Secondary missile injury from lightning strike

A 48-year-old-woman was struck dead by lightning on October 24, 2010, in Pretoria, South Africa. The cause of death was due to direct lightning strike. Examination showed secondary missile injury on her legs. This secondary missile (shrapnel) injury was caused by the lightning striking the concrete pavement next to her. Small pieces of concrete were located embedded within the shrapnel wounds. This case report represents the first documented case of secondary missile formation (shrapnel injury) due to lightning strike in the literature.     

Postmortem dog bites after sexually motivated homicide with multiple stab wounds--differential diagnostic aspects

The body of a 20-year-old woman that had undergone significant putrefaction was found lying on the bed of her apartment in a supine position. The legs were straddled and apart from a T-shirt, she was naked. The inner side of the right thigh showed a circumscribed 20 cm x 40 cm defect exposing the underlying muscles. The wound margin was ragged and superficial scratch-type abrasions were found in the vicinity of the injury margin. The investigating police officers classified the injuries to be caused postmortem by a crossbreed dog that was inside the apartment. No other signs of external force were found on the body at the death scene and due to the previous history of the deceased, a drug death was assumed. Autopsy revealed 13 vital stab wounds in the neck and aspiration of blood in the lungs as well as signs of manual strangulation. The observed coincidence of injuries due to postmortem animal depredation and stab wounds, although in different localization, can be regarded as a rare entity in the light of the literature. The morphological appearance of traumatic injuries due to other causes can be modified by the simultaneous presence of postmortem injuries caused by animals and difficulties can arise concerning the differential diagnosis especially under poor conditions (e.g. advanced putrefaction) at the death scene.     

Fatal accidental hanging by a high-chair waist strap in a 2-year-old girl

High chairs are commonly used to feed children after 6 months. Related injuries are oftentime minor and rarely leading to death. We describe a case of a 2-year-old female child who used to jump alone on her high chair and also had the habit to fasten the straps by herself. Her mother found her hanging by the waist straps. A thorough investigation showed that she climbed her high chair and fastened the waist straps but not the crotch one. The girl slid down into the seat, trapping her neck in the waist straps and thus resulting in hanging. In here, we concluded that the victim's death was caused by asphyxia, itself, caused by accidental hanging. The present case is of a special interest because of the rare similar cases reported. This case suggests that a correct restraint use and a close supervision would have prevented such a fatal issue.     

Sudden Unexpected Death Due to Graves' Disease During Physical Altercation

We report a case of a 30‐year‐old woman who suddenly collapsed after having a physical altercation with her husband. Despite immediate resuscitation, she died on arrival at the hospital. The victim's parents requested an autopsy because they believed that their daughter was killed by her husband. Postmortem examination revealed that the victim had a diffusely enlarged thyroid gland and cardiomegaly with left ventricular hypertrophy. There was no evidence of significant trauma on the body. Further postmortem thyroid function tests and review of her medical history indicated that her death was due to Graves' disease. To the best of our knowledge, this is the first case reported of sudden death due to cardiac arrhythmia from Graves' disease induced by physical and emotional stress associated with the criminal activity of another person. The autopsy findings are described. In addition, the literature is reviewed and the significance of postmortem evaluation of thyroid hormones in the cases of sudden death is discussed.     

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.     

Metastatic cancer of the urinary bladder: can it be a nonnatural death?

Deaths from metastatic carcinoma are almost exclusively viewed as wholly natural deaths. However, if it can be shown that a cancer has arisen as a result of a prior traumatic injury and the body's healing response to the injury, or treatment thereof, then in select cases, the manner of death shall reflect that of the precipitating injury. This case report is that of a woman who was rendered quadriplegic from spinal cord injury sustained in a motor vehicle crash when she was 22 years old. She died at the age of 49 years from widely metastatic squamous cell carcinoma of the urinary bladder. Her bladder cancer most likely arose from decades-long chronic irritation of the bladder epithelium by physical contact with an indwelling Foley catheter and urinary infections. Over the years, the chronic bladder irritation likely precipitated metaplastic, dysplastic, and finally neoplastic changes of the bladder epithelium, providing a link between her spinal cord injury, the indwelling Foley catheter, and her bladder cancer, engendering an accidental manner of death. The manner of death reflected the circumstances of her injury that predisposed her to the cancer that eventually caused her death.     

