Sudden death due to delayed rupture of hepatic subcapsular hematoma following blunt abdominal trauma

Blunt abdominal trauma can cause sudden, unexpected death due to injuries to internal organs. Rupture of a hepatic subcapsular hematoma is a relatively rare cause of sudden death following minor blunt abdominal trauma. Death may be delayed several days to weeks. The autopsy is an invaluable diagnostic tool that can be utilized to uncover sudden deaths due to abdominal trauma. The case of an alcoholic who died of a ruptured hepatic subcapsular hematoma is presented. The death investigation revealed that the victim had sustained blunt abdominal trauma during a fall a few days prior to death.     

Fatal renal hemorrhage after extracorporeal shock wave lithotripsy

Renal hematoma is one of the most severe complications of extracorporeal shock wave lithotripsy (ESWL). ESWL is used in the noninvasive treatment of urinary calculosis. The shock waves can lead to capillary damage, renal parenchymal or subcapsular hemorrhage. We present a case with fatal complication and the result of the medico-legal evaluation. A 71-year-old woman was treated by ESWL, renal hematoma was detected during the clinical observation, and the patient died. The death occurred despite close clinical observation as a consequence of a rare complication of ESWL. The mechanism of death was hemorrhagic hypovolemic shock due to renal hemorrhage complications due to ESWL for treatment of renal calculi. This therapeutic complication is a known complication of appropriate treatment.     

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.     

Spontaneous umbilical cord hematoma: an unusual cause of fetal mortality: a report of 3 cases and review of the literature

Spontaneous hematoma of the umbilical cord represents a rare cause of fetal morbidity and mortality and the outcome is poor in half of the cases. There are many risk factors, such as infections, morphologic anomalies, alterations of the vessel walls, prolapses, twisting and traction of the cord, but in many cases the causes remain unknown. We present 3 cases of umbilical cord hematoma which took place at the end of the pregnancy and were followed by perinatal death of the fetus. In the 3 cases, which were autopsied including macroscopical and histopathologic examination of the placenta and the umbilical cord, a cordonal pathology was present; in all cases, there were alterations of the vascular wall, and in the third case inflammatory vasculopathy was found. In all 3 cases, the cause of death was attributed to acute anoxia due to the cordonal hematoma.     

Fatal poisoning with blue vitriol

Cases of fatal poisoning with cupric compounds are relatively rare in everyday life and are not covered much in forensic literature. A case was encountered of fatal poisoning with a blue vitriol solution introduced into the uterine cavity in order to interrupt a pregnancy. A 39-year-old woman brought to the hospital by ambulance complained of pain in the lumbar region and profuse bloody genital discharge, which had appeared 3 days earlier. She believed she was 2 months pregnant and denied artificial interruption of the pregnancy. Upon examination, her condition was grave: a weak pulse of 80; blood pressure 100/60. The abdomen was soft, the liver and spleen not enlarged. Pasternak symptom was negative. The uterus was soft, painless and enlarged to 9 weeks of pregnancy. The uterine cervix was clean, the orifice closed. Discharge was profuse and bloody. The diagnosis was that she was 9 weeks pregnant and had a missed criminal abortion. Scraping out the uterus and corresponding therapy to control bleeding were ineffective. An operation was performed--extirpation of the uterus. However, despite the steps taken, the bleeding did not stop, and the patient's condition continued to worsen. 10 hours after being admitted to the hospital, she died. During forensic investigation, diffused, violet-colored cadaverous spots were discovered. Extensive subcutaneous hemorrhage was detected around the areas of injection. The skin covering was edematous; when pressed with a finger, areas of depression remained. There was about 250 ml of watery blood in the abdominal cavity. Internal organs were anemic. There were multiple subpleural, subepicardial, subcapsular, intraorgan and intramuscular micro- and macro-punctate hemorrhages; bleeding into the mucosa of the gastrointestinal tract and urinary tracts; and cerebral and pulmonary edema. Forensic histological examination showed acute circulatory disturbance with perivascular and peridiapedetic hemorrhage; concentrations of aggregated and hemolyzed erythrocytes in the small vessels and capillaries; cerebral, pulmonary and stromatic edema. In the kidneys there was coaugmentation of renal glomeruli; epithelial necrosis of part of the coiled ducts; lower epithelium in places had pigment grains; primarily in openings of straight ducts there were pigment cylinders; extreme plethora of the surrounding area, and infiltration from annular cells and polynuclears. Forensic chemical analysis showed 12.8 mg of copper; 6.6 mg in the uterus and 5.6 mg in the kidneys. From data obtained it can be concluded that the patient died from cupric compound poisoning, complicated by interruption of the pregnancy and uterine hemolytic hemorrhage. It was later established that during the month before being admitted to the hospital the patient introduced a solution of blue vitriol into the uterine cavity to interrupt the pregnancy.     

