Fatal Diabetic Ketoacidosis—A Potential Complication of MDMA (Ecstasy) Use

A 19‐year‐old woman with insulin‐dependent diabetes mellitus was found dead in bed having allegedly recently taken ecstasy and consumed alcohol. At autopsy, there were microhemorrhages in the brain with subnuclear vacuolization and Armanni–Ebstein changes in renal tubules. Biochemical analyses confirmed diabetic ketoacidosis (vitreous glucose—46.5 mmol/L; β‐OH butyrate—13.86 mmol/L.). Toxicological analyses of blood showed a low level of 3,4‐methylenedioxy‐methamphetamine (MDMA) (0.01 mg/L), with acetone but no alcohol or other common drugs. Death was attributed to diabetic ketoacidosis most likely provoked by mixed MDMA/alcohol ingestion. Although the use of illicit drugs by young individuals with diabetes mellitus is being increasingly recognized, it has been noted that there is minimal information about the relationship between drug use and acute diabetic complications. Toxicological screening of cases of lethal diabetic ketoacidosis in the young may clarify lethal mechanisms in individual cases and also help to determine the extent of this problem.     

Clinical Characteristics of Fatal Methamphetamine‐related Stroke: A National Study

The study aimed to determine the clinical characteristics of fatal methamphetamine‐related stroke in Australia, 2009–2015. There were 38 cases, 60.5% male, with a mean age of 40.3 years. In no case was there evidence that this was the first time methamphetamine had been used by the decedent, and 52.6% had known histories of injecting drug use. The stroke was hemorrhagic in 37 of 38 cases. In 21.1% of cases, the stroke was purely parenchymal and, in 18.4%, involved purely the subarachnoid space. A ruptured berry aneurysm was present in 31.6% and in 68.8% of initial subarachnoid hemorrhages. There was evidence of systemic hypertension in 8 of 25 cases in which full autopsy findings were available. With increased use of methamphetamine, there is a high probability of increased hemorrhagic stroke incidence among young people. In cases of fatal hemorrhagic stroke among young cases presenting to autopsy, the possibility of methamphetamine use should be borne in mind.     

An Unusual Cause of Headache and Sudden Death of a Young Sailor—Postmortem Computed Tomography and Histological Findings of a Fatal Retroperitoneal Malignant Mixed Germ Cell Tumor

A 26‐year‐old Caucasian sailor, with no past medical history aside from headache for the last 1 week, was found dead in his cabin. The body was stored in a refrigerator on board and disembarked for autopsy 3 days later. Autopsy showed a large, nodular, necrotic and hemorrhagic retroperitoneal mass, and smaller hemorrhagic nodules in the brain, lungs, liver, and left kidney, with the brain being markedly edematous. Both testes were descended and normal. Histologically, the retroperitoneal mass showed a malignant mixed germ cell tumor comprising choriocarcinoma, embryonal carcinoma, and teratoma components. Retroperitoneal extragonadal germ cell tumors are uncommon, and this case of a young male who presented with headache and sudden death due to metastases is extremely rare.     

An Uncommon Accident and Unusual Cause of Death—A Fatal Domestic Ram Attack

Domestic animal attacks are not common; their fatal attacks are even rarer. Herein, a case of a 78‐year‐old woman attacked by a ram is presented. She sustained multiple head and chest injuries. The autopsy findings and the inspection of the scene revealed that the fatal aortic injury had been caused by direct force from the front, which subsequently caused a powerful anteroposterior chest compression, resulting in an incomplete tear by flexion and compression of the aortic arch. The aortic dissection propagated in both an ante‐ and retrograde direction, with intact adventitia. However, due to a rise in pressure in the formed false lumen, dissection propagated downward to the base of the heart, and further into the subepicardial adipose tissue, forming a subepicardial hematoma. This hematoma gradually compressed the proximal sections of the coronary arteries, impairing their filling, and producing a myocardial ischemia. In addition, circulation had probably been already disturbed by the right‐sided pneumothorax, as well as a possible pneumomediastinum.     

A Fatal Shot with a Signal Flare—A Crime Reconstruction*

Abstract: A reconstruction of an incident of a fatal wounding of a football fan with a parachute flare was performed. Physical and chemical examinations of the victim’s trousers and parts of a flare removed from the wound in his leg were performed by means of an optical microscope and a scanning electron microscope coupled with an energy dispersive X‐ray spectrometer. Signs of burning were seen on the front upper part of the trousers, including a 35–40 mm circular hole with melted and charred edges. Postblast residue present on the surface of the trousers contained strontium, magnesium, potassium, and chlorine. Also the case files—the medical reports and the witnesses’ testimonies—were thoroughly studied. It has been found that the evidence collected in the case supported the version of the victim being shot by another person from a distance.     

