Acute Aortic Dissection Diagnosed after Embalming: Macroscopic and Microscopic Findings

A 58‐year‐old man died suddenly in Madagascar and poisoning was suspected. The body was embalmed after death and the general state of preservation was good. We found a major aortic dissection with a large false lumen from the aortic root to the common iliac arteries and a hemopericardium with formalinized blood clot. The intimal tear was on the ascending aorta, and an intramural hemorrhage was noted at the right coronary artery, attesting to a retrograde dissection. Microscopic studies confirmed aortic dissection with extensive intramural hemorrhage and also confirmed the retrograde dissection to the right coronary artery with a reduction of 90% of the true lumen. Classically, aortic dissection occurs in individuals with hypertension and individuals with genetic disorders of collagen formation. The diagnosis is often first established at the postmortem examination. Aortic dissection is therefore dealt with largely in necropsy studies. The usual cause of death is rupture into the pericardial sac. One case of bloodless dissection has been reported but the sudden death was explained by acute myocardial ischemia secondary to dissection of the left coronary artery. In our case, we found major hemopericardium and also intramural hemorrhage at the right coronary artery. We were able to make the diagnosis of aortic dissection and exclude the suspicion of homicide 15 days after death and after embalming.     

Ultrastructural and immunofluorescent detection of herpes simplex virus after embalming and burial

The practice of embalming preserves body tissues, and embalmed bodies may resist decay processes for many decades with relatively little change. As the chemicals used for embalming are poisonous to microorganisms, bacterial and viral cultures are futile after such funerary procedures are performed. However, embalming may act as a virtual tissue fixative, especially with arterial perfusion, and identification methods other than culture may be used to detect and identify pathogenic organisms. In the case presented here, a death from a fulminating, but unidentified, illness in a young girl was successfully diagnosed as herpes hepatitis by immunofluorescent and electron-microscopic studies of tissue obtained 3 weeks after she was embalmed and interred. Routine embalming and burial should not eliminate these diagnostic procedures from consideration in specific situations where potentially useful information may be realized.     

Detection of ketosis in vitreous at autopsy after embalming

Ketosis occurs in ketoacidosis or malnourishment. When either is suspected in relation to a death, it may be important to analyze for ketosis at autopsy. We encountered a case where starvation was suspected in a deceased nursing home resident, where the body had been embalmed prior to autopsy. Gas chromatography (GC) was unable to separate acetone from formaldehyde, a component of embalming fluid. The Acetest is a simple test that can detect acetone and acetoacetate in body fluids. We validated the Acetest with GC on vitreous. The Acetest and GC were consistent except at very low levels of acetone or acetoacetate. The sensitivity of the Acetest for acetoacetate in vitreous was 10 mg/dL, consistent with early starvation. Significant interference from embalming fluid did not occur. The Acetest was negative in the described case. The Acetest is a simple and useful test for the detection of ketosis in embalmed autopsies.     

Descending thoracic aortic aneurysm rupture during postpartum period

Aortic aneurysm refers to the pathological dilatation of the normal aortic lumen involving one or several segments. Thoracic aortic aneurysms are much less common than aneurysms of the abdominal aorta. Descending thoracic aortic aneurysm leading to dissection and spontaneous rupture is a potentially catastrophic illness. Although rare, dissection and rupture of a preexisting aortic aneurysm have been reported during pregnancy and early puerperium. To the best of our knowledge, such cases among young pregnant women are rarely reported in literature. Herein, an autopsy case of spontaneous rupture of a clinically undiagnosed descending thoracic aortic aneurysm during early puerperium in a young woman is presented along with the review of relevant literature. The victim was found dead on her hospital bed on the seventh day of puerperium. Autopsy with ancillary investigations revealed that the young woman died because of hemothorax from a ruptured dissecting descending thoracic aortic aneurysm secondary to chronic aortitis.     

Ascending Aortic Rupture through a Penetrating Atherosclerotic Ulcer: A Rare Cause of Sudden Unexpected Death

Spontaneous rupture of the aorta through an atherosclerotic lesion without preexisting aortic aneurysm, dissection, or history of trauma is very rare. Without prompt aortic repair, all cases result in sudden death with a definitive diagnosis made only intraoperatively or during autopsy. The phenomenon has been uniformly found in individuals with hypertension. The author reports a sudden unexpected death caused by spontaneous rupture of the ascending aorta in a 57‐year‐old man with a history of hypertension. The ascending aortic wall showed a longitudinal intimal tear measuring approximately 1 cm in length and rupture of the ascending aorta through an atherosclerotic ulcer, leading to massive hemopericardium and eventual death. Chronic hypertension and a penetrating atherosclerotic ulcer of the ascending aorta were the apparent underlying etiologies of the aortic rupture in the present case. This case illustrates not only the association between a rupture and a penetrating atherosclerotic ulcer with a silent death, but also raises awareness of possible such deaths.     

