Cerebral traumatism with a playground rocking toy mimicking shaken baby syndrome

Shaken baby syndrome (SBS), one of the most deadly and devastating forms of child abuse, is caused by violent shaking. The combination of subdural hematoma, retinal hemorrhage, brain swelling, and diffuse axonal injury is highly typical of this syndrome and faced with these autopsy findings, induced traumatic lesions are strongly considered. However, it is known that motor-vehicle accidents and falls from great height can also produce this pattern of injury. Nevertheless, stories of arms fall, couch fall, or bumped head while the baby is being carried are generally considered incompatible with SBS. We here report a case of a 2-year-old boy presenting with all the classic autopsy findings of SBS from a playground rocking toy shaken by an older child.     

Simulation of homicide to hide child's suicide

A case of pretending a homicide to conceal a child suicide is reported in which characteristic findings of the postmortem examination and conclusions from the analysis of forensic autopsy series provided substantial support for the police investigation. In the late night hours of a spring day the police authorities were informed that a 10-year-old girl had been found dead on a playground near its parents' house. As injuries of the neck were recognized by the police officers a homicide investigation was initiated. The post mortem examination showed a furrow symmetrically slanting from the front to the nape of the neck, discrete punctate haemorrhages of the skin of the face and numerous 'tram-line' bruises of the back, buttocks and extremities. These findings indicated as cause and manner of death suicidal hanging following corporal punishment. Confronted with these conclusions the mother immediately made a corresponding confession.     

全面系统的法医学尸体检验及常见失误的防范

法医学尸体检验是法医学检案鉴定工作中的重要环节,是保证鉴定质量的基础和前提。虽然各人所做方法、步骤略有不同,每一案例又各有特殊性,但力求全面系统和规范是其基本要求。狭义的全面系统尸体检验是指尸体解剖时不仅应剖验颅、胸、腹腔这“三大腔”,还应剖验脊髓腔及其它应解剖的部位。如脊髓腔、关节腔、骨骼、眼球、周围神经和软组织等。而广义上的全面系统法医学尸体检验则应包括上述尸解和提取并保存适当、足量、可靠的检材标本这两方面。其常见的失误有:①案情不清,致尸检方案错误;②准备不足,盲目尸检;③仅作局解,片面不全;④尸解不规范,操作不标准;⑤观察不仔细,遗漏损伤或病变;⑥描述不准,记录不明,图照不清;⑦取材不适当,不能反映事实。     

Primary intimal sarcoma of the pulmonary artery misdiagnosed as pulmonary thromboembolism: A case confirmed at medicolegal autopsy

Misdiagnosed PAS confirmed at medicolegal autopsy Pulmonary artery sarcoma (PAS) is a rare disease and usually indistinguishable from acute or chronic thromboembolic disease of the pulmonary arteries. We present a case of pulmonary artery sarcoma in a 54‐year‐old male, who was clinically misdiagnosed as pulmonary thromboembolism. The patient died of disease; however, the actual diagnosis of PAS was made after a medicolegal autopsy. PAS can be a diagnostic challenge for both clinicians and pathologists. In an autopsy case with a clinical suspicion of pulmonary thromboembolism, if there is an abnormal gross appearance in the pulmonary artery, the forensic pathologist should have a high index of suspicion of PAS, which should be ruled out by a histopathologic examination.     

A suicide with neuromuscular blocker

We experienced an autopsy case in which a 29-year-old woman committed suicide by parenteral application of a neuromuscular blocker combined with thiobarbital. These medicines were easily accessible to the victim who was an anesthesiologist in a hospital. Paralyzing the respiratory muscles the usual dose of neuromuscular blockers can cause death unless a breathing apparatus is used. Unusual medicines given in small doses are difficult to detect in the autopsy materials. In our case in the course of forensic investigation we successfully identified the traces of a neuromuscular blocker by mass spectrometry.     

A case of suicide disguised as natural death.

A case report describing the suicide of a physician classified initially as a natural death. Faced with the vehement protest of the family of the deceased the magistrate decided to request a 'preventive' forensic autopsy. Forensic investigations revealed the cause of death as being a pentobarbital intoxication and the circumstances favoured the hypothesis of a genuine suicide. This case illustrates that the tendency of magistrates to request or not an autopsy is related to their experience or intuition.     

Homicide due to intravenous metallic mercury injection followed by sodium cyanide injection

We report a case of homicide due to intravenous mercury injection followed by meperidine and sodium cyanide injection. A 35-year-old woman was found dead in bed at home by her husband. Reportedly, she had been sick for more than 5 months. Initial death investigation revealed no evidence of foul play. Her death was believed to be natural. Therefore, her body was buried without an autopsy. Two months after death, her family requested an autopsy because they suspected her physician husband killed her. Her body was exhumed, and an autopsy was performed. Postmortem examination revealed numerous metallic mercury globules in the pulmonary arteries. Toxicological analysis revealed a high concentration of mercury in the tissue samples of the lungs, liver, heart, and kidney. In addition, cyanide and meperidine were also found in the heart and liver. The detailed case history and postmortem examination findings are described.     