The Forensic Pathology of Fatal Attacks by the Large Mammals Inhabiting the Nordic Wilderness—A Literature Review

Fatalities due to animal attacks are rare in forensic medical work but have been known to pose problems due to their potential to mimic homicide. This review summarizes reported cases of fatal attacks by large mammals that inhabit the Nordic wilderness, namely brown bear, moose, wild boar, and wolf, and attempts to elucidate injury patterns that can guide the forensic pathologist to identifying the species and modus operandi of the attacker. A tendency toward a species‐specific injury pattern was observed. Injuries by bear and especially wolf are dominated by biting whereas moose and wild boar do not seem to bite their victims. The bear uses its paws, both for hitting, resulting in crush injury and fractures, and clawing with resulting excoriations and possible penetrating injuries. Crush injuries and fractures appear, on the other hand, to be minimal or absent in attacks by wolf and wild boar.     

An Autopsy Case of Acute Massive Hematochezia Caused by Superior Mesenteric Vein Thrombosis: A First Report in Forensic Medicine

Superior mesenteric vein thrombosis (SMVT) is an uncommon cause of intestinal ischemia and massive gastrointestinal bleeding. This report describes a man with alcoholic liver cirrhosis, who died of massive hematochezia due to SMVT. A medicolegal autopsy disclosed a thrombus at the superior mesenteric vein and hemorrhagic infarction of the bowel wall, an area also within the territory of the superior mesenteric vein. Liver cirrhosis, an enlarged spleen, and esophageal varices without rupture were also observed, but ulcers and variceal bleeding were not. Other organs showed no significant findings. His blood alcohol level was 0.14% w/v. Thus, this man died from severe hematochezia associated with SMVT due to liver cirrhosis and alcohol dehydration, which can lead to coagulopathy and rapid progress of thrombus formation. This is the first report on an alternate cause for massive gastrointestinal hemorrhage with a cirrhotic patient in a forensic autopsy.     

Wandering Dementia—A Syndrome with Forensic Implications

Wandering behavior in dementia may result in significant injury or death. Search of files at Forensic Science South Australia over a 20‐year period (1998–2018) identified nine individuals with dementia who were found deceased having been reported as missing from home/residential facilities (M:F, 6:3; age range, 54–92 years; average, 77.7 years; median, 80 years). The established clinical diagnoses were of dementia in seven cases and Alzheimer disease in two. Deaths were unnatural in six cases: hypo/hyperthermia three, drowning two, train impact one; natural in two cases due to ischemic (N=1) and valvular heart disease (N=1); and undetermined in one case due to marked decomposition. There were five fatalities in winter. Exposure and drowning were significant causes of death. The increasing aging population means cases of lethal wandering dementia will be more often encountered among forensic cases in future. Issues around duty of care and suicide should be considered in evaluating cases.     

Pathological Features of Fatal Crocodile Attacks in Northern Australia, 2005–2014

Eleven deaths from crocodile attacks in the Northern Territory, Australia were reviewed. The male:female ratio was 8:3; age range—10–62 years, average 29.4 years. Four children were included (one boy and three girls, aged 10, 11, and two at 12 years), and there were seven aboriginal victims (64%). The attacks were witnessed in eight cases with the victims swimming in freshwater N = 5, standing on a river bank N = 1, fishing in fresh water N = 1, or diving in the sea N = 1. At autopsy, several distinct patterns of injury were observed ranging from complete traumatic disruption of the body with only incomplete remains for examination (N = 5), to crushing of the head with fractures of the skull (N = 4), crushing of the chest with fractures of the ribs and sternum (N = 2), and avulsion of limbs (N = 4). In one case, there was decapitation. Autopsy evaluations were complicated by decomposition and loss of body parts.     

Inferior Vena Cava Tumor Thrombosis Secondary to Metastatic Uterine Cancer: A Rare Cause of Sudden Unexpected Death

Pulmonary tumor thromboembolus (PTTE) secondary to uterine cancer is a rare cause of sudden unexpected deaths in the elderly population. Additionally, tumor extension to the inferior vena cava (IVC) makes it rarer. No such cases have been previously reported in the forensic literature. We report this phenomenon in a previously healthy 70‐year‐old woman with no other known risk factors for the development of deep vein thrombosis. The deceased was found dead while watching television with her relatives. Autopsy examination revealed that her death was attributed to a saddle embolus lodged in the main pulmonary arteries. A uterine tumor was discovered, and microscopic examination revealed low‐grade endometrial stromal sarcoma with angiolymphatic invasion. The tumor cells were also found in the embolus and the remnant thrombosis attached to the inner wall of the IVC. This case demonstrates a sudden unexpected death caused by acute PTTE following seeding of uterine cancer into the IVC and raises awareness of such events.     

