Fatal cervical necrotizing fasciitis (a report of two cases of confirmed odontogenic origin and one of possible odontogenic origin).

Three cases of cervical necrotizing fasciitis (CNF), two of confirmed odontogenic origin and one of probable odontogenic origin, were observed from 1993-1999. This is in addition to three cases previously reported by this office. A rare sequelae of dental infection, CNF can be a severe, rapidly progressing infection of the cervical tissues having a mortality rate of up to 50%. "Hospital gangrene" was first described during the Civil War. It was later to be described as necrotizing fasciitis and later yet was designated as a separate clinicopathological diagnosis.     

The shaken baby syndrome: a serious diagnosis on an insecure foundation?

The discussion concerning the causes of infantile subdural bleedings (SDB) as well as retinal hemorrhages has become quite controversial in the last few years. The long-standing interpretation that most of these cases are the result of abuse--especially by the shaken baby syndrome (SBS)--was doubted, and the role of accidental events was emphasized. In many cases, there are no objective witnesses who observed the incident and no unambiguous traces of abuse, so that the diagnosis "shaken baby syndrome" often has to be established indirectly. A subdural bleeding (SDB) in an infant can undoubtedly be due both to an accidental and an intentional injury. Therefore, the SDB itself does not allow to draw far-reaching conclusions as to its cause. However, if an infant died or was hospitalized in a deep coma with several bridging vein ruptures and minor subdural bleeding, these findings are not compatible with an alleged minor fall. In the presence of several bridging vein ruptures, most authors are of the opinion that this is the result of a significant traumatization. In contrast to most other reports, the reliable demonstration of BV ruptures is a routine element of the postmortem diagnostic procedures at the Berlin institute of forensic medicine. In this way, a mechanical trauma can be clearly identified as the cause of the infant's death. If several bridging veins are torn, this proves a significant trauma and rules out a banal incident. The current controversial discussion on the reliability of the SBS diagnosis often makes it difficult not only for the clinician, but also for the forensic expert, to draw safe conclusions in the presence of a combination of findings long considered typical of the shaken baby syndrome. This situation is the background for presenting and discussing the major SBS findings reported in the literature and comparing them with our own expiriences. In our opinion there is still no justification for a fundamental change in the position to interpret such cases as a consequence of severe trauma caused by another person.     

Necrotizing fasciitis: manifestations, microbiology and connection with black tar heroin

A 10-year review of records of the King County Medical Examiner's Office found 87 deaths due to necrotizing fasciitis and related necrotizing soft tissue infections. In 64 of these cases there were sufficient details to provide an analysis of the manifestations, microbiology, and source of infection. One half (32) of the cases were due to injection of black tar heroin, the nearly exclusive form of heroin in the Northwest United States. Of those due to black tar injection, 24 were clostridial infections with various species represented, eight of which were Clostridium sordellii. Of the 32 cases not associated with drug injection, streptococcal species predominated, with Streptococcus pyogenes isolated in 14 cases. Only three of 32 cases not associated with injection drug use were clostridial infections. These differences were statistically significant. Staphylococcus aureus was isolated from 14 cases; two were methicillin-resistant strains. Overall, 28 of the 64 cases were polymicrobial infections, 15 due to black tar injection and 13 not associated with drug injection. This study supports the conclusion that necrotizing fasciitis due to black tar heroin injection is predominantly a clostridial disease, and in this way differs significantly from necrotizing fasciitis due to other causes.     

The value of the hospital autopsy. A study of causes and modes of death estimated before and after autopsy

Among 312 consecutive deaths in a Danish Central Hospital autopsy was performed in the pathology department on 266 cases, i.e. 85%. Retrospectively, the underlying causes of death were estimated from the clinical information alone by an experienced clinician and subsequently compared with the autopsy report. The definite cause of death was determined jointly by the clinician and the pathologist. The clinician's diagnosis was thereby confirmed as incorrect in 18% of the cases if small differences in site and type of malignant tumours were not considered. This is less than in many other investigations, but it is stressed that this could partly be because formal errors in completing the death certificate were avoided. The main causes of death were ischaemic heart disease and neoplasia. Clinical diagnosis of malignant diseases was never found to be erroneous. There was a slight tendency to clinically overestimate ischaemic heart disease, but in general the different errors outweighed each other, so that the total number of different causes of death before and after autopsy was nearly the same. The original death certificate was investigated in 12 accidental cases. Hereby it was found that the mode of death was originally stated erroneously as natural in 7 cases, i.e. 4.5%. It is concluded that hospital autopsy is still needed for the control and correction of causes of death, and it is stressed that clinicians as well as pathologists should be more aware of cases with a trauma in the history to avoid errors in the mode of death. Such errors can imply legal as well as insurance problems.     

