Postmortem diagnosis of cerebral malaria

Human cerebral malaria is a frequent encephalopathy that occurs in the endemic tropical-subtropical zones. There are a smaller number of imported cases in continental zones where the diagnosis sometimes remains difficult to establish. Fifteen days after the death of a 36-year-old male French citizen in Africa, an investigation to determine the cause of death was conducted. Histologic examination of the brain permitted the diagnosis of cerebral malaria. Because of the popularity of overseas tourism and because this disorder may appear as "sudden death," these victims may be referred to a forensic pathologist. This case demonstrates the role a forensic pathologist may play in determining the cause of death in cerebral malaria.     

Postmortem diagnosis of hypertonic dehydration

Beside morphological signs of hypertonic dehydration as tinting of skin, sunken eyes, dry surface of the galea or dry cutting areas of organs, a chemical profile of vitreous humor was proposed as a diagnostic tool for the diagnosis of hypertonic dehydration. The profile consists of an elevation of sodium >155 mmol/l, chloride >135 mmol/l and urea >40 mg/dl. This profile was named dehydration pattern. The value of this dehydration pattern for the diagnosis of hypertonic dehydration will be discussed by a short review of the literature and case reports. So far, the published literature on the dehydration pattern is not a sound scientific basis for the diagnosis of dehydration.     

Postmortem roentgen diagnosis of the skull]

In this prospective study, skulls of 164 dead bodies were x-rayed in two different planes. The findings were assessed independent to the results of the subsequent autopsy, however afterwards compared with the autopsy findings. In 86 cases (53.4%) x-ray findings were significant. Dislocated calvarium fractures were clearly visible on the x-rays, however non-dislocated calvarium fractures as well as fractures of the visceral cranium and skull base were difficult to detect. Gas and foreign bodies could easily be observed. Similar to the clinical assessment the indication for a post-mortem x-ray of the skull must consider the case history and the respective condition of the corpse (for example putrefaction, charred body).     

Postmortem diagnosis of meningococcemia by detection of capsular polysaccharides

Detection of specific meningococcal capsular polysaccharide (CPS) in postmortem blood permits rapid diagnosis of meningococcemia and differentiation from pneumococcemia and septicemia caused by Haemophilus influenzae Type b. We present studies validating application of latex agglutination assay for CPS on blood samples collected at autopsy, delineate the circumstances when CPS testing is indicated, and illustrate the usefulness of this procedure by several recent cases. Blood samples from victims dying of injury or disease other than infection were examined to determine whether the postmortem interval, bacterial contamination, anticoagulants, or delay in testing would result in false positive assays. Series 1 samples, collected so as to minimize bacterial contamination, were immediately submitted for assay. Series 2 evaluated the effect of adverse conditions of collection, anticoagulation, and prolonged sample storage. Despite extended postmortem intervals of up to 14 days, heavy bacterial contamination, prolonged storage at 4 degrees C, deep hemolysis, and presence of anticoagulants, false positive assays were seldom observed.     

Postmortem diagnosis of diabetes mellitus. Quantitation of fructosamine and glycated hemoglobin

Fructosamine and glycated hemoglobin were determined in samples from 52 cadavers autopsied in the Forensic Pathology Institute of the University of Copenhagen (Denmark). The population studied comprised 15 adult subjects with history of diabetes mellitus and 37 adult non-diabetic subjects. The fructosamine/total protein ratio was 1.7 times higher in diabetic than in non-diabetic subjects, as was the case for glycated hemoglobin. Measurement of glycated serum protein appears to be a useful tool for the postmortem diagnosis of fatal diabetic coma and glucose concentration before death.     

Postmortem diagnosis of syphilitic aortitis, including serological verification on postmortem blood

304 postmortem blood samples were serologically examined for syphilis at Statens Seruminstitut. Seventy-six percent of the samples were usable and gave clear-cut results (18% positive, 34% negative and 24% borderline). Twenty-four percent were indeterminable. The blood samples originated from 304 medico-legally examined bodies, 301 of whom were autopsied. The indications for the serological examinations were suspicion of syphilitic aortitis (SA) on the basis of the macroscopical appearance of the aorta at the autopsy--or information on earlier syphilis. Ninety-seven cases of SA were verified macro- and microscopically, 53 being lethal. The serological results were positive in half of these 97 cases, negative in 15, borderline in 21 and indeterminable in 12. A little more than half of the 97 cases were known in advance in the nation-wide syphilis index at the State Serum Institute. The variegated findings in the remaining part of the material are discussed. It is concluded that serological examination of postmortem blood may be a valuable adjuvant for the pathologist for the diagnosis of SA and other syphilitic manifestations.     

Postmortem chest computed tomography for the diagnosis of drowning:a feasibility study

It may be difficult to distinguish the cause of death in drowning cases without specific findings. The aim of this study was to explore the forensic value of thoracic postmortem computed tomography (PMCT) using routine images and three-dimensional (3D) image reconstructions. The imaging data of PMCT examinations of six drowning cadavers, aged 21–54 years, were analyzed. Twelve victims of sudden death from coronary artery disease (CAD) were chosen as a control group. After 3D bilateral lung images were reconstructed using image processing software, an interactive medical image control system was used to measure and analyze parameters including lung volume, lung volume ratio, mean CT value of the whole lung, and lung CT value distribution curves. Lung volume and lung volume ratio were used to assess the shape changes of the lung. Lung CT value distribution curves showed the corresponding number of pixels of the different CT values in the lung image. Lung volume was not significantly larger in drowning cases (mean 2 958 cm³) than in controls (mean 2 342 cm³). Lung volume ratio values in the drowning group (mean 0.3156) were greater than those in the control group (mean 0.2763); (P = 0.02). There was no significant difference between the drowning and control group in the mean CT value of the whole lung. There were differences between lung CT value distribution curves in drowning victims and controls, with drowning victims showing a single peak and CAD cases showing a bimodal distribution. Thoracic PMCT is helpful for the forensic medical diagnosis of drowning. Lung volume ratio and lung CT value distribution are potential indicators to distinguish between drowning and CAD.     