Missed Opportunities for Diagnosis of Post‐traumatic Thrombosis: A Case Series and Literature Review

Thrombosis is caused by abnormalities in the composition of the blood, the quality of the vessel wall, and the nature of the blood flow. Herein, we present four cases of fatal thrombus formation after a trauma, which were missed at clinical diagnosis as the symptoms were misinterpreted. We stress that a blunt trauma can be fatal because of its direct and indirect kinetic energy effects at the subacute phase. This report highlights the importance of considering thrombosis in the diagnosis of closed trauma, which is usually missed because of lack of awareness for early diagnosis and treatment or is detected too late for any therapeutic intervention, which can result in avoidable morbidity and mortality.     

Photogrammetric Documentation of Regions of Interest at Autopsy—A Pilot Study

In this pilot study, the authors tested whether photogrammetry can replace or supplement physical measurements made during autopsies and, based on such measurements, whether virtual computer models may be applicable in forensic reconstructions. Photogrammetric and physical measurements of markers denoting wounds on five volunteers were compared. Virtual models of the volunteers were made, and the precision of the markers' locations on the models was tested. Twelve of 13 mean differences between photogrammetric and physical measurements were below 1 cm, which indicates that the photogrammetric method has a high accuracy. The precision of the markers' location on the models was somewhat less, although the method is still promising and potentially superior to the current procedures used for reconstructions. The possibility to measure any distance on a body, even after the autopsy is concluded and the corpse is no longer available, is one of the biggest benefits of photogrammetry.     

Inter‐Rater Reliability of Total Body Score—A Scale for Quantification of Corpse Decomposition

The degree of body decomposition can be quantified using Total Body Score (TBS), a scale frequently used in taphonomic or entomological studies of decomposition. Here, the inter‐rater reliability of the scale is analyzed. The study was made on 120 laymen, which were trained in the use of the scale. Participants scored decomposition of pig carcasses from photographs. It was found that the scale, when used by different people, gives homogeneous results irrespective of the user qualifications (the Krippendorff's alfa for all participants was 0.818). The study also indicated that carcasses in advanced decomposition receive significantly less accurate scores. Moreover, it was found that scores for cadavers in mosaic decomposition (i.e., representing signs of at least two stages of decomposition) are less accurate. These results demonstrate that the scale may be regarded as inter‐rater reliable. Some propositions for refinement of the scale were also discussed.     

A Fatal Case of Poisoning with Fentanyl Transdermal Patches in Japan

Fentanyl transdermal patches have been used to treat cancer‐ and noncancer‐related chronic pain. However, its inappropriate or illegal application may cause fatal poisoning. We herein present the case of a Japanese woman in her 40s who was found dead with seven 25‐μg/h fentanyl transdermal patches on her body. We established a detailed toxicological analysis procedure to quantify fentanyl, and its metabolite norfentanyl, and other drugs (acetaminophen, allylisopropylacetylurea, celecoxib, estazolam, promethazine, and sertraline) in human whole blood by ultra‐high‐performance liquid chromatography–tandem mass spectrometry. The measured fentanyl and norfentanyl concentrations in the femoral and cardiac blood were 0.051 and 0.072 μg/mL and 0.033 and 0.076 μg/mL, respectively. The decedent's fentanyl concentrations were consistent with previously reported postmortem blood levels for fatal cases of poisoning by fentanyl transdermal patches. Based on the decedent's case history, autopsy findings, and toxicological analyses, the cause of death was identified as intoxication with transdermal fentanyl.     

Medicolegal Aspects of Post‐traumatic Gastroduodenal Ulcers: A Retrospective Study*

Abstract: Retrospective examination of 5‐year autopsy material showed the presence of posttraumatic gastroduodenal ulcers (PGDU) in 17.7% of decedents deemed to be at risk. They were more common in males (77%) and in patients aged over 50. In the majority of cases (76%) the survival period was <12 days; in 16.5% it was < 48 h. PGDU developed most commonly in victims of polytrauma and isolated craniocerebral injury, with ISS values ≥16; patients with spinal cord injuries were at greatest risk. Most frequently affected was the stomach, exhibiting numerous, usually superficial lesions, while solitary acute and exacerbated chronic peptic ulcers were more common in the duodenum. Complications of PGDU developed in 40% of cases, mostly in the form of hemorrhage; in 20% of cases PGDU have contributed to death. Medicolegal aspects of PGDU are, most frequently, concerned with the causal relationship between trauma, PGDU, and fatal outcome, as well as the potential for allegations of medical negligence.     