Commotio cordis as a result of a fight: Report of a case considered to be imprudent homicide

Commotio cordis is a clinic-pathological syndrome related to sudden death in young people involved in sports activities. It has been described, mainly, in athletes without previous cardiac anomalies who received a minor blow to the chest which produces ventricular fibrillation and cardiac arrest in the absence of structural damage to the ribs, sternum, or heart. There are few reported cases of commotio cordis associated with violent, non-sports related actions, which are commonly considered to be imprudent homicides. We present the case of a 20-year-old man, who was kicked in the chest during a fight; he suddenly collapsed although advanced cardio-respiratory resuscitation started shortly. Autopsy showed no cardiac lesions concluding that death was due to commotio cordis (blunt trauma to the chest). Toxicological analysis determined the presence of 5.14 mg/L benzoylecgonine in blood. On the basis of medico-legal investigation, the official prosecution considered the death to be imprudent homicide and the aggressor was sentenced to 4 years in prison. We emphasize the importance of the knowledge of the death circumstances through the witnesses’ testimony, prior to beginning the autopsy, to confirm this important medico-legal diagnosis. Arrhythmogenic effects of cocaine and its contribution in the production of these deaths are also exposed.     

Differential diagnosis of accident and resuscitation traumas

The purpose of this paper is to define the criteria for the differential diagnosis of trauma following resuscitation and road accidents. To this end, 311 cases of thoracic and epigastric trauma were selected from the 2893 medico-legal autopsies carried out between 1979 and 1982 at the Institute of Forensic Medicine of the University of Heidelberg. Cardiopulmonary resuscitation had to be considered as the cause of trauma in 140 of these, but 45 of this group were excluded from further evaluation as they had been the victims of blunt trauma and no clear-cut distinction was possible between trauma resulting from an accident and trauma resulting from resuscitation. Thus, we were left with 95 cases of internal injury that presented as emergencies and in whom death followed resuscitation, as a group for comparison with 171 road accident victims who had not received cardiopulmonary resuscitation. Rib fractures, predominantly on the left side, were established in half the cases resuscitated, sternal fractures also being found in one-third of these victims. Bleeding at various sites, including hemato-thorax, was rare, with an incidence of 15%, thus making it highly unlikely that serious traumas caused by resuscitation were a major factor in the cause of death. This paper encompasses an extensive discussion on serious injuries, such as aortic and gastric ruptures, in this connection.     

Sudden death due to delayed rupture of hepatic subcapsular hematoma following blunt abdominal trauma

Blunt abdominal trauma can cause sudden, unexpected death due to injuries to internal organs. Rupture of a hepatic subcapsular hematoma is a relatively rare cause of sudden death following minor blunt abdominal trauma. Death may be delayed several days to weeks. The autopsy is an invaluable diagnostic tool that can be utilized to uncover sudden deaths due to abdominal trauma. The case of an alcoholic who died of a ruptured hepatic subcapsular hematoma is presented. The death investigation revealed that the victim had sustained blunt abdominal trauma during a fall a few days prior to death.     

Can Birth Trauma Be Confused for Abuse?

Abstract: An unexpected infant death is usually investigated with a complete autopsy. If evidence of prior trauma is found at autopsy in these cases, suspicion is raised for nonaccidental trauma. In a young infant, the residua of trauma received during birth has the potential to be incorrectly interpreted as nonaccidental trauma. We report a the findings of a 4 1/2‐month‐old‐infant that died unexpectedly with a healing linear skull fracture and a circular lesion over the calvarium found at autopsy. Though this lesion was concerning, the remainder of the autopsy and the histological findings did not support a diagnosis of recent trauma. Review of the literature describing birth injuries made the diagnosis of healing, residual birth trauma more convincing in this case.     

Sudden unexpected death in a child with varicella caused by necrotizing fasciitis and streptococcal toxic shock syndrome

A 4-year-old child with chickenpox infection for 5 days prior to death complained of swelling and pain in his right leg that required medical assistance in the emergency department. Radiologic study was normal, and analgesic and bandage of the leg were prescribed. Some hours later, he presented cyanosis, dizziness, and vomiting and collapsed. A complete forensic autopsy was performed 12 hours after death. External examination of the body showed numerous crusty varicella skin lesions, especially over the trunk, and swelling and reddening of his right leg. The brain was swollen, with cerebellar herniation, and both adrenal glands were hemorrhagic.Microscopically, neutrophilic infiltration and muscle fiber necrosis were observed in soft tissues of his right leg, and fibrin microthrombus were numerous in capillaries of the plexus choroideus, larynx, lungs, and adrenals. Bacterial emboli were present in most of the tissues. Microbiologic cultures of blood and cerebrospinal fluid showed group A beta-hemolytic streptococcus (Streptococcus pyogenes). Death was attributed to fulminant streptococcal toxic shock syndrome, with necrotizing fasciitis as a complication of varicella.     

