardation: accident versus child abuse

This case study involved death of a 6-year-old child with a history of mental retardation secondary to meningitis at 11 months, spastic quadriplegia, seizure disorder, and hydrocephaly with a remote ventriculoperitoneal shunt placement and gastric tube feedings. Reportedly, the child was co-sleeping with his mother when she awoke and discovered him lying prone and not breathing on the carpeted floor next to the bed. He was transported to the hospital and died in the emergency room of unknown causes. The medical examiner assumed jurisdiction of the body. The external examination revealed petechial hemorrhages on the neck and face, with patterned linear pressure abrasions on the chest, arms, and face. X-rays revealed leg fractures of different ages. This case emphasizes the importance of coordination of death scene investigation, medical history review, and autopsy results through a forensic team approach to determine the accurate cause and manner of death.     

An unusual case of post-mortem redistribution of ethanol

We report an unusual case of post-mortem redistribution of ethanol in a woman diver who died by drowning in seawater. The ethanol concentrations were right heart blood 0.60 g/l, left heart blood 2.08 g/l, femoral venous blood 0.63 g/l, gastric contents 5.87 g/l, bile 0.83 g/l. The mechanisms of post-mortem redistribution of ethanol described in the literature, that is, early redistribution from the stomach or the lung parenchyma in the case of inhalation of gastric contents, are inadequate to account for the degree of variation observed between the measurements. We believe that this difference in concentration is explained by the presence of seawater in the pulmonary alveoli at the time of death.     

Fatty degeneration in renal tubule epithelium in accidental hypothermia victims

The diagnosis "death due to hypothermia" is mainly based on circumstances and gross autopsy findings like frost erythema and gastric erosions. Up to now, there are no reliable histologic criteria available to confirm the diagnosis "death due to hypothermia." However, fatty changes of organs have been reported already in the literature as a histological finding contributing to the diagnosis "death due to hypothermia." To evaluate these reports, cases with well-documented hypothermia (study-group; n=83), cases with other causes of death (control-group; n=25) and additionally also seven cases with a past medical history of diabetes mellitus were investigated. Renal tissue autopsy samples were taken from both the left and the right kidney and investigated for signs of fatty degeneration within the renal tubule epithelium. The results were compared with regard to macroscopic signs of hypothermia (Wischnewski-ulcers, erythema), as reported in the autopsy protocols. The results lead to the conclusion, that fatty degeneration is a very reliable histologic diagnostic criterium in cases of hypothermia, comparable to the significance of Wischnewski-ulcers.     

Philemon and Baucis Death? Two cases of double deaths of married couples

When two human corpses are found in temporal and locational context the assumption of a non-natural cause of death is close at hand. Suicide, extended suicide, homicide or accident (particularly with carbon monoxide) come to mind. When, however, a natural cause of death emerges for both after autopsy and further examinations, this provokes the question whether this incidence is coincidental. In our two presented cases, a married couple each was found dead together. In both cases, the wife needed nursing and was being cared for by a husband who died of cardiac disease shortly before the wife died. In one case, the wife died of acute uncompensated chronic congestive heart failure. In the other case, the cause of death of the wife was hypovolemic shock due to acute gastrointestinal bleeding from recurrent gastric mucosal erosion. It is to be discussed for both cases whether, given the pre-existing illness, the acute stress of the situation in view to the husbands' death may at least have favored the occurrence of death and may, thus, have led to the criminologically conspicuous situation of finding.     

Comparison between computed tomography (CT) and autopsy findings in cases of abdominal injury and disease

We report 10 autopsy cases involving fatal pathological changes in abdominal organs, for which findings of computed tomography (CT) on admission or after death were compared with autopsy findings. Two of the cases were death due to natural causes and eight were death due to traffic accidents. From the findings at autopsy, the causes of death were considered to be rupture of an aortic aneurysm in one case, gastrointestinal bleeding due to gastric cancer in one case, retroperitoneal bleeding in two cases, laceration of the liver in three cases, and traumatic rupture of the small intestine in three cases. CT findings revealed ascites or retroperitoneal bleeding in eight cases. However, in the cases of small-intestinal rupture, CT findings on admission revealed no free air. Therefore, ascites on CT should be regarded as a useful indicator of blunt abdominal trauma. Hepatic portal venous gas, known to be a post-mortem change, was significantly evident on post-mortem CT in cases of traumatic liver or intestinal injury, and was also seen in cases where the period between the accident and CT examination was long.