Suicide via insulin overdose in nondiabetics: the New Mexico experience

Four cases of self-injected insulin overdose in nondiabetic individuals are presented. Included are two cases of presumed insulin overdose (no autopsy), one case with elevated vitreous insulin (autopsy), and one case with elevated postmortem blood insulin and low blood C peptide (autopsy). These cases demonstrate the need for a thorough scene investigation, complete autopsy, and proper collection and storage of specimens to certify a death caused by insulin intoxication as well as to determine the manner of death. Appropriate collection and preservation of postmortem blood samples are discussed.     

Sudden death owing to right atrial hemangioma

Primary cardiac tumors are rare, with an autopsy incidence of 0.03%. Seventy-nine percent to 85% of primary cardiac tumors are benign, and of the benign tumors, cardiac hemangiomas account for 5-10% of cases. Most cardiac hemangiomas are asymptomatic and are discovered incidentally at autopsy, or by echocardiography, computerized tomography, or magnetic resonance imaging. We report a case of sudden death owing to cardiac hemangioma in a 22-year-old woman who collapsed while shopping and became unresponsive. The autopsy revealed a hemorrhagic mass on the surface of the right atrium which was infiltrating and replacing the wall of the right atrium; histopathological examination confirmed the tumor was a cavernous hemangioma. Fewer than 20 cases of right atrial cavernous hemangiomas have been reported in English literature, emphasizing the rarity of our case.     

Fatal paradoxical air embolism diagnosed by postmortem imaging and autopsy

The recognition and visualization of an arterial gas embolism are difficult. We report a case of sudden death caused by paradoxical air embolism of coronary and cerebral arteries, diagnosed by the pre autopsy computed tomography (CT) scanning. A 54-year-old woman suddenly died after the self-removal of the jugular vein catheter. Postmortem imaging examination using CT scanning showed multiple gas embolisms in the cerebral arteries, pulmonary artery, right atrium and ventricle, left ventricle, aorta, and coronary arteries. These findings suggested that the occurrence of acute ischemia of the brain and heart caused by massive air inflow to the artery. Conventional autopsy revealed a patent foramen ovale of the heart. These results indicated that the patient died of paradoxical air embolization of the coronary and cerebral arteries through a patent foramen ovale because of right-to-left shunting. The use of postmortem imaging as an aid for conventional autopsy has proved to be of advantage in the case of gas embolism.     

The use of moxibustion scars in the identification of individuals in forensic medicine

The use of moxibustion today does not only take place in Eastern Asia, but recently also in Europe and the United States. Moxibustion scars are often seen in autopsy cases in Japan. However, no reports of the use of moxibustion in autopsy cases have been reported. This paper reports on an autopsy case in which moxibustion scars were used to extrapolate on the past symptoms of the deceased, date of therapy and the location of the moxibustion clinic which administered the moxibustion.     

Dieulafoy lesion of the esophagus causing massive upper gastrointestinal bleeding and death: a case report

Dieulafoy lesion is a rare cause of upper gastrointestinal bleeding. We present a case report of sudden and unexpected death in a previously healthy male where autopsy revealed a classic Dieulafoy lesion with a submucosal artery protruding through a small mucosal defect in the esophagus, thereby exposing it to stress and consequent rupture. Advances in endoscopic techniques have drastically reduced mortality from Dieulafoy lesion. Nevertheless, it is an important diagnosis to be kept in mind when autopsy reveals an upper gastrointestinal bleeding.     

Analysis of Forensic Autopsy in 120 Cases of Medical Disputes Among Different Levels of Institutional Settings

Despite advances in medical science, the causes of death can sometimes only be determined by pathologists after a complete autopsy. Few studies have investigated the importance of forensic autopsy in medically disputed cases among different levels of institutional settings. Our study aimed to analyze forensic autopsy in 120 cases of medical disputes among five levels of institutional settings between 2001 and 2012 in Wenzhou, China. The results showed an overall concordance rate of 55%. Of the 39% of clinically missed diagnosis, cardiovascular pathology comprises 55.32%, while respiratory pathology accounts for the remaining 44. 68%. Factors that increase the likelihood of missed diagnoses were private clinics, community settings, and county hospitals. These results support that autopsy remains an important tool in establishing causes of death in medically disputed case, which may directly determine or exclude the fault of medical care and therefore in helping in resolving these cases.     