The shielding capacity of the standard military flak jacket against ballistic injury to the kidney

An animal model was designed to evaluate the ability of the standard military flak jacket to protect the kidneys from direct ballistic trauma. Yorkshire swine were anesthetized and their flanks were protected by flak jackets. Ballistic insults ranging from a low-velocity handgun to a high-velocity rifle were evaluated. The results demonstrate that a flak jacket provides adequate protection against low- and mid-velocity projectiles since none of the animals from this group had evidence of internal trauma and because only minor superficial surgical attention would have been required. Survivability in each case was considered to be excellent. The flak jacket failed to provide any protection against several types of high-velocity bullets. These weapons caused severe internal injury to the genitourinary system as well as to other major organ systems. Survival would have been unlikely.     

Sudden Unexpected Death due to Chiari Type I Malformation in a Road Accident Case

This case concerns a sudden death of a patient with Chiari I malformation. A 17‐year‐old female was seen unconscious then fell off a motorbike during the vehicle acceleration. The girl was confirmed dead on the way to hospital, being previously asymptomatic and with a clean medical record. Autopsy findings showed an extremely extra‐long cerebellar tonsillar herniation in the left side and unexplained multiple small cavities in cerebral hemispheres. Microscopic findings revealed loss and abnormal migration of the Purkinje cells, as well as capillary congestion in the herniated tonsil. The cause and mechanisms of this sudden death are considered as the cardiopulmonary dysfunction and arrest resulted from compression of the medulla and cervical cord, which was induced by both the positional insult and minor head trauma. In addition, this study stresses the importance of cervical cord examination in the case of unexpected sudden death following road accidents.     

A case of panhypogammaglobulinemia masquerading as child abuse

A case of panhypogammaglobulinemia in a 15-month old boy is presented. The child was followed at a local university teaching hospital for pneumonia, failure to thrive, and possible child abuse/neglect. Following minor trauma to the face, massive sepsis developed in the child. The mother was afraid to seek medical care because she was fearful of legal action against her. Upon the child's demise at home, police and medical examiner involvement ensued. The correct diagnosis was established at autopsy.     

Rupture of liver cell adenoma with fatal massive hemoperitoneum resulting from minor road accident

Blunt abdominal trauma can cause rapid death resulting from serious injuries of internal organs. The liver is commonly involved and may show tearing, usually in its upper surface, resulting in hemoperitoneum eventually leading to death. Minor trauma implies serious liver damage only when previous pathologic changes causing enlargement of the organ are present. The case of a 25-year-old woman who died as a consequence of a minor road accident is reported. At autopsy, the body showed no external injuries, the only relevant finding being a massive hemoperitoneum from the rupture of an unusually large liver cell adenoma. Liver cell adenomas carry a serious risk of spontaneous rupture, which may result in the death of the patient. The occurrence of the rupture after a minor blunt abdominal trauma is highly unusual.     

Acute necrotizing bacterial tonsillitis with Clostridium perfringens

Bacterial infection with Clostridium perfringens in children less than 2 years of age is frequently associated with meningitis, necrotizing gastrointestinal infection, and postoperative infections. However, a review of the literature reveals no reports of these bacteria infecting the tonsils. A 9-month old black female was found unresponsive at the baby-sitter's and was rushed to the hospital. Shortly after admission to the emergency department death was pronounced. An autopsy performed on this otherwise healthy infant revealed shock and acute necrotizing bacterial tonsillitis. The initial report of this infant's death was questionable sudden infant death syndrome and questionable smothering. Postmortem cerebrospinal fluid, blood, and lung cultures grew pure colonies of C. perfringens. The necrotizing tonsil revealed no significant gross lesions. Microscopically, large numbers of gram-positive rods were easily recognized and were compatible with C. perfringens. Because the oropharynx is a common portal of entry for infectious agents, it is essential to sample tissues of Waldeyer's ring and especially the tonsils to find infectious diseases that may become systemic.     

