Factors and circumstances influencing the development of hemorrhages in livor mortis

Petechial hemorrhages or ecchymoses in the skin of the face and/or in eyelids and/or conjunctivae are one important feature in postmortem diagnosis of lethal strangulation. On the other hand, petechial bleedings can occur in various causes of death, especially in cases of neck or thoracic compression, they can occur in acute cardiac failure, as a result of blood or skin diseases or as a postmortem phenomenon. The focus of this investigation (retrospective study of 279 corpses, found initially in a prone position or some other face down position) was to analyse the frequency of postmortem (hypostatic) hemorrhages and factors which may influence their development. Petechial hemorrhages in livor mortis in the skin of the trunk and extremities were found in 110 cases (39%). The frequency ranged from 41% in the side position and 44% in the kneeling position to 50% in the prone position. Increasing intensity of livor mortis resulted in an increasing frequency of hemorrhages, up to 59%. In cases with a body-mass-index (BMI) of more than 26 the frequency of hemorrhages increased up to 64%. In cases without livor mortis when the corpses were found as well as in cases with complete movement of livor mortis after turning the corpses, no hemorrhages were found. If hypostasis was partly or completely fixed, the rate of hemorrhages increased up to 50%, without additional increase in longer postmortem intervals. Obviously postmortem petechiae develop neither very soon nor days after death, but within a period of several hours after death.     

A Case of Accidental Fatal Aluminum Phosphide Poisoning Involving Humans and Dogs

Aluminum phosphide is one of the commonest poisons encountered in agricultural areas, and manner of death in the victims is often suicidal and rarely homicidal or accidental. This paper presents an unusual case, where two humans (owner and housemaid) and eight dogs were found dead in the morning hours inside a room of a house, used as shelter for stray dogs. There was allegation by the son of the owner that his father had been killed. Crime scene visit by forensic pathologists helped to collect vital evidence. Autopsies of both the human victims and the dogs were conducted. Toxicological analysis of viscera, vomitus, leftover food, and chemical container at the crime scene tested positive for aluminum phosphide. The cause of death in both humans and dogs was aluminum phosphide poisoning. Investigation by police and the forensic approach to the case helped in ascertaining the manner of death, which was accidental.     

A fatal doxepin poisoning associated with a defective CYP2D6 genotype

It has been suggested that the polymorphism of the CYP2D6 gene can contribute to occurrence of fatal adverse effects. We therefore investigated postmortem toxicology cases of fatal drug poisonings related to CYP2D6 substrates, with the manner of death denoted as accidental or undetermined. CYP2D6 genotypes were determined in 11 consecutive cases with samples available for DNA analysis. A case of fatal doxepin poisoning with an undetermined manner of death was found to coincide with a completely nonfunctional CYP2D6 genotype (*3/*4), indicating a total absence of CYP2D6 enzyme and suggesting a poor metabolizer phenotype. The doxepin concentration was 2.4 mg/L, the concentration of nordoxepin 2.9 mg/L, and the doxepin/nordoxepin ratio 0.83, the lowest found among the 35 nordoxepin-positive postmortem cases analyzed during the same year. No alcohols or other drugs were detected in the case. The CYP2C19 genotype was determined as that of an extensive metabolizer. The high N-desmethylmetabolite concentration is not consistent with acute intoxication. It is therefore probable that the defective genotype has contributed to the death, possibly involving repeated high dosage of doxepin. Our case strongly emphasizes that a pharmacogenetic analysis in postmortem forensic setting may reveal new insight to the cause or manner of death.     