Case report of sudden death after a blow to the back of the neck.

A 13-year-old girl experienced a fall during gym class that caused immediate unresponsiveness and death. The lone witness reported that the decedent lost her balance as she approached a hurdle and fell, striking her head on a crossbar of the hurdle near the ground. Autopsy revealed no external injury. Internal injury that could be demonstrated anatomically was confined to a contusion within the right semicapitis muscle at the base of the skull. In the absence of an anatomic cause of death, possible explanations of the death include a cardiac dysrhythmia, a vasovagal stimulus, and diffuse axonal injury caused by a concussive force to the junction of the medulla and spinal cord. Animal studies have shown that severe concussion can cause death via profound autonomic dysfunction without leaving anatomic evidence of injury, and that the essential component of concussion is an element of rotational injury to the brain. The authors believe that the blow to the neck caused this death by the transmission of a concussive force through the reticular activating system. The prompt work of police in distinguishing the lone witness from several people in the area who thought they knew what had happened was essential for diagnosis. On reaching our conclusions, the authors notified first the family, then the superintendent of the school system, and finally the news media. The authors told each party in turn that they would be contacting the others.     

Sudden Death from Cardiopulmonary Arrest on Arrival of a Patient with Pulmonary Tuberculosis: A Case Diagnosed by Postmortem CT and Autopsy

Sudden death due to massive hemoptysis during management of tuberculosis occurs in a considerable number of patients. However, when massive airway hemorrhage occurs in a patient in whom tuberculosis has not been confirmed and a blood is not apparent externally on the face/body, it is difficult to immediately identify the cause of death as airway obstruction by tuberculous bleeding in the airway. We encountered an 83‐year‐old Japanese woman with her medical history included treatment of tuberculosis in her 20s who was in cardiopulmonary arrest on arrival (CPAOA), and the cause of sudden death could not initially be identified. Postmortem CT (PMCT) and autopsy revealed that the cause of sudden death was airway obstruction/asphyxia by tuberculous massive airway hemorrhage. Identification of the cause of death facilitated a subsequent active contact investigation and led to prevention of secondary tuberculosis infection.     

Sudden Unexpected Death Due to Left Subclavian Artery‐esophageal Fistula Caused by Fish Bone

A 53‐year‐old woman was admitted to the hospital due to unexpected dizziness and died the following morning. To investigate the cause of death, a forensic autopsy along with histological examination was performed 3 days after her death. The major findings of the autopsy were that a fish bone had pierced the left subclavian artery after perforating the esophagus with 680 mL of blood in the stomach and bloody and tarry contents were present in the intestines, and the cause of death was confirmed to be subsequent hemorrhagic shock. Unfortunately, none of her family realized that she had eaten a fish 4 days before the tragedy until the fish bone was found. The present case is rare and instructive. The histopathological findings of left subclavian artery‐esophageal fistula induced by a fish bone can be used as a reference in forensic practice.     

Sudden death resulting from chicken bone perforation of the esophagus

Sudden death caused by foreign-body perforation of the esophagus is distinctly uncommon. We report the death of an elderly patient in a nursing home who exsanguinated after she swallowed a chicken bone that perforated her esophagus and right common carotid artery.     

Death of a Female Prostitute Due to Intestinal Obstruction by an Unknown Substance

A young adult black female, known to be a prostitute and suspected of smuggling narcotics, was found dead in her apartment in a state of early decomposition. Oval‐shaped gray‐white masses of exogenous origin protruded from the anus. The autopsy showed dilatation of the folds of the large intestine, which were almost completely filled with these oval‐shaped gray‐white masses of foreign material. The uterus was enlarged with multiple large leiomyomas. Toxicological tests of blood and the foreign material revealed no toxicologically relevant substances. Kaolin was detected in a sample of the foreign material from the large intestine. The immediate cause of death was intestinal obstruction due to the formation of a kaolin bezoar with simultaneous compression of the large intestine by the enlarged myomatous uterus. Subsequent revelation of a habit the deceased had brought from her native country led to the conclusion that this exotic custom was responsible for her death.     

