Sudden death as a complication of bacterial endocarditis

Three cases are reported to demonstrate the range of possible lesions and wide variation in lethal mechanisms that may be found in cases of unexpected death subsequently shown to be due to bacterial endocarditis. Case 1: A 36-year-old man was found dead on his bedroom floor surrounded by drug paraphernalia. At autopsy, acute myocardial ischemia was present caused by coronary artery ostial occlusion complicating acute bacterial endocarditis of the aortic valve. Case 2: A 54-year-old man with chronic renal failure was found dead in bed at home. At autopsy, a left middle cerebral artery territory cerebral infarct was present due to septic embolization from bacterial endocarditis involving the aortic valve. Case 3: A 23-year-old man was found collapsed in a pool of blood. At autopsy, upper airway hemorrhage from an arteriobronchial fistula was present caused by septic pulmonary infarction from previous endocarditis of a congenital ventricular septal defect. This report demonstrates that bacterial endocarditis may still be a cause of sudden and unexpected death presenting to forensic mortuaries and that the underlying mechanisms may involve complex sequences of pathological changes that compromise vascular function.     

Detection of "uncommon" tranquillizers-sedatives during screening toxicological analysis

A 56-year-old man is discovered unconscious in a pool of blood in the kitchen of his house. According to findings, the man used a 22 long Rifle to fire 14 shots at his thorax with trajectories going from front to back, from right to left and on a nearly horizontal level. All the projectiles got into the left front side of his thorax and came out just under the back of his left armpit. One of them then got through his left arm and fractured his left humerus. According to the findings made on the premises and the position of the bloodstains, we think that man put his rifle against the wall, resting on a pipe. He fired, unloading two clips into his thorax. He had to handle the bolt of the rifle before each shot. To reload, he took the bullets which were on the nearby table on which blood marks can be seen. When reloading at a certain moment, he sat down in his armchair and when he wanted to stand up, he leaned on the armrests, on which blood marks can be seen. The last bullet was probably the one which went through his left arm, preventing him from keeping on shooting. His death, caused by a hypovolemical shock, was obviously very slow.     

Extra- and intracranial injuries of the cerebral arteries as a sequela of assault

The case of an 47-year-old man is reported, who was injured in a fight while under the influence of alcohol. The culprit knocked him down and stamped several times on the left side of his head. The victim became unconscious. At the hospital, subarachnoid hemorrhage and massive ventricular bleeding was diagnosed via CT. Despite the implantation of a ventricular shunt, there was repeated massive cerebral pressure and arterial bleeding. Brain death occurred after 8 days. The main finding at autopsy was nearly complete disruption of the left inferior posterior cerebellar artery as the source of the lethal bleeding. The histological examination showed some additional, incomplete ruptures of this vessel and of the left intracranial vertebral artery. This is a typical result of "minor head injuries" sustained in fights: arterial rupture (ipsilateral) as a result of overstretching. Fracture of the left zygomatic arch and maxilla; no skull fracture; no primary traumatic brain damage. The extracranial carotid arteries were intact. When the vertebral arteries were examined (in the undamaged cervical spine), there was a surprising finding: distant dissection of the right vertebral artery between C1 and C2, which perhaps occurred as a result of compression (contralateral to the impact) of this region.     

Bone marrow emboli versus fat emboli as the cause of unexpected death

Thromboemboli were found diffusely throughout the pulmonary vasculature system of a 76-year-old white female who died unexpectedly 3 days following injury and repair of a left hip intracapsular fracture. A diffuse chronic nonspecific myocarditis with marked fat atrophy, an acute myocardial infarct of the posterior left ventricular papillary muscle, and an acute right lower lobe bronchopneumonia are believed to be the cause of death.     

Virtopsy--fatal motor vehicle accident with head injury

A man wearing no protective helmet was struck by a motor vehicle while riding a bicycle. He was loaded on his left side, and the impact point of his head was his occiput on the car roof girder. He was immediately transported to the general hospital, where he passed away. Postmortem examination using multi-slice computed tomography (MSCT) revealed an extensively comminuted fracture of the posterior part and the base of the skull. Observed were deep direct and contrecoup brain bruises, with the independent fractures of the roof of the both orbits. Massive subdural and subarachnoidal hemorrhage with cerebral edema and shifting of the mid-line towards left side were also detected. MSCT and autopsy results were compared and the body injuries were correlated to vehicle damages. In conclusion, postmortem imaging is a good forensic visualization tool with great potential for documentation and examination of body injuries and pathology.     