Methanol Detected in a Subdural Hematoma as an Embalming Artifact

Analysis of subdural hematomata has been used to suggest antemortem drug concentrations, with the assumption that materials within the hematoma are less subject to metabolism or degradation during any survival period and postmortem interval. We report the case of an 87‐year‐old woman whose death had not been reported to the coroner's office until postembalming. Autopsy revealed a traumatic brain injury with subdural hematoma causing a mass effect. Testing of the clot indicated a methanol concentration of 51.8 mg%. No additional analyses were detected. These findings suggest that methanol can be present in a postmortem hematoma sample, yet not represent a poisoning. Our findings also suggest that while the interior of hematomata do not necessarily represent completely “protected space” from postmortem diffusion of some blood constituents, such diffusion is not facile, and analysis may still provide useful indications of antemortem drugs present, if not actual concentrations.     

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.     

Fatality involving complications of bupivacaine toxicity and hypersensitivity reaction

This case represents unusual findings of elevated bupivacaine and tryptase concentrations following local anesthetic, bupivacaine, administered as a scalene nerve block for elective rotator cuff repair surgery. Following bupivacaine injection, the patient exhibited almost immediate seizure activity, bradycardia, and cardiac arrest. Resuscitative efforts including cardiopulmonary bypass restored a cardiac rhythm. However, the clinical medical status of the patient progressively declined and he died 7 h following administration of the local anesthetic. Autopsy revealed several abnormalities of the heart including cardiomegaly, myocardial bridging, and lipomatous hypertrophy of the intraatrial septum, which may have contributed to bradycardia and arrhythmia. Postmortem toxicology results revealed elevated bupivacaine and tryptase concentrations. Elevated postmortem bupivacaine concentrations 7 h following administration and abrupt onset of seizures indicate unintentional intravascular injection instead of nerve and tissue infiltration. An elevated postmortem tryptase concentration points to the possibility of a hypersensitivity reaction to bupivacaine.     

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.     

Estimating Sex Using Metric Analysis of the Scapula by Postmortem Computed Tomography

Postmortem computed tomography (CT) has been extensively used in the last decade for identification purposes and in various anthropologic studies. Postmortem CT measurements of scapulae, analyzed using logistic discriminant function developed in this study, showed 94.5% accuracy in estimating sex. Data analyzed using the Dabbs and Moore‐Jansen (2010) discriminant function and the discriminant function generated in this study provided nearly identical results with disagreement in only one case. Height and weight were not statically significant in sex prediction. The results of this study show that data obtained from volume rendered postmortem CT images can be considered reliable and treated as a practical option to standard anthropological methods, especially in mass fatalities as a rapid triage tool for sex determination.     

Why We Need Postmortem Analysis of Cardiac Implantable Electronic Devices

The prevalence of cardiac implantable electronic devices (CIEDs), pacemakers and implantable cardioverter defibrillators (ICDs) is increasing. However, postmortem analysis of CIEDs is not performed routinely. Fourteen consecutive CIEDs were analyzed. The indication for and date of implantation, technical data, CIED reprogramming, heart rhythm disturbances, patient demographics and medical consultations were investigated. Death during the first year after implantation was seen in 54%, whereof 71% consulted a physician within 10 days before death. The time of death was attributed to a particular day in 29%. There was a relationship between CIEDs and cause/manner of death in 50%. Although limited by a small sample size, this study advocates the routine postmortem CIED analysis for forensic and clinical purposes in selected cases. Patients with CIEDs seem to show an increased risk of death during the first year after implantation. The analysis of CIEDs can be helpful in evaluating the time/cause/manner of death.     

The Red Swamp Crayfish Procambarus Clarkii (the Louisiana Crayfish) as a Particular Scavenger on a Human Corpse

An 85-year-old man was found deceased floating in an irrigation ditch 18 days after his disappearance. During crime scene investigation, specimens of the red swamp crayfish Procambarus clarkii were found in proximity of the body. The feeding activity of these nonendemic crayfishes contributed to the formation of specific injuries on the body and in the production of a large substance defects inside the corpse. The aim of this paper was to illustrate the scavenging activity of P. clarkii on a human body and highlight the potential postmortem artefacts caused by this species. This is the first report on a real case of postmortem injuries produced by P. clarkii crayfishes on a submerged human body. So far, crustaceans are not considered useful for the estimation of the minimum postmortem interval. However, the important modifications on the corpses deriving from the activity of these animals should be kept in consideration.     

A “concrete” identification in a dismemberment case

Homicide perpetrators can use concrete as a means to conceal their victims. When concrete encasement is encountered in the forensic field, albeit rarely, it is often coupled with postmortem dismemberment. This method of obscuring the evidence presents unique investigative obstacles, specifically related to identification. Various approaches to obtaining fingerprints from decedents encased in concrete have been suggested and implemented over the years. The presented case is that of an initially unidentified 44-year-old male, who was subject to postmortem dismemberment and concrete encasement. Meticulous excavation techniques facilitated preservation of evidence and an anatomical reconstruction of the body. These techniques enabled inspection of the incision sites of the dismembered remains during the postmortem examination. Identifiable jewelry and tattoos were noted at autopsy. Further, the resulting concrete molds could be utilized to obtain fingerprints. These prints were used to ultimately identify the decedent.     

