Autoerotic asphyxial death initially misinterpreted as suicide and a review of the literature.

Death during autoerotic activities is of special concern to law enforcement officials, medical examiners, the family of the decedent, and society in general. As in the probing of any violent demise, accurate identification, management, and preservation of all physical evidence; complete photographic documentation of the scene and the body; reconstruction of the scene; and interviews with the family and acquaintances (psychological autopsy) are mandatory for proper study, evaluation, and interpretation of the case. Because of a lack of knowledge on the part of many people, including professionals, about these activities and the fact that many autoerotic fatalities share common characteristics with suicide and homicide, these cases are often misinterpreted. The authors present a case of autoerotic accidental asphyxial death which was initially misinterpreted as suicide.     

Criteria for the classification as a "domestic-setting corpse"--a literature search and review to define the term

In German medical and media circles (daily routine, specialist literature, press, novels), the term "domestic-setting corpse" is frequently used, but the term is only vaguely defined. The authors thus decided to perform an in-depth study of the literature, including historic textbooks and all German- and English-language medicolegal journals, going as far back as their first issues, in an attempt to more clearly define the term. Inclusion criteria used in the search were a post-mortem interval of at least 24 hours prior to discovery and discovery of the corpse in a domestic setting. In the literature, 37 cases that complied with the above-mentioned inclusion criteria were found. These cases frequently described "advanced decomposition", often "unclear cause of death" and "problems in identification". These characteristics can thus be considered as being additional pointers in the definition. However, we suggest that the two general defining characteristics of a "domestic-setting corpse" are a post-mortem interval of more than 24 hours before discovery and the discovery of the corpse in a domestic setting.     

Sudden death caused by myocardial tuberculosis: case report and review of the literature

A 25-year-old fit man died suddenly while playing social soccer. Autopsy revealed an infiltrative lesion involving the left ventricle with overlying pericarditis. No other significant pathologic changes were observed. Histologic examination showed necrotizing granulomatous inflammation. No acid-fast bacilli were demonstrated in the pericardial fluid or on histologic examination. The presence of Mycobacterium tuberculosis DNA complex was confirmed by use of the ligase chain reaction technique. The differential diagnosis of myocardial tuberculosis includes sarcoidosis, rheumatic fever, rheumatoid arthritis, giant-cell-containing tumors, idiopathic (giant-cell) myocarditis, and bacterial infections such as tularemia and brucellosis. This case illustrates the protean manifestations of tuberculosis and highlights the use of molecular biologic techniques in arriving at a definitive diagnosis in cases of suspected tuberculosis.     

From alcohol to liquid ecstasy (GHB)--a survey of old and modern knockout agents. Part 3: gamma-hydroxybutyric acid ("liquid ecstasy")

Currently, gamma-hydroxybutyric acid (GHB/"liquid ecstasy") is frequently abused as a knockout substance. Its detection and the interpretation of the results present numerous problems which are illustrated by case reports. In this context, hair analysis and the increasing significance of gamma-butyrolactone (GBL) are also discussed.     

Ownership of high-risk ("vicious") dogs as a marker for deviant behaviors: implications for risk assessment

This study examined the association between ownership of high-risk ("vicious") dogs and the presence of deviant behaviors in the owners as indicated by court convictions. We also explored whether two characteristics of dog ownership (abiding licensing laws and choice of breed) could be useful areas of inquiry when assessing risk status in settings where children are present. Our matched sample consisted of 355 owners of either licensed or cited dogs that represented high or low-risk breeds. Categories of criminal convictions examined were aggressive crimes, drugs, alcohol, domestic violence, crimes involving children, firearm convictions, and major and minor traffic citations. Owners of cited high-risk ("vicious") dogs had significantly more criminal convictions than owners of licensed low-risk dogs. Findings suggest that the ownership of a high-risk ("vicious") dog can be a significant marker for general deviance and should be an element considered when assessing risk for child endangerment.     

Intracranial arteriovenous malformations presenting as sudden unexpected death: a report of 3 cases and review of the literature

Intracranial arteriovenous malformations (AVMs) are cerebrovascular abnormalities due to maldevelopment of the regional capillary bed, producing lesions with arteriovenous shunting. AVMs may account for as many as 1% of all sudden deaths; however, case reports in the literature are exceedingly rare. We present 3 cases of sudden death due to hemorrhage of AVM and discuss the literature and the differential diagnosis in cases of sudden death due to intracranial hemorrhage.     