Suicide by blunt force trauma

Suicide by self-inflicted blunt force injury is rare. The authors report a case of a 48-year-old man who initially appeared to have died of a homicidal beating. The pertinent autopsy findings consisted of blunt force closed head injury combined with numerous cutaneous abrasions and contusions of the entire body. Further inquiries confirmed a medical history of paranoid schizophrenia and a previous attempt at suicide. This case represents an extreme example of severe blunt trauma sustained during fatal self-mutilation and masquerading as a homicide. It also underscores the importance of correlating a thorough background investigation with autopsy findings in determining the appropriate manner of death.     

Unusual and Fatal Case of an Undiagnosed Intravascular Large B-cell Lymphoma: The Oncologist’s Great Imitator†

Intravascular lymphoma (IVL) is a rare subtype of extranodal lymphomas that is characterized by the selective growth of neoplastic cells within the lumen of small vessels. Authors document the case of an unexpected death caused by an undiagnosed intravascular large B-cell lymphoma with multi-organ involvement, which had initially manifested as an infection and then as an unclarified central nervous system pathology. Histological examination showed a diffuse intravascular large B-cell brain lymphoma with prominent cerebral involvement. The relevance of the case report reveals the importance of an autopsy of an extremely rare and threatening pathology that in most cases is diagnosed only postmortem. As a result, the role of the forensic pathologist becomes particularly important. When specifically performing an in-depth autopsy evaluation with a specific histologic analysis, it is possible to identify the intravascular lymphoma and declare a more accurate cause of death.     

An Exceptional Case of Acute Respiratory Failure Caused by Intra‐Thoracic Gastric Perforation Secondary to Overeating

An 18‐year‐old female patient arrived at the emergency department complaining of abdominal pain and fullness after a heavy meal. Physical examination revealed she was filthy and cover in feces, and she experienced severe abdominal distension. She died in ED and a diagnostic autopsy examination was requested. At external examination, the pathologist observed a significant dilation of the anal sphincter and suspected sexual assault, thus alerting the Judicial Authority who assigned the case to our department for a forensic autopsy. During the autopsy, we observed anal orifice expansion without signs of violence; food was found in the pleural cavity. The stomach was hyper‐distended and perforated at three different points as well as the diaphragm. The patient was suffering from anorexia nervosa with episodes of overeating followed by manual voiding of her feces from the anal cavity (thus explaining the anal dilatation). The forensic pathologists closed the case as an accidental death.     

Ancillary studies in amniotic fluid embolism: a case report and review of the literature

The incidence of amniotic fluid embolism during pregnancy is approximately 1/50,000 and has a mortality rate in excess of 80%. The postmortem diagnosis of amniotic fluid embolism can be challenging for forensic investigators and pathologists. At autopsy, usually signs of disseminated intravascular coagulation suggest an amniotic fluid embolism. A definitive diagnosis of amniotic fluid embolism cannot be made until ancillary studies are performed on the decedent's tissues. We report a case of a 37-year-old G3P2 white female who was 36 weeks gestation when her membranes spontaneously ruptured. She suddenly became breathless, went into cardiogenic shock, and died. The autopsy revealed gross and microscopic findings of amniotic fluid embolism, which was confirmed with ancillary studies consisting of special stains, immunohistochemistry, and a serum tryptase level. The authors hope this case report, including gross and microscopic autopsy findings with procedural and ancillary studies, and review of the literature will help investigators and pathologists in the diagnosis of amniotic fluid embolism.     

Papillary hyperplasia of the lingual tonsil and sudden death in epilepsy.

Papillary hyperplasia of the lingual tonsils is a rare entity not previously reported at autopsy. We report a case that occurred in a 19-year-old man who died suddenly from his epilepsy, associated with aspiration of gastric contents. We describe the pathological features of this unusual condition, discuss the possible significance in this case and stress the importance of routine examination of the tongue and pharynx in every autopsy.     

Fatal rupture of hepatic adenomatosis: Autopsy case and review of the literature

Hepatic adenomatosis is a rare disease consisting of multiple adenomas in otherwise-normal liver parenchyma. Though the discovery of this entity goes back several years, its diagnosis is still challenging in terms of its definition and pathophysiology. Clinically, patients may be completely asymptomatic and the diagnosis is only made incidentally through imaging tests. The discovery could be made when complications occur such as intraperitoneal hemorrhage with hypovolemic shock due to the rupture of an adenoma. We report a fatal case of a ruptured adenoma in a case of hepatic adenomatosis discovered at autopsy. In order to achieve a better view of this disease, we conducted a literature review on this subject describing the pathogenesis, manifestations, and autopsy contribution to addressing this entity.     

Occult aspiration of a nut in an elderly patient: a case report

Occult foreign body aspiration is an uncommon but serious occurrence in the elderly population. A case is presented in which the foreign body, a nut, was uncovered only at autopsy.