Forensically relevant unexpected delivery after unrecognized or denied pregnancy

The authors report on two cases of supposed unknown pregnancy, in which the newborns were found dead in the lavatory by the emergency physician. Besides the classical questions of newborn's autopsies concerning vitality, viability and cause of death, position was to be stated towards the probability of an unexpected birth. In the first case the mother's statement of not having been aware of her pregnancy was plausible considering the general circumstances such as corpulence, continued bleedings and intact family situation; autopsy proved a (rare) twin stillbirth as a result of fetal hypoxaemia caused by grave placental dysfunction and misinsertion of the umbilical cord. Contrary to this, in the second case, a live birth, a denial of pregnancy was more likely to be assumed due to misinterpretation of typical symptoms of pregnancy in combination with professional and private stress.     

Fatal Spontaneous Retropharyngeal Hematoma with Airway Obstruction in the Setting of Treatment with Dipyridamole

We report a fatal case of airway obstruction caused by spontaneous retropharyngeal hematoma (RH) in the setting of treatment with dipyridamole. A 90-year-old woman presented with cervical swelling, neck and chest ecchymoses, and complaints of dyspnea. She suffered cardiopulmonary arrest in the ambulance, and her death was confirmed after transportation to the hospital. The major finding of postmortem computed tomography (PMCT) prior to autopsy was widening of the prevertebral soft tissue. The results of the autopsy indicated that the cause of death was mechanical asphyxia, secondary to pharyngeal and laryngeal compression caused by the RH. There were no evident injuries, medical interventions, or particular diseases, suggesting the spontaneous cause of the RH. To the best of our knowledge, this is the first report of a fatal case secondary to spontaneous RH that was revealed through PMCT imaging.     

Inferior Vena Cava Tumor Thrombosis Secondary to Metastatic Uterine Cancer: A Rare Cause of Sudden Unexpected Death

Pulmonary tumor thromboembolus (PTTE) secondary to uterine cancer is a rare cause of sudden unexpected deaths in the elderly population. Additionally, tumor extension to the inferior vena cava (IVC) makes it rarer. No such cases have been previously reported in the forensic literature. We report this phenomenon in a previously healthy 70‐year‐old woman with no other known risk factors for the development of deep vein thrombosis. The deceased was found dead while watching television with her relatives. Autopsy examination revealed that her death was attributed to a saddle embolus lodged in the main pulmonary arteries. A uterine tumor was discovered, and microscopic examination revealed low‐grade endometrial stromal sarcoma with angiolymphatic invasion. The tumor cells were also found in the embolus and the remnant thrombosis attached to the inner wall of the IVC. This case demonstrates a sudden unexpected death caused by acute PTTE following seeding of uterine cancer into the IVC and raises awareness of such events.     

A caliber-persistent artery of the gastric wall resulting in fatal haemorrhage

A 12-year-old girl was admitted to hospital with haematemesis. Her family suffered from histidinaemia. Due to her numerous injuries the police suspected a crime. After a short period of clinical treatment she died. Autopsy showed the left ureter to be narrowed and a consecutive abscedens pyelonephritis. Pyloric ulcer caused erosion of a caliber-persistent artery which led to death with haemorrhage. The death had nothing to do with violence. Adequate surgical treatment could have saved the patient's life.     

Kinking of a coronary artery as a rare complication in mitral valve replacement

We present the case of a 70-year old woman who had elective mitral and aortic valve surgery. She underwent surgery without complications for about 4h until 4 pm. Approx. 3h after surgery her condition deteriorated. 1500ml of blood were collected in the chest drainage until 11 pm. An emergency thoracotomy in the patient's bed showed a ventricular rupture. Death occurred around 11:30 pm. At autopsy, the implants of the biological mitral and aortic valves were found to be sewn tightly. There was no vascular injury and no unusual bleedings to the mediastinum. In the left ventricular wall, a rupture of 1cm and a surrounding fresh myocardial infarction area of 10cm×6cm was noted. Preparation of the coronary arteries showed moderate coronary atherossclerosis without stenosis or clots. The left circumflex coronary artery (LCX) showed a sharp, obviously stenosing kink which had been caused by the mitral valve surgery. Exsanguination due to ventricular rupture following myocardial infarction caused by implant-related "kinking" of a coronary artery, was found to be the cause of death.     