Trophoblastic microemboli as a marker for preeclampsia-eclampsia in sudden unexpected maternal death: a case report and review of the literature

The authors report the case of a 25-year-old white woman at 7 months' gestation who died suddenly and unexpectedly at home. Anatomic findings at autopsy included a tongue contusion, glomerulonephritis, changes indicative of systemic hypertension, and trophoblastic microemboli in the lungs. Review of the prenatal care record disclosed 3+ proteinuria 2 days before death. The features of the postmortem examination were consistent with clinically undiagnosed preeclampsia-eclampsia and glomerulonephritis. The authors discuss the rarity of fatal preeclampsia-eclampsia, the contribution of concomitant glomerulonephritis, and the significance of trophoblastic microemboli in the lungs.     

Cerebrovascular malformation causing sudden death. Analysis of three cases and review of the literature

Three unusual cases of sudden death resulting from cerebrovascular malformation (CVM) are presented. CVMs are highly variable in location and morphology, and may be difficult to detect. Two of the patients discussed here had CVMs that involved the circle of Willis directly, and produced rapidly fatal subarachnoid hemorrhage at the base of the brain; both of these subjects were in their late 30s. One had a history of epilepsy; the other had been completely asymptomatic prior to the catastrophic event. The third was an asymptomatic 6 year old with a cerebellar CVM, who survived long enough for inconclusive neurosurgical intervention. In all three cases, the diagnosis was not made prior to autopsy; in one case, the circumstances of death were initially misleading. The relevant literature is reviewed and discussed, with emphasis on differential diagnosis, anatomic examination, and background investigation.     

喉气管支气管炎猝死法医学检验文献回顾

喉气管支气管炎是一种罕见的上呼吸道感染,病变主要涉及上呼吸道声门下至支气管部位,发病多见于学龄前儿童。患者常见的,瞄床表现为喘呜,犬吠样咳嗽甚至呼吸窘迫。严重的喉气管支气管炎可导致急性呼吸道阻塞引起呼吸功能衰竭死亡。喉气管支气管炎所导致猝死在法医学实践中较为罕见。本文回顾了喉气管支气管炎相关的文献报道并结合2例典型喉气管支气管炎急性发作导致猝死的案例进行综述,主要探讨喉气管支气管炎患者临床表现、尸体检验以及法医病理学检查特征。     

Isolated myocarditis as a cause of sudden death in the first year of life

A series of three cases of isolated myocarditis, presenting as sudden death in infancy, occurred over a period of 3 months. This prompted a review of the autopsy records of the Children's Hospital of Winnipeg. Over a period of 40 years, 24 cases of isolated myocarditis were traced from 3196 autopsies. Most (21 of 24) cases of isolated myocarditis occurred in infants less than 12 months of age. In 16 of the infants there were either no antecedent clinical signs (sudden deaths), or a short clinical history of less than 24 h duration. Heart weights, however, were greater than the 99th percentile of published normals in three infants and above the 95th percentile in a further 16 infants. Areas of hypertrophied fibres were seen even in infants with a short history. These latter findings suggest that a latent phase of myocarditis may exist. The responsible pathogens were identified very rarely, due to a lack of suspicion of the existence of myocarditis, and it is suggested that samples of myocardium should be submitted for virologic examination in all cases of sudden death in the first year of life.     

Aortoesophageal fistula and sudden death. A report of two cases and review of the literature

Two cases of aortoesophageal fistula are presented. The etiology, symptoms, and diagnosis of aortoesophageal fistula are reviewed. Signs and symptoms of gastrointestinal hemorrhage followed by sudden collapse hours to days later should prompt consideration of an aortoesophageal fistula. Accidental ingestion of foreign bodies, particularly by children, is a frequent etiology.     

Sudden death in toddlers caused by influenza B infection: a report of two cases and a review of the literature

Sudden fatal cases of influenza B infection in a 4-year-old girl and a 2-year-old boy are presented. Both children complained of abdominal pain without respiratory, neurologic or cardiac symptoms; additionally the girl had vomiting within 2 days of death. Autopsy revealed histological changes in the respiratory system consistent with a viral infection. Influenza B infection was identified by immunohistochemistry in the girl and real-time polymerase chain reaction in the boy. Additional testing including cultures, toxicology, and screening for metabolic disorders were negative. These cases illustrate the usefulness of viral testing, especially for influenza, in the medical legal autopsy of children even when the classic respiratory symptoms of flu are lacking.     