Fate and Behavior of Gunshot Residue—A Review

A review of the literature concerning the fate and behavior of gunshot residue (GSR) is presented. A number of concomitant parameters including firearm and ammunition type, plume and GSR material characteristics, travel distances, chemical composition and GSR morphology are critically discussed in relation to their effects on the distribution and deposition, transfer and persistence processes of GSR. The underlying mechanisms associated with such processes are also considered. Knowledge of these processes on GSR materials could provide valuable information concerning scene preservation and subsequent forensic sampling. The number of GSR particles deposited can vary significantly with each firearm discharge, highlighting the potential to produce distinctive data in each individual case. With the continual development and compositional changes of new ammunition types, further evaluation of the effect these processes may have on GSR evidence and their possible influence on the interpretation of the analytical results should be given due consideration.     

Fatal Injuries of Law Enforcement/Correctional Officers Attacked with Sharp‐Edged Weapons,

According to the National Law Enforcement Memorial Fund, there were 117 law enforcement fatalities in the United States in 2015. Assaults with sharp‐edged weapons have resulted in a total of over 400 fatalities in the United States. The goal of the current research was to examine sharp‐edged weapon assaults against law enforcement and correctional agents that resulted in a fatal outcome. A total of twelve autopsy reports were reviewed from across the United States. Four cases involved law enforcement officers, seven involved correctional officers, and one was an off‐duty border officer. The male‐to‐female ratio was 11:1. A total of 70.2% of the wounds analyzed were stab wounds (n = 85), and 29.8% of the wounds were slash wounds (n = 36). Based on this review, the neck, shoulder, and chest regions were the most vulnerable to single fatal stab/slash wounds. Multiple stab/slash wounds often resulted in exsanguination. The use of body armor was only noted in one case.     

“Tampering to Death”: A Fatal Codeine Intoxication Due to a Homemade Purification of a Medical Formulation

Many homemade tamper processes of medical codeine formulations are available on selected “forums” on the Internet, where recreational codeine users claim to be able to purify codeine by removing additives, such as acetaminophen, to avoid or limit adverse effects. In this work, it is reported and discussed a fatal case of codeine intoxication. The findings of objects such as jars, filters, and tablets, and amounts of unknown liquid material at the death scene investigation suggested a fatal codeine intoxication after the tampering procedure called “cold water extraction.” Toxicological results obtained from the analysis of both the nonbiological material and the body fluids of the decedent integrated with the information collected at the death scene investigation confirmed the above‐mentioned hypothesis. This report underlines the importance of a tight interconnection between criminalistics and legal medicine to strengthen the identification of the cause of death and the reconstruction of the event.     

Variation in Methods of Cardiac Dissection—A Potential Confounder in Measuring Cardiac Weight at Autopsy

To evaluate whether the weight of the heart measured at autopsy may be affected by the type of dissection, a prospective study was undertaken of the weights of sequential cases of nonpediatric hearts. Four hundred fifty‐eight hearts were examined (age range 17–96 years; mean 55.9 years; M:F = 3:1). The hearts were each weighed fresh, once the apex had been sliced, the auricles of the atria opened and blood drained, and again once the cardiac chambers had been opened completely. The difference in the partially and fully opened heart weights (range 146–1028 g; mean 434.8 g; range 134–1011 g; mean 420.8 g, respectively) (p < 0.05) ranged from 0 to 100 g (mean 14 g). In the most extreme example, the weight of the partially opened heart was 30.3% higher than that of the fully opened specimen. Failure to fully open the heart prior to weighing may result in significant error.     

The Intergenerational Cycle of Criminality—Association with Psychopathy*

Abstract: Preventive interventions early in life are likely to lower the risk of intergenerational transmission of criminal behavior. We investigated if psychopathy among homicidal offenders is associated with criminal offending among the offenders’ offspring. The basic sample consisted of consecutive Finnish homicide offenders (during 1995–2004) who had been subjected to a forensic psychiatric examination and rated for a file‐based PCL‐R, and their offspring. Criminal behavior among both genders of the offspring was more common than in the general population. In general, the offspring’s crimes against others (e.g., threat, intimidation, deprivation of freedom, breach of domicile) were associated with their parent’s psychopathy. A grandfather’s major mental disorder was associated with a high rate of crime committed by the offspring. Especially, the sons of male psychopathic homicidal offenders had the highest rate of committing crimes, which was often expressed as vandalism. However, both genders of offspring seem to require special preventive programs to ameliorate these problems.