The role of environmental factors in the causation of sudden death in infants: two cases of sudden unexpected death in two unrelated infants who were cared for by the same babysitter

We report two cases of sudden unexpected death in two unrelated African American female infants, 2 months and 4 months old. Both infants were attended to by the same babysitter in the same apartment and died 39 days apart in the same bed and in the same bedroom. The autopsy of the first infant revealed sudden unexplained death in an infant. Toxicologic analysis for carbon monoxide (CO) was not performed because it was not suspected. When the second infant died, investigation into the ambient air quality within the apartment revealed high levels of CO emanating from a poorly ventilated and defective hot water heater, which was located across a hallway from the bedroom where the two babies died. CO saturation levels in the postmortem blood samples of the two babies were elevated and were similar (13% and 14%). Nicotine and cotinine were not detected in the blood sample of the two infants. Cherry-red livor mortis was absent. Acute CO intoxication was determined to be the underlying cause of these two unexpected deaths. These two cases underscore the need to integrate ambient air analysis and postmortem CO analysis as routine components of the comprehensive death investigation of infants who die suddenly and unexpectedly.     

Change in the postmortem formation of hypostasis in skin preparations 100 micrometers thick

Twenty-three paired skin samples from 19 autopsies without putrefaction were taken from areas of livor mortis that (1). did not blanch with finger pressure and (2). blanched with strong pressure by tweezers. Three-dimensional microscopic viewing of 100-microm benzidine-stained skin sections demonstrated small blood vessels filled with red blood cells. The diameters of the clumps of red blood cells were greater in the sections from non-blanched areas than in the blanched areas, suggesting that fixation of hypostasis soon after death depends on sedimentation of intravascular red blood cells and passive dilatation of small vessels rather than on postmortem hemolysis.     

Diesel fumes do kill: a case of fatal carbon monoxide poisoning directly attributed to diesel fuel exhaust with a 10-year retrospective case and literature review*

While it is known that diesel fuel combustion engines produce much lower concentrations of carbon monoxide (CO) than gasoline engines, these emissions could certainly generate lethal ambient concentrations given a sufficient amount of time in an enclosed space and under suitable environmental conditions. The authors report a case of CO poisoning which was initially referred for autopsy as a presumed natural death of a truck driver found in the secure cab of a running diesel tractor trailer truck. Completion of the preliminary investigation ascribed death to complications of ischemic heart disease (IHD), pending toxicological analysis that included quantification of CO. When the toxicology results showed lethal blood COHbg, the cause of death was re-certified as CO intoxication secondary to inhalation of (diesel) vehicular exhaust fumes. Because of the unique source of fatal CO intoxication in this case, the contributory IHD and the possible contaminants in the putrefied blood, a 10-year retrospective review was conducted on all nonfire related CO deaths autopsied (n = 94) at the Office of the Chief Medical Examiner in Louisville, KY from 1994 to 2003. For validation of the COHbg detection method used by the Kentucky Office of Forensic Toxicology (KYOFT), blood samples from these cases along with controls were submitted to three laboratories using various analytical methods yielding no statistically significant differences. Lastly, an extensive literature review produced no scientifically reported cases of fatal CO poisoning attributed to diesel fuel exhaust.     

Spectrophotometric evaluation of postmortem lividity

Under low ambient temperatures normally bluish postmortem lividity adopts a bright red or pink colour due to resaturation of haemoglobin with O2. The most important differential diagnosis in the presence of pink hypostasis is carbon monoxide poisoning. To answer the question if objective measuring methods allow differentiation of hypostasis with regard to cold exposition or carbon monoxide poisoning, spectrophotometric measurements were performed and the colorimetric measures as well as the spectral reflectance curves of the postmortem lividity were determined. The colorimetric measures CIE-L*a*b* showed similar values for all bright red livores mortis; differentiation between CO intoxication and cold exposition was not possible. Reflectance curves of pink hypostasis after cold storage showed the typical pattern of O2-rich blood with reflectance minima at wavelengths 541 nm and 576 nm and a reflectance maximum at 560 nm. Pink hypostasis because of carbon monoxide poisoning showed a shift of the reflectance maximum toward 555 nm and a flattened curve in all cases with COHb concentrations exceeding 52%, whereas these changes were not regularly observed with lower COHb levels.     