Acute poisoning involving the pyrrolidinophenone-type designer drug 4'-methyl-alpha-pyrrolidinohexanophenone (MPHP)

A 36-year-old woman consulted the medical emergency unit of a private health center for abdominal pain and gastroenteritis of 5 days duration. Acute right pyelonephritis was diagnosed. Five hours after admission she became unconscious in a state of clinical shock. She was transferred to an intensive care unit but resuscitation attempts were unsuccessful and she died 3 h later. Three days after death, she was buried in the family vault. Five days after the burial, her husband lodged a complaint with the public prosecutor because he had not received a clear explanation from the physicians concerning the cause of his wife's death. After analysis of the medical records of the deceased by two forensic pathologists, a medicolegal autopsy was ordered by the public prosecutor. The corpse was exhumed and autopsy performed 9 days after death. Massive hemoperitoneum was diagnosed with a macroscopically ruptured subcapsular hematoma. Pathological study confirmed acute right pyelonephritis and demonstrated the precise cause of the hemorrhage: rupture of the hepatic artery at the hilar part, following infectious arteritis which was probably secondary to the acute pyelonephritis. To the best of our knowledge, this is the first published report of such a case.     

The forensic medical evaluation of subcapsular splenic injuries

Data on 63 cases of subcapsular spleen lesions are analyzed. Circumstances of trauma infliction period of the 2-nd stage of spleen capsule rupture, morphological types of subcapsular spleen lesions, microscopic changes in different posttraumatic periods are presented.     

Morphological findings in Zieve's syndrome (author's transl)]

The macroscopic and microscopic findings of a case of Zieve's syndrome are described (fatty liver, icterus, hyperlipemia and hemolytic anemia in chronic alcoholism). The outstanding macroscopic finding is milky turbidity of the blood in arterial and venous vascular channels as well as hepatomegaly and anaemia of internal organs. A prominent feature of the histological picture is the high-grade lipaemia of the large and small vessels (arteries and veins), capillary occlusions resembling fat embolism in all organs and severe diffuse fatty metamorphosis of the liver. Circulatory disorders and the cause of death are discussed.     

Fatal postpartum spontaneous liver rupture: case report and literature review

Maternal hepatic rupture is a rare complication of pregnancy that can be fatal to both mother and child. This phenomenon is most often associated with preeclampsia/eclampsia and/or HELLP syndrome, which is defined by a collection of clinical features including hemolysis (H), elevated liver enzymes (EL), and a low platelet count (LP). These disease processes are typically identified and treated during pregnancy, often in the last trimester. The described case is unusual in that the decedent had no known history of preeclampsia/eclampsia or HELLP syndrome during this pregnancy, and she died suddenly several days postpartum of liver rupture with massive intraperitoneal hemorrhage following a routine cesarean section delivery and an uneventful hospital course. Similar cases are infrequent in the literature, which is reviewed in this report.     

Fatty liver, encephalopathy, and sudden unexpected death in early childhood due to medium-chain acyl-coenzyme A dehydrogenase deficiency.

A case of sudden death associated with fatty liver and encephalopathy is described in a 4-year old white boy with medium-chain acyl-coenzyme A dehydrogenase (MCAD) deficiency. The death was caused by hypoglycemia triggered by fasting and vomiting associated with a minor viral infection. The differential diagnosis of the hepatoencephalopathy is discussed in relation to other conditions, especially Reye's syndrome. The forensic pathologist should be familiar with MCAD and other deficiencies of beta-oxidation of fatty acids as a cause of sudden unexpected death in children in order to advise parents in genetic counseling to prevent disability or death of other affected, but still asymptomatic siblings.     

A heat gelatinized subdural hematoma in a burned cadaver as an indication of a vital accident

The autopsy of a carbonized male cadaver revealed a subdural hematoma which permitted by absence of soot aspiration and carbon monoxid intoxication to think of a crime with following fire setting. This was confirmed later by detective investigations. The most impressive finding of this case was a heat-gelatinized subdural hematoma highly resembling to a postmortem epidural burn hematoma, which could easily lead to an error conclusion. The problems in the diagnosis of the causes of death in carbonized bodies are discussed and the taking into account of crimes is accentuated.     

The psychodynamics of the presidential assassin and an examination of the theme/graphic variables of his threatening correspondence

A case of fatal Reye's syndrome presenting as the second sudden infant death in a family is described. The increasing interest in fatty change in the liver in cases of sudden infant death syndrome is noted and it is suggested that standardised interpretation of findings is essential if its significance is to be correctly evaluated.     