心包液检测在法医学鉴定中的应用

心包液是存在于心包腔内的一种浆液.相对于血液易受自溶和腐败等死后变化的影响、玻璃体液含量少、脑脊液易受血液污染等缺陷,心包液存在于封闭的浆膜腔内,不易受尸体死后变化的污染和影响,且容易获取,不仅是临床上重要的检测样品,在法医鉴定中也有广泛的应用前景.本文阐述了心包液的理化性质及临床应用,重点综述了心肌病变、溺死或窒息时心包液中不同生物化学检测指标的变化及其在法医病理学鉴定中的意义,并介绍了心包液在法医物证学、法医毒物分析等相关领域的应用情况.随着研究的深入,心包液在法医学领域中将发挥越来越广泛的作用.     

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.     

Death caused by a signal rocket--not an isolated case*

Fatalities related to sporting events are predominantly caused by blunt force injuries especially due to the emotional involvement of crowd, but occasionally other types of trauma are reported as well. A case of very rare trauma caused by shooting with a hand-held parachute signal rocket during a football match is presented. A 17-year-old football fan sustained fatal injuries, a combination of mechanical trauma caused by rocket penetration, as well as extensive thermal burning of the thoracic viscera. Analysis of the event was based on autopsy findings and evidence produced by medicolegal and ballistic experts. Improper use of a hand-held signal rocket, designed for marine distress signals, may cause serious injuries either mechanically, due to explosion, or as a result of thermal discharge. In the reported case, pattern of injuries is discussed, and medical finding corroborated to other available evidence. The presented case is a reminder that the forensic pathologist should be informed accordingly on the type and features of weapon suspected to produce injury, to be able to understand traumatic changes, and look for potential presence of foreign bodies at postmortem examination.     

Subaortic Pseudoaneurysm of the Left Ventricle Complicating Staphyloccal Endocarditis*

Abstract: Subaortic pseudoaneurysms are rare but can be a cause of sudden death in young individuals. This case report involves a 20‐year‐old Vietnamese male who died suddenly from rupture of a subaortic pseudoaneurysm with resultant hemopericardium with tamponade. He had a history of bicuspid aortic valve with recent but healed Staphylococcal endocarditis. A review of the literature reveals few similar cases and enlightens the association between aortic bicuspid valve, endocarditis, and subvalvular aortic aneurysm. The pathogenesis as well as recent studies that identified aneurysm predisposing genes in patients with bicuspid aortic valve will be discussed.     

The Eyeball Killer: Serial Killings with Postmortem Globe Enucleation

Although serial killings are relatively rare, they can be the cause of a great deal of anxiety while the killer remains at‐large. Despite the fact that the motivations for serial killings are typically quite complex, the psychological analysis of a serial killer can provide valuable insight into how and why certain individuals become serial killers. Such knowledge may be instrumental in preventing future serial killings or in solving ongoing cases. In certain serial killings, the various incidents have a variety of similar features. Identification of similarities between separate homicidal incidents is necessary to recognize that a serial killer may be actively killing. In this report, the authors present a group of serial killings involving three prostitutes who were shot to death over a 3‐month period. Scene and autopsy findings, including the unusual finding of postmortem enucleation of the eyes, led investigators to recognize the serial nature of the homicides.     

Acute Fatal Coronary Artery Dissection Following Exercise‐related Blunt Chest Trauma

Coronary artery injury such as acute coronary dissection is an uncommon and potentially life‐threatening complication after blunt chest trauma. The authors report an unusual autopsy case of a 43‐year‐old healthy man who suddenly collapsed after receiving a punch to the chest during the practice of kung fu. The occurrence of the punch was supported by the presence of one recent contusion on the left lateral chest area at the external examination and by areas of hemorrhage next to the left lateral intercostal spaces at the internal examination. The histological examination revealed the presence of an acute dissection of the proximal segment of the left anterior descending coronary artery. Only few cases of coronary artery dissection have been reported due to trauma during sports activities such as rugby and soccer games, but never during the practice of martial arts, sports usually considered as safe and responsible for only minor trauma.     

Site‐, Technique‐, and Time‐Related Aspects of the Postmortem Redistribution of Diazepam,Methadone, Morphine,and their Metabolites: Interest of Popliteal Vein Blood Sampling

Sampling site, technique, and time influence postmortem drug concentrations. In 57 cases, we studied drug concentration differences as follows: subclavian vein‐dissection/clamping versus blind stick, femoral vein‐dissection/clamping versus blind stick, right cardiac chamber, and popliteal vein‐dissection and clamping only. Cases were distributed in group #1 (all cases with both techniques), group #2 (dissection/clamping), and group #3 (blind stick). Sampled drugs were diazepam, methadone, morphine, and their metabolites. To assess PMR, mean concentrations and ratios were calculated for each group. Time‐dependent variations of blood concentrations and ratios were also assessed. Results indicate that site, method, and time may influence postmortem distribution interpretation in different ways. Popliteal blood seems less subject to PMR. In conclusion, our study is the first to evaluate concurrently three main aspects of PMR and confirms that the popliteal vein may represent a site that is more resistant to the changes seen as a result of PMR.