Drugs in postmortem adipose tissues: evidence of antemortem deposition

INTRODUCTION: Drug concentration measured in postmortem adipose tissue may or may not reflect antemortem concentration. To examine the possibility of whether the presence of basic drugs in adipose tissue is the result of postmortem change, we examined: tissues with and without livor mortis, concentration gradients within the adipose layer, and the stability of drug concentrations during the postmortem period. CASE REPORTS: Five drug-related deaths with case histories and analytical data are presented. Adipose tissues with and without livor mortis from the thigh area of the same decedent were analyzed for cocaine. The cocaine concentration of the tissue exhibiting 4+ livor was equivalent to the concentration observed in tissue without livor. Analyses of cross sections of adipose tissues containing cocaine and methamphetamine disclosed that drug concentrations were equally distributed throughout the layer, from just beneath the dermis to directly above the muscle. When morphine and temazepam concentrations were measured in adipose tissues collected from similar sites, but at different times, from the same cadaver, they remained essentially the same over 3 days (approximately 80 h). CONCLUSIONS: Since concentrations were the same in areas with and without livor mortis, the possibility of redistribution into adipose from blood or vascular channels is eliminated. The absence of a concentration gradient within the adipose layer rules out diffusion or permeation from muscle into the adipose layer, and the failure of morphine or temazepam concentration to change over time indicates that drugs in the adipose tissue are stable during the postmortem interval. Our findings support the notion that drugs identified in postmortem adipose tissue are there because of antemortem deposition and not because of any postmortem change or event.     

Postmortem serum catecholamine levels in relation to the cause of death

Catecholamines are major humoral factors and neurotransmitters that contribute to various stress responses. However, they have been considered unstable due to agony, terminal medical care and postmortem interference. The present study was a comprehensive investigation of postmortem serum levels of adrenaline (Adr), noradrenaline (Nad) and dopamine (DA) with regard to the cause of death in serial medicolegal autopsy cases (n=542) including fatalities from various traumas and diseases. There was a slight tendency toward postmortem increases of Nad and DA in cardiac blood as well as Adr and Nad in peripheral blood, a slight age-dependent decrease in Adr and DA in right heart blood, and a marked increase in serum DA due to administration during critical medical care. When these factors were taken into consideration, significantly higher cardiac blood levels were observed for Adr and Nad in injury and asphyxiation cases and for Adr in fatal methamphetamine (MA) abuse and other poisoning cases, whereas those levels were lower in fatal hypothermia. Drowning, fire fatality, acute cardiac death and cerebrovascular disease showed intermediate Adr and Nad levels. The DA level was elevated in cases of injury, hyperthermia, MA fatality and other poisoning. Topographical analyses suggested that the major sources of increased serum catecholamines in cases of injury was abdominal viscera including adrenal glands, and that in cases of asphyxiation, drowning, fire fatality, hyperthermia, MA fatality, other poisoning, acute cardiac death and cerebrovascular disease was the extremities in addition to abdominal viscera. However, there was in part a large case-to-case difference in each marker related to individual causes of death. These findings differed markedly from clinical observations and suggest that the postmortem serum catecholamine levels may reflect the magnitude of physical stress responses during the process of death in individual cases.     

54例氯化琥珀胆碱中毒案件的法医学分析

目的观察分析氯化琥珀胆碱中毒案件的法医学表现,以期提高氯化琥珀胆碱中毒的检验鉴定。方法收集54例氯化琥珀胆碱中毒案例,通过病理学、毒理学变化及案件特点进行回顾性分析,观察氯化琥珀胆碱中毒的检验鉴定规律。结果氯化琥珀胆碱中毒的病理学表现以急性肺淤血、肺水肿等一般猝死改变为主,部分死者心肌排列紊乱及断裂。死者心血中均检见琥珀胆碱成分,皮肤组织部分检见琥珀胆碱成分。结论氯化琥珀胆碱中毒具有死亡快、手段隐蔽、难以抢救、易漏检等特点。对于猝死案件、死因可疑案件应将氯化琥珀胆碱作为常规检验指标,防止此类案件的未检或漏检。     

Cessation of livor in defined pressure conditions

In 28 cases of sudden death, the corpses were tested for the effect of different storage temperatures (5 degrees C, 14 degrees-15 degrees C, 25 degrees C) regarding the reaction of livor mortis to known pressure conditions (force and duration of pressure). The reaction is dependent on the storage temperature but there is no linear relationship. At certain storage temperatures the postmortem lividity reaction is dependent on the amount and duration of the pressure. In addition, at defined storage temperature and pressure conditions, there are large interindividual differences in the estimation of time of death.     