日本多田氏法计算颅内血肿体积公式的适用范围

通过对日本多田氏法计算颅内血肿体积公式的理论来源论证,揭示了多田氏认识颅内血肿问题和解决颅内血肿体积问题的思维方式,明确界定了多田氏法计算颅内血肿体积公式的适用范围;并针对该体积公式适用范围以外的颅内血肿,首次提出了模拟血肿形体,然后计算其体积的简便方法。     

胎盘血肿致死胎的法医学鉴定

孕妇外伤能引起胎盘血肿,但较为少见,特别是胎盘血肿与疾病共存时,各自对胎儿死亡的参与程度,与损伤程度鉴定有直接的关系.在法医学鉴定中如何全面地收集鉴定资料,如何选择最佳方法进行材料汇总,如何对它们之间的伤病关系进行客观的分析、论证,准确、及时地出具鉴定结论,是法医学鉴定中的难点.本文结合胎盘的结构和功能,综述了常见引起胎盘血肿的原因,血肿部位和时间与损伤的关系,胎盘疾病和损伤的参与度分析,以及胎儿的死亡原因、死亡机理,为胎盘血肿致死胎的法医学鉴定提供参考.     

A death due to perirenal hematoma complicating extracorporeal shockwave lithotripsy

Perirenal hematoma is an occasional complication of extracorporeal shockwave lithotripsy (ESWL) which does not usually require treatment. A 79-year-old woman died 23 h after ESWL. Forensic autopsy was performed to determine whether medical treatment contributed to her death. The cause of death was hemorrhagic shock due to massive hematoma from a ruptured small vein in the perirenal adipose capsule. No injury to other organs was found and the patient had neither coagulation abnormality nor venous disease. Perirenal hematoma can easily be diagnosed with abdominal sonography, if pain or symptoms of anemia develop. Doctors must be aware of the possibilities of severe renal hematomas after ESWL.     

Neonatal death following clozapine self-poisoning in late pregnancy: an unusual case report

The report presents a fatal poisoning of a neonate occurring in the final stage of gestational life and evoked by his mother, who, while 9 months pregnant, took a toxic dose of clozapine aiming at committing suicide. She was also severely poisoned, but ultimately was saved. The woman had been taking the medication due to schizophrenia and depression prior to conception, and the discontinuation of the drug in the course of pregnancy increased the risk of the woman attempting suicide. In the course of comprehensive toxicological analysis based on the developed analytical procedure with the use of LC-APCI-MS, clozapine and its two metabolites, norclozapine and clozapine-N-oxide, were determined in postmortem blood, liver and kidney in concentrations explaining the death of the neonate. The interpretation of the above-described case is complex and--apart from toxicological aspects--also involves issues associated with psychiatry, pharmacotherapy in pregnancy and medicolegal problems.     

Application of compact ultrasound imaging device to postmortem diagnosis

In regions with low autopsy rates, forensic examiners often have to rely on external findings. Imaging techniques can assist the external examination and provide a more objective diagnosis. The SonoSite 180, a portable ultrasound device, was used for the examination of dead bodies. The influence of different degrees of decomposition was estimated. Even in cases with intestinal gas formation images of internal organs could be obtained with special techniques. Various pathological findings were detected by ultrasound and verified by autopsy (e.g. pericardial tamponade, cardiac hypertrophy, fatty liver, aortic aneurysm, metastatic liver, etc.). The experiences with the SonoSite 180 are promising. The device can be carried to the death scene or to the morgue and therefore serve as a valuable tool for medicolegal applications.     

Reye's syndrome in a child on long-term salicylate medication

A case of Reye's syndrome in a four-year-old child on long-term salicylate medication for rheumatoid arthritis is reported. Severe fatty changes of the liver, lipid vacuolation in the renal proximal tubules, and severe brain oedema were the prominent postmortem findings. Symptoms of a trivial infection and vomiting just before death added to the resemblance of this case to Reye's syndrome.     

脑外伤所致精神障碍的影响因素

目的 对脑外伤所致各种精神障碍的发生率、表现形式及影响因素进行相关性研究.方法 以淮南市精神病医院近5年来进行医学鉴定的脑外伤所致各种精神障碍患者共388例为研究对象,在距脑外伤后6个月至1年内由至少3名精神科医师根据"中国精神疾病分类方案与诊断标准(第2版修订本)"(CCMD-2-R)对他们的精神状态进行评估.结果 (1)脑外伤所致精神障碍中智力障碍的发生率为74.2%,以轻度以下的智力障碍为主.(2)颅内血肿、脑干损伤、脑损伤范围、格拉斯哥分度量表评分(GCS)、合并精神障碍及文化程度对智力损伤程度的影响较大.(3)脑干损伤、颅内血肿、GCS、脑损伤范围、昏迷时间与有无智力障碍关系密切;脑损伤范围、脑挫裂伤、额叶损伤、颅内血肿与精神病性症状关系密切;额叶损伤、开颅治疗、颅内血肿与人格改变关系密切.结论 在颅脑创伤所致精神障碍的鉴定中,应结合颅脑创伤的性质,全面评估其精神状态.     

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.