Simon's bleedings as a vital sign of hanging--a literature review

The intervertebral haemorrhages described by Simon in 1968 as a vital sign of hanging have been verified and endorsed by other authors. They occur in 40-50 % of hanging cases, most frequently in the lumbar spine, in younger age groups, and in cases of free suspension. The haemorrhages are not unique to hanging, but may occur in particular as a result of other traumatic elongation or overextension of the spinal column (e. g. in the course of traffic accidents). In cases of decomposition of the body, "false positive" findings are relatively common. As external findings scarcely provide any reliable vital signs of hanging, there is still a high demand for autopsies. In addition to Simon's bleedings, internal findings which are diagnostically conclusive also include microscopic examinations of the lungs and the neck musculature. More recent findings such as haemorrhages in the back and auxiliary respiratory muscles as well as the intestinal wall, if confirmed, could supplement Simon's bleedings. Frei's fibre sample and evidence of histamine in the ligature mark should not be neglected. Finally, it must be emphasized that the forensic assessment of hanging cases should always be based on a criminological and forensic evaluation of all the circumstances of the offence as well as on post-mortem findings.     

Dicyclomine in the sudden infant death syndrome (SIDS)--a cause of death or an incidental finding?

We report a case of a small infant apparently dying of the Sudden Infant Death Syndrome (SIDS) with a postmortem blood dicyclomine level of 200 ng/mL. Review of the literature and the comparison with blood dicyclomine values from four rabbits given equivalent doses suggests that a blood dicyclomine value of 200 ng/mL probably is in the therapeutic range for infants. Although safely used for years for infantile colic, recently, the administration of dicyclomine has been related to acute episodes of apnea, seizures, and coma. In the absence of those acute reactions, we feel that a 200-ng/mL blood dicyclomine level in a child dying of apparent SIDS should not prevent categorization of the death as SIDS.     

Sudden death due to dissecting pulmonary artery aneurysm: a case report and review of the literature

Pulmonary artery aneurysm and pulmonary artery dissection are rare antemortem diagnoses, most often associated with sudden death. These pathologic entities are strongly associated with chronic pulmonary hypertension due to structural cardiac defects, either congenital or acquired. We report the case of a 49-year-old woman who died suddenly due to dissection and rupture of a large pulmonary trunk aneurysm, with subsequent cardiac tamponade. Key historical and physical findings are described. Additionally, we present a discussion of the incidence, clinical presentation, pathogenesis, and pathologic diagnostic features of pulmonary artery dissection.     

Organization structure as a factor in innovation: A review of the literature

There are several approaches to the organization of an activity. Some of the better known methods are by function, project or a matrix. Each of these methods is investigated in terms of its effect on innovation. Some of the advantages and disadvantages of each are discussed. All discussion is carefully supported by reference to current literature.     

Human herpesvirus-6 and sudden death in infancy: report of a case and review of the literature

Investigation of sudden death in infancy is a vital function of the medical examiner's office. Surveillance of these cases may lead to recognition of new diseases or new manifestations of previously described diseases. Human herpesvirus-6 (HHV-6) is a relatively newly described virus that has been recognized as a cause of acute febrile illness in early childhood. While most cases are apparently self-limited, seven fatal cases have been reported. We present a case of a seven-month-old Latin American male with recent otitis media and vomiting who was found dead in bed. Autopsy revealed interstitial pneumonitis with an atypical polymorphous lymphocytic infiltrate in the liver, kidney, heart, spleen, lymph nodes, and bone marrow, associated with erythrophagocytosis. Polymerase chain reaction (PCR) analysis of formalin-fixed paraffin-embedded tissue was positive for HHV-6 and negative for Epstein-Barr virus (EBV) and cytomegalovirus (CMV). HHV-6 was also detected in the atypical lymphoid infiltrate by in-situ hybridization.     

Complex suicides--a review of the literature

The term "complex suicide" stands for suicides committed by using more than one method. A distinction can be made between planned and unplanned complex suicides (primary/secondary combinations). In planned complex suicides 2 or more methods are applied simultaneously in order to make sure that death will occur even if one method fails. In unplanned complex suicides the mode of performance is changed after the first method chosen failed or was working too slow or proved to be too painful. In planned complex suicides typically two of the generally common methods of suicide (e.g. ingestion of medicines, hanging, use of firearms, drowning, fall from a height) are combined. But also unusual combinations have been described such as the simultaneous firing of two guns, self-immolation in combination with other suicide methods or shooting oneself while driving a car. In unplanned complex suicides self-inflicted injuries by sharp force, especially cuts of the wrists, are often found as the primary act of suicide. In some cases the suicide switches from cuts to stabs (mostly to the heart region). Other methods often used after the first phase of suicide are hanging and jump from a height. In the literature the use of up to 5 suicidal methods applied one after the other have been described.     

Sudden, unexpected death due to cardiac fibroma. Report of a case and review of the literature

A case of cardiac fibroma in a 58-year-old woman with a history of atrioventricular block is described. The patient died suddenly at home 6 days following the insertion of a pacemaker. Review of the pertinent literature is presented.