Multiple suicidal gunshots to the head

We report two cases of suicide by multiple gunshots to the head. The first victim (of two shots) fired the first shot, which was observed, into his mouth, leading to damage to the left optic nerve and frontal lobe. The man still was able to drive his car home, where he shot himself in his right temple. He died 2 days later. The second victim (of three shots) was a 58-year-old man who was found dead on his bed. Reconstruction of the case disclosed that the first shot had passed through his tongue and slightly damaged the second cervical vertebral body. He then shot himself in his right temple, leading to damage of the temporal lobe. Finally, he shot himself in his left temple, resulting in destruction of the pons. In the first case, an amateurishly modified 8-mm blank revolver firing 6.35-mm- (.25)-caliber ammunition was used; in the second case, a rifle firing 5.6-mm (.22)-caliber ammunition with a reduced charge was used. In both cases, low-energy transfer to brain tissue by the initial bullets was due to low bullet energy or due to the bullets' missing the brain or vital centers.     

Atypical "body packing syndrome"--a case report

A case of ingested cocaine is reported in which death must be classified as body packer syndrome although both the temporal relationship and the number of packets were atypical. The deceased, a consumer of hard drugs who smuggled for his own use, was found in his flat. He was resuscitated and survived for another four days in hospital. Only four intact drug packages were found in the upper gastro-intestinal tract. The concentrations of cocaine in blood and organs were relatively low but in a potentially lethal range. The case is presented, and its particularities as well as the option of induced vomiting as a way of preventing the fatal outcome are discussed.     

Self‐inflicted Firearm Discharge from Heating Using a Gas Burner

A male in his 70s was found lying dead in the living room of his house. A gunshot entrance wound was observed in the left orbit, with a lead slug and wadding left in the skull, which exhibited fatal cranio‐cerebral trauma. A cartridge had been discharged from a handmade launcher, or zip gun, that had been fixed to a spare gun barrel on a pipe chair, by heating the launcher from the side using a gas burner. The deceased had owned guns for hunting in the past and had returned the license, but he had retained a spare barrel and live cartridges at home. In this unique case of suicide, a zip gun was discharged by heating with a gas burner.     

From chronic rhinitis to death: Fatal outcome of nasal polyposis treatment

Introduction

Nasal polyposis (NP) is considered to be the state of chronic inflammation of nasal mucosa and sinuses presenting with various nasal symptomatology. In most cases, it is treated conservatively. Recently, functional endoscopic sinus surgery (FESS) was developed as the valuable and advantageous surgical procedure to treat NP. Despite the inherited risks of this procedure, its complication rate is considered to be acceptable compared to potential benefits for the patient.

Case

Fifty-five-year-old man was admitted to the hospital for surgical removal of the nasal polypus. After the usual pre-surgery procedures, the patient underwent FESS. Under general anesthesia, left sphenoid sinus was opened and cleaned from the imflammatory discharge, polypus was excised, and following the trepanation the left maxillary sinus was left to drain out. Polypus and pieces of sinonasal mucosa were sent to pathohistological analysis, which yielded in diagnosis of inverted sinonasal papilloma.The early postoperative recovery was regular, but 2 h upon the surgery, the patient started to lose consciousness gradually falling into the state of coma. CT scan and angiography of the head revealed pneumocranium, defect of the left ethmoidal sinus, hematoma in the left frontal cerebral lobe, as well as the hemorrhage in all four cerebral ventricles. A series of neurosurgical procedures followed in the next 8 days. Despite the attempts to resolve above complications, the patient remained comatous and died 16 days after the polypectomy.Autopsy revealed the extensive oval-shaped defect on the skull base in the left posterior part of cribrous plate of the left ethmoid bone. The brain appeared swollen and heavily congested, showing the zone of subarachnoidal hemorrhage in basal face of left frontal lobe. Frontal serial sections revealed large intracerebral haematoma in basal periventricular structures of left frontal lobe extending to the whole ventricular system. Apart from the above, most prominent finding was bilateral bronchopneumonia. The cause of death was attributed to bronchopneumonia following the brain trauma, manner of death ruled as violent.

Conclusion

Although majority of the patients suffering from chronic rhinosinusitis or NP recover well after the endoscopic surgery, the possibility of undesirable outcome must not be ignored. This case calls for assessment of potential medical liability caused by malpractice. Having in mind rather high prevalence of chronic rhinosinusitis and NP, legal aspects of postoperative death should be carefully analyzed.     