Carbon monoxide poisoning. Five-years' experience in a defined population.

A review is presented of 302 cases in East Denmark in 1982-1986 in which the manner of death was fatal carbon monoxide (CO) poisoning. The incidence of this far too frequent single-substance poisoning has as yet not decreased over the years despite preventive measures. The number of fatal CO poisoning cases may diminish as a result of a natural gas project in progress. The purpose of this survey, therefore, is to contribute to the evaluation of the actual causes of these fatal poisonings in East Denmark, and to discuss existing measures that prevent gas poisonings, in the expectation of a decline both in gas suicides and in accidental gas poisonings within the next few years.     

An apple a day does not always keep the doctor away...

The authors describe a case of suicide in the workplace. A 45-year-old man employed by a fruit and vegetable packing company was found dead in a room containing a modified atmosphere for the packaging of fruits and vegetables. The rescue team measured the carbon monoxide (CO) concentration of the ambient air with a digital CO tester and found a level higher than 600 particles per million. Analysis of an arterial blood sample taken with an airtight syringe revealed the absence of CO but high levels of carbon dioxide (CO(2)). Autopsy revealed no significant injury and police investigators found a handwritten note of intent, describing a recent personal crisis. The authors concluded that the cause of death was suicide by asphyxiation secondary to CO(2) intoxication and notably oxygen (O(2)) depletion. This manner of suicide is rare and most cases previously described in the literature were accidental intoxications. To the best of our knowledge, this is the first case of suicide by CO(2) intoxication and O(2) depletion in a room with a modified atmosphere.     

溴敌隆及其代谢物-苄叉丙酮在犬体内的死后分布

目的研究溴敌隆及其代谢物-苄叉丙酮在中毒致死犬体内死后分布规律,为溴敌隆中毒检材的采取提供实验依据。方法分别经口给予犬2倍和4倍LD_(50)溴敌隆,待其死亡后迅速解剖取材,气相色谱-质谱联用法测定心血、外周血、尿、胆汁、心、肝、脾、肺、肾、脑、左下肢肌、膀胱、胃、胃内容、胰等脏器和体液中溴敌隆和代谢物-苄叉丙酮的含量。结果犬经2倍和4倍LD_(50)溴敌隆灌胃染毒后3d开始出现出血症状,(178.40±20.94)h后死亡。溴敌隆和代谢物-苄叉丙酮在各组织脏器及体液中的死后分布为:溴敌隆2LD_(50)组溴敌隆:胆汁尿、肝、心、肾心血、外周血、脾、肺等;苄叉丙酮:胆汁、尿、心血、外周血、肺、胃内容中含量高于其他脏器。溴敌隆4LD_(50)组溴敌隆:胆汁、尿肝、外周血心血、胃内容物等脏器。苄叉丙酮:胆汁、尿、肺浓度高于其他脏器。结论溴敌隆及其代谢物-苄叉丙酮在中毒致死犬体内死后分布不均匀,溴敌隆在胆汁、尿、肝脏、心血和外周血含量较高,代谢物-苄叉丙酮在胆汁、尿、肺较高。胆汁、尿、肝脏、心血、外周血可作为疑似溴敌隆中毒毒物分析的检材。     

95例尸体血中HbCO％的分析

血中碳氧血红蛋白饱和度(简称HbCO％,下同)含量是判断一氧化碳中毒,推断火灾中尸体生前状态的依据。本文证明:血中HbCO％与其年龄、性别及不同情况下CO中毒有关。一氧化碳中毒的尸体含量较高(平均大于60％);火灾事故中遇难的尸体含量中等(平均在30～50％);而被杀后投入火场或服毒后自焚则较低(平均小于20％)。     