Acute deaths in nonpregnant adults due to invasive streptococcal infections

Streptococcal organisms, part of the normal human bacterial flora, occasionally become infectious pathogens responsible for a wide array of clinical syndromes, ranging from mild pharyngitis to death. Notably, infections due to group A and group B beta-hemolytic strains are well known for causing invasive disease leading to death. These deaths, while often suspected clinically, occasionally are not diagnosed until autopsy. We present 3 rapid deaths, with very different presentations, due to streptococcal infection. Two decedents experienced sudden deaths due to pneumonia and severe meningoencephalitis caused by group B beta-hemolytic streptococcal infection, a common cause of neonatal meningitis but only rarely reported in nonpregnant adults. The final case involves a 69-year-old male who presented to the emergency room with a complaint of shoulder pain but over the next several hours developed signs of necrotizing fasciitis, became septic, and died. While antemortem cultures were negative, owing to antibiotic administration, postmortem cultures of bone and deep soft tissue were positive for group A beta-hemolytic Streptococcus sp. Acute and sudden deaths due to infectious etiology represent an uncommon yet well-documented occurrence. The importance of appropriate postmortem cultures in these situations and a review of the literature will be discussed.     

Commotio cordis: A case report of a fatal blow

Commotio cordis secondary to a blunt blow to the chest wall can result in ventricular fibrillation and sudden death in children. While it is commonly reported in adolescents during sporting activities, it may result from non-accidental trauma especially in infants and younger children. We report a case of a 6-month-old baby boy who presented to the emergency department in cardiac arrest. The patient's hospital records, postmortem imaging, and the autopsy results were reviewed. External examination of the infant did not reveal any evidence of trauma. Postmortem imaging revealed multiple healing posterior rib fractures and a metaphyseal corner fracture, both considered fractures highly specific for physical abuse. The autopsy revealed a structurally normal heart with no microscopic abnormalities. The infant's father confessed to hitting the child on the chest after which the child became unresponsive. Given the constellation of postmortem imaging and autopsy findings in addition to the father's confession, the child's death was ruled as a homicide secondary to commotio cordis. Since there are no structural and microscopic abnormalities in the heart autopsy in cases of commotio cordis, timely on-scene investigation and a thorough investigation regarding the mechanism of injury are required to make this diagnosis. Early identification of non-accidental trauma is crucial and can prevent further abuse in other siblings.     

Necrotizing fasciitis: reports of three fatal cases simulating and resulting from assaults

Necrotizing fasciitis is a progressive, potentially fatal, rapid, necrotizing infection of the subcutaneous tissues and fascia often caused by a mixture of organisms or by infection with group A Streptococcus pyogenes with or without Staphylococcus aureus. Three cases are presented that have been encountered in forensic pathologic practice. Two cases presented after assaults, and the third simulated an assault and burglary. The history, scene, and pathologic findings are presented with a brief review of the literature.     

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.     

Traumatic basal subarachnoid hemorrhage. Report of six cases and review of the literature

Basal subarachnoid hemorrhage due to rupture of normal extra- and intracranial arteries, in association with minor trauma to the face and neck and alcohol intoxication, has been well described but often goes unrecognized at autopsy. This results in the incorrect classification of the manner of death as natural. Six cases of subarachnoid hemorrhage due to mild-to-moderate blows to the head or neck are presented. All were men in the age range 28-61 years (mean, 38.8 years). Four had blood alcohol levels of 0.09-0.28 g % at autopsy, and five of six were comatose or dead within 30 min of the initiating trauma. Traumatic ruptures of otherwise normal extra- and intracranial arteries were identified in four cases. The site of rupture was not found in one case, and the final case had rupture of a fibrotic intracranial vertebral artery. Multiple sites of incomplete and complete rupture were found in four cases. Postmortem angiography was used in one case to demonstrate the site of rupture prior to removal of the brain. Postmortem angiography and careful gross and histologic examination of extra- and intracranial cerebral arteries is recommended in all cases of basal subarachnoid hemorrhage where minor trauma to the head or neck has occurred prior to collapse or death, especially if the decedent was intoxicated at the time of the trauma.     

Comparing Known and Reconstructed Circumstances of Death Involving a Blunt Force Trauma Mechanism through a Retrospective Analysis of 21 Skeletonized Individuals

Little is known about to what extent the events surrounding death can be reliably reconstructed from blunt force trauma analysis alone. In this study, we reconstruct circumstances of death from a blind blunt force trauma analysis using a sample of 21 individuals of known death circumstances, obtained from two identified skeletal collections in Portugal. Fresh versus dry bone trauma and probable mechanism of fracture production were identified. The overall pattern of injuries was then used to reconstruct the most likely circumstances of death. Results show an agreement between the proposed and the reported circumstances for 13 individuals (68.4%), disagreement for 3 (15.8%), and similarity in 3 cases (15.8%). Although the significant amount of agreement highlights the potential of trauma analysis, the cases with disagreement draw attention to the pitfalls and shortcomings of attempting to reconstruct the death circumstances from skeletal trauma analysis alone.