Asphyxia protracted after shaking trauma

A case of "shaken baby syndrome" (SBS) is reported. A 3 1/2 months old female baby has been found by his mother death in bed. The circumstances predicted a case of Sudden Infant Death Syndrome (SIDS), but the father, a disc-jockey, who had to look for the baby, had left a notice: "Gitti--i didn't want it, I don't know what had happened, I'm sorry!". The corpse of the baby had no external signs of violence. At the medicolegal examination we found small subarachnoidal and subdural hemorrhage from ruptured bridge veins and signs of prolonged asphyxia. Few hours later the father could be arrested. He told that he had shaken the baby, because she didn't stop crying. The infant lost conscious and he layed him down to the bed with his face below. Then he looked TV for at least a few minutes. After insufficient reanimation he had left the house. The court found the man to be guilty of fatal infant child abuse and convicted him to detention of 8 months. The main signs of SBS are discussed (subarachnoidal and subdural hemorrhage, intraretinal and periretinal hemorrhages, brain edema). Especially in the german speaking Europe many medical examiners are not familiar with this form of infant child abuse.     

Accidental sharp force fatalities--beware of architectural glass, not knives.

In a retrospective evaluation of 799 consecutive autopsies of victims of sharp force performed between 1967 and 1996 in Münster and Berlin, only 18 cases (2.3%) were classified as accidents. A typical pattern was present in 15 cases: inebriated adults (1.4-3.6g/l BAC) fell into an architectural glass surface in the form of a door or window (12 cases), an aquarium, a mirrored wardrobe or a telephone cell. Another man fell into a large drinking glass. Many victims in this group showed multiple scratches, abrasions and superficial incisions as well as one or more deep tear/cut/puncture injury. The wound margins can be clean-cut or irregular and abraded. Death was mostly caused by exsanguination except for one case of air embolism and one case of cerebral injury. The fatal injuries were produced by large and dagger-like slivers of glass, by sharp-edged fragments of glass remaining inside the frame or by a portion of glass which fell down and acted in a way similar to a guillotine. Ordinary types of flat glass were involved in all cases and it is not until the impact that sharp fragments or cutting edges are produced. So the motion of the person commonly provides the force necessary for a fatal injury. This was also true for the remaining two cases not involving architectural glass. A farmer suffered cerebral injury from a fall into the long prong of a pitch fork, and the wounding agent was a knife in only one case. A man who stated that he had fallen into the knife in his hand died from pneumonia after inadequate therapy following a single stab injury to the periphery of the left lung and liver. Accidents where the victim is killed by his own knife therefore appear to be extremely rare.     

Sudden death after release from police detention]

3 fatalities shortly after discharge from police custody are reported. Case 1: A 55-year old alcoholic was discharged from police custody after taking a blood sample under violent conditions and found dead in his flat 2 days later. Cause of death: arrhythmia due to acute coronary insufficiency or alcoholic cardiomyopathy. Case 2: A 27-year-old alcoholic was met highly intoxicated twice in the course of one day, was put in the family's care and was found dead the next morning. Cause of death: alcohol/drug intoxication with agonal aspiration. Case 3: A 32-year-old man known to be prone to seizures and to become aggressive under the influence of alcohol was left by the police in medical care confined to a litter in a "hog-tied" fashion with the help of 3 belts. Cause of death: cerebral hypoxia after respiratory and cardiac arrest of unknown reason. A causal relationship with positional restraint is discussed. The cases reported underline the duty of the police to examine prior to discharge from custody with the appropriate lot of care whether the person held in custody has recovered from the helpless state due to disease, injury or intoxication or if medical treatment is required.     

不同损伤程度脑震荡鼠逆行性遗忘变化比较

目的研究不同损伤程度脑震荡(CC)大鼠逆行性遗忘(RA)之变化情况。方法用金属单摆打击装置复制大鼠不同损伤程度脑震荡模型,用Morris水迷宫检测脑震荡后大鼠逆行性遗忘变化情况。结果单纯性脑震荡(PCC)大鼠打击后72h内出现逆行性遗忘,伤后4d出现认知受损,随后恢复。复杂性脑震荡(CCC)大鼠打击后5d内既有逆行性遗忘的存在,又有认知功能受损,5d后恢复。结论大鼠不同损伤程度脑震荡后均出现逆行性遗忘,且脑震荡损伤程度不同,逆行性遗忘持续时间亦不同,脑震荡程度越重,RA持续时间越长。     