Death scene evaluation in a case of fatal accidental carbon monoxide toxicity

Exposure of humans to high concentrations of carbon monoxide can result in death, due to the formation of carboxyhaemoglobin (COHb), which impairs the oxygen carrying capacity of the haemoglobin. Carbon monoxide is responsible of a great number of accidental domestic poisonings and deaths throughout the world, particularly in homes that have faulty or poorly vented combustion appliances. A case is reported, in which a 21-year-old woman was found dead, due to carbon monoxide poisoning from a gas water heater, despite the puzzling evidence that the heater has been used for more than 10 years without any problem. An evaluation of the exposure to CO was performed, by measuiring the rate of production of CO from the heater, and using the Coburn-Forster-Kane equation to describe the kinetics of the poisoning process. The death was attributed to an accidental poisoning from carbon monoxide due to a sum of unfortunate circumstances.     

Carbon Monoxide Poisoning and Death in a Large Enclosed Ventilated Area

A 55‐year‐old man with a medical history of tobacco use suddenly collapsed while power washing an empty indoor pool in a hotel. The decedent was transported to the local hospital where he was pronounced. A postmortem examination revealed atherosclerotic heart disease and bilateral pulmonary edema and congestion. A postmortem blood carbon monoxide (CO) level was 27% saturation, and a CO performed on hospital admission blood was 49% saturation. CO poisoning is a common cause of toxicological morbidity and mortality in the United States. The circumstances most often occur in an enclosed environment and may be intentional or unintentional. CO poisoning has been reported in open, well‐ventilated spaces, but rarely results in death. A warning label was present on the engine clearly stating the dangers of CO emission. However, there was a false sense of security due to the large size of the pool room and the presence of industrial blowers that were being used for ventilation.     

Dissecting Thoracic Aortic Hematoma Masquerading as Blunt Force Injury of the Neck

Discoloration of the skin of the anterior and lateral neck may raise suspicion for blunt force injury, particularly cervical compression, in an unwitnessed death. We present a case of an elderly woman with an unwitnessed death at home which highlights an external examination finding of blue/purple discoloration of the skin of the neck and links this finding with those from internal examination at autopsy. Pertinent negatives include absence of conjunctival and mucosal petechiae, absence of cutaneous abrasions of the neck, and absence of contusions of the anterior neck musculature. This case illustrates a natural disease entity, spontaneous dissection of a thoracic aortic hematoma, masquerading as blunt force injury externally and highlights the importance of having an appropriate index of suspicion when triaging jurisdictional cases for postmortem examination to accurately determine cause and manner of death.     

不同死因大鼠死后不同时间红细胞溶血速度比较

目的观察不同死亡原因大鼠尸体血液中红细胞溶血速度的变化规律,为死亡原因的法医学推断提供新思路。方法 40只SD大鼠随机分为4组,分别以断髓、置于99%CO的空间、高坠、勒颈方式处死后,取各组大鼠右心室血液,于死后即刻（0h）、8h、16h、24h、32h、40h、48h、56h、64h、72h,采用显微镜数码图像法进行全血红细胞计数（CBC）,并对组内和组间数据进行统计学比较分析。结果 4组血液红细胞数量在死后即刻至72h期间,均随时间的延长因溶血而减少。其中0~16h,各组溶血速度无明显差异（P〉0.05）;16~48h,速度加快,溶血速度以CO中毒组（88.50±25.99）%最快,其次为高坠（69.33±29.52）%和断髓组（48.78±3.17）%,机械性窒息组（41.90±9.61）%最慢,组间比较具有显著性差异（P〈0.05）;56h后,溶血速度再次减慢,至72h机械性窒息组仍有少量红细胞存在。结论 4组不同死因大鼠死后不同时间红细胞计数均减少,各组间差异具有统计学意义,其变化特征可为死亡原因的推断提供新的思路。