Three unusual neuropathologic-related causes of sudden death

We discuss the autopsy findings of three medico-legal cases of sudden death associated with uncommon neuropathologic findings of which the general forensic pathologist may not be familiar. Case 1 was a 43-year-old man who died of a seizure due to malignant melanoma of the temporal lobe associated with neurocutaneous melanosis (NCM). Case 2 was a 57-year-old woman with a history of mental retardation and incoordination because of chronic lead poisoning, who died of a pulmonary thromboembolism due to deep venous thrombosis status post left leg fracture after a fall down a staircase. Autopsy revealed atrophy and gliosis of her cerebellum as a result of childhood lead poisoning. The third patient was a 75-year-old woman who died as a result of acute bacterial leptomeningitis at the cervico-medullary junction with acute inflammation of the connective tissue of her upper cervical spinal column associated with subluxation of her atlantoaxial (AA) joint, also known as Grisel's syndrome.     

Determination of ethchlorvynol in body tissues and fluids after embalmment

A 54 year-old female expired at her residence. Her husband, a physician, signed a certificate stating that her death was due to cerebrovascular accident (CVA) and released her body to a funeral home, where she was embalmed. Since the deceased had a long history of medical problems and drug abuse, an autopsy was performed and no evidence of CVA was found. Toxicological analyses of body fluids and tissues revealed the presence of ethchlorvynol in high concentration in the bile (112 mg/l). The bloody fluid collected from the heart contained a concentration of ethchlorvynol below the limit for quantitation. Other findings included phenobarbital (32.8 mg/l) in heart bloody fluid and methanol (an ingredient of embalming fluid). The significance of the findings is discussed in relation to embalmment prior to autopsy and toxicological analyses. Ethchlorvynol concentration in the bile is compared to other fatal cases due to ethchlorvynol overdose.     

Posttraumatic stress disorder in a World War II concentration camp survivor caused by the attack of two German shepherd dogs: case report and review of the literature

A 79-year-old woman suffered from acute posttraumatic stress disorder (PTSD) and a loco typico, non-displaced fracture of her right distal radius due to an incident involving the assault of two unleashed owned dogs, which suddenly ran into her and aggressively jumped on her chest and knocked her down to the ground. Recovery for her damage claim concerning pain and disability due to her right forearm fracture caused by the incident, was not the issue in the litigation concerned. However, the issue of delayed impact of her previous Holocaust experience placed a significant challenge on M.N., as a plaintiff, in establishing a causal link between the posttraumatic stress disorder concerned and the alleged harmful action of the defendants, the owners of the two dogs. The case reported here proved interesting and instructive not only in the sense of addressing main issues relevant to litigation for psychological damage related to reactivated PTSD and delayed PTSD, but also in the sense of pointing at the clinical relevance of dog assaults on humans which, even without dog bite injuries, may result in a severe traumatization and eventual civil lawsuit.     

Mechanical airway obstruction caused by accidental aspiration of part of a ballpoint pen

The authors present three cases of death in children aged 4, 9, and 10 years, respectively, that were first thought to be caused by herbal or other poisonings but at autopsy were found to be caused by airway obstruction from aspiration of ballpoint pen parts. Aspiration of a foreign body is a leading cause of accidental death in children, but the circumstances in these cases were unique. In the first case, a 4-year-old child died shortly after a visit to a traditional healer. The child's mother blamed him for the death and fatally assaulted him. The second case was a 9-year-old who died at school. Case 3 was a 10-year-old who collapsed while playing with a ballpoint pen in her mouth. In the latter two cases, the relatives alleged poisoning. At autopsy, there was no evidence of trauma, disease, or poisoning in all three cases. Ballpoint pen parts were present in the larynx, carina, and left main bronchus, respectively. Features of "asphyxial" death were present, and included subconjunctival hemorrhages, subendocardial hemorrhages, and congestion of the face and internal organs. These deaths are preventable by education of children, parents, and teachers. Ballpoint pen manufacturers should also modify the design of these pens to improve their safety.