"Overkill" in a case of neonaticide

A 14-year-old girl was found unconscious in a pool of blood by her mother in the family bathroom. A gynecological emergency operation revealed a state after spontaneous delivery. A few days later the corpse of a newborn, smeared with blood, was found by the father of the girl in a laundry basket in the bathroom. The autopsy revealed signs of blunt force against the cranium as well as multiple lesions caused by sharp force in the area of the neck and the thorax. The newborn died of hemorrhagic shock due to severance of the left subclavian artery. The pattern of injuries is presented. In addition, the girl's statement with respect to the course of events is discussed. Finally, this rare manner of committing neonaticide is compared with former reports in the literature.     

Inadvertent clavicular fractures caused by "chiropractic" manipulations in an infant: an unusual form of pseudoabuse

A nine-month-old child was found unresponsive in his crib, five hours after his last feeding. At autopsy, there were no external or internal signs of abuse or neglect, and a few visceral pleural and epicardial petechiae were consistent with the sudden infant death syndrome (SIDS). However, postmortem total body radiographs revealed healing, symmetrical clavicular fractures and a healing left medial humeral epicondyle fracture. The parents had no explanation for these injuries and denied causing any harm to the child. The location and nature of the fractures strongly suggested abusive origin, and the case was reported to the police and the district attorney's office as child abuse. During the investigation, information from the parents indicated that the child had undergone "chiropractic" manipulations by an unlicensed therapist, between three and four weeks prior to death, to correct supposed "shoulder dislocations." This time interval correlated with the histologic age of the injuries, and the history explained their unusual bilateral location and appearance. The parents were exonerated of abuse charges, and the death was ascribed to SIDS.     

Post-mortem finding of a non-fatal left heart ventricle perforation by a pleural drain. A case report

A 76-year-old male with a previous history of heart arrhythmia and decompensation was treated for a complicated thoraco-abdominal trauma. Accidentally, a pleural drain was inserted in his heart through the ventricular septum, perforating the left ventricle, the drain tip being buried in its posterior wall. This injury was not recognized until autopsy. The patient died 7 days after insertion of the drain of lung emboli, which were related to his primary trauma and not to the heart perforation.     

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.     

Neurosurgical vascular complications associated with aneurysm clips evaluated by postmortem angiography.

Neurosurgical vascular complications were evaluated by postmortem angiography in a consecutive prospective series of 63 patients in Helsinki who suffered a fatal outcome following neurosurgery for ruptured intracranial aneurysm. Operative vascular complications were revealed in 28 (44%) of the cases. Massive intraoperative bleeding resulting from rupture of the aneurysm or adjacent major artery during dissection or clip application complicated the operation in 16 (25%) patients. Clip-induced obstruction of cerebral arteries was detected by angiography in seven cases (11%). In six of the patients an adjacent cerebral vessel was accidentally clipped. In one case a kinking of the clip had caused obstruction of the right anterior cerebellar artery with resulting frontal infarct. A combination of rupture of the internal carotid artery and accidental ligation of the left posterior cerebellar artery occurring simultaneously during the clipping of a ruptured basilar aneurysm was detected in one patient (2%). Other types of complication were revealed in four cases (6%): detachment of clip with re-bleeding; clipping of an uninvolved aneurysm instead of the ruptured one; displacement of the clip beneath the ruptured aneurysm. Operations on ruptured basilar artery aneurysm were significantly (P less than 0.01) more prone to complications. The results indicate that operative vascular complications play a significant role in the mortality of aneurysm patients. Post-mortem angiographic technique with contrast medium that vulcanizes at room temperature is particularly suitable for demonstration of the haemodynamic significance of clip-induced cerebrovascular accidental occlusions, and is the only method at autopsy to reveal an occlusion caused by a kinking of a properly placed aneurysm clip.     

Fatal stun gun injury using a modified animal sedation gun

A 54-year-old butcher attempted to commit suicide with a manipulated "humane killer". He removed the recoil spring, the rubber bush and also the screw forming the muzzle end, which to our knowledge has never been described in a case report before. Due to this manipulation the entire bolt left the weapon, as a free projectile, penetrated the forehead and lodged inside the skull, from where it could not be removed neurosurgically. The patient died from the consequences of the severe cerebral injury 3 days later.