Postmortem biochemistry

Postmortem biochemistry may provide significant information in determining the cause of death. Due to the rapid postmortem breakdown of metabolism and active membrane transport only analytes which are stable in blood can be determined on this fluid compartment, other parameters have to be analysed on other fluid compartments like vitreous humor (VH). However, using another fluid compartment as a mirror of blood at the moment of death involves severe methodical problems. The conceptual problems of reference values in vitreous humor as a mirror of blood are addressed. Additionally, the necessary steps to be taken before calculating the discriminating values between "normal" and "diseased" are described. For all chemical determinations, a clear definition of the site of sample acquisition is necessary. Up to now chemical determinations on alternative fluids have mainly been carried out using instruments calibrated for urine or serum. Developing calibrated methods for analysis of alternative fluids is a further task for the future.     

Postmortem skeletal lesions

Postmortem bone alterations are very frequent and can raise the issue of their nature (antemortem, perimortem or postmortem defects). The aim of this work is to study various aspects of defects which were not assessed as perimortem trauma, from a series of 50 defects examined, resulting from 24 forensic cases. This study emphasizes the variability of size, shape and number of postmortem defects. Usually the diagnosis of antemortem defects is helped by a careful examination of some characteristics as the edges of the defects, the areas of discoloration of the edges and of the whole bone. Elsewhere it appears very difficult to know the true nature (antemortem, postmortem, or perimortem alterations) of the bone.     

Postmortem dental radiography

Comparison of postmortem and antemortem dental radiographic films or digital images is a common procedure for establishing identity of human remains. This article describes some problems with producing postmortem dental radiographs in a medical examiner setting and gives methods for circumventing these difficulties. Resection of the jaws, when permitted, significantly simplifies the postmortem radiographic technique. When producing an actual postmortem panoramic dental radiograph (orthopantomogram) from a dry skull, stabilization of the specimen for exposure by the moving beam source may be accomplished simply by placing the specimen upside down on an anthropologist's skull ring. Image "burnout" in the anterior segment, which results from absence of the tissues of the neck, may be avoided by appropriate placement of radiodense objects such as "zippered" plastic bags filled with water or other fluid material, freezer gel packs, or a block of self-polymerizing acrylic. These methods may increase future postmortem dental radiography efficiency.     

Postmortem stability of DNA

High-molecular-weight DNA was recovered postmortem in sufficient quantities from various human organ tissues as well as from blood, although not all organs were equally well suitable. Good DNA stability was found in brain cortex, lymph nodes and psoas muscle over a period of three weeks postmortem. Spleen and kidney showed good DNA stability up to five days postmortem but after longer periods, rapid degradation was observed. Yields of DNA from blood were not consistent because of the non homogeneity of samples. Blood clots were rich with DNA. Generally, the amount of degraded DNA correlated directly with the duration of the postmortem period. However in some cases, DNA degradation was already prominent after a short period. However in some cases, DNA degradation was already prominent after a short period. Case histories showed that high environmental temperature at the site of death and/or infectious diseases prior to death were the main factors for rapid autolysis. Gradual disappearance to complete loss of the long fragments (15-23 kb) was observed in DNA fingerprinting using the minisatellite probe 33.15. No extra-bands were noted, thus excluding erroneous conclusions. However, evidentiary value of older samples was lower.     

Postmortem concentrations of citalopram

The postmortem concentrations of citalopram in blood, bile, liver, and vitreous humour were investigated in 14 cases using a specially developed high performance liquid chromatography assay. Concentrations from drug and non-drug related deaths were categorized to determine a postmortem therapeutic and toxic range. Therapeutic citalopram concentrations for blood, bile, liver, and vitreous humour ranged to 0.4 mg/L, 2.1 mg/l, 6.6 mg/kg, and 0.2 mg/L, respectively. In one potentially fatal response to citalopram, concentrations were 0.8 mg/L, 6.0 mg/L, 0.3 mg/L for blood, bile and vitreous humour, respectively.     

Postmortem pink teeth.

A series of cases is reported in which pink teeth were observed during the postmortem period. Most cases were associated with decomposition in a moist environment. Experimental procedures led to the extraction of pink material from dentin and demonstration that hemoglobin and serum proteins were present. The pink-tooth phenomenon was duplicated in human teeth by instilling into the pulp chambers whole blood and blood with the red cells hemolyzed. The change was manifested in teeth of dogs after freezing, heating, and decomposition in a moist environment. The authors postulate that pink teeth occur as a result of breakdown of red blood cells in the pulp chamber of the tooth and diffusion of hemoglobin and other serum proteins into the dentin via the dential tubules. Histochemical studies show that the brown or gray material in some teeth subjected to postmortem aging is probably hemoglobin and serum proteins. Factors of age, vascularity of the pulp chamber, and postmortem conditions are discussed in relation to the postmortem development of pink teeth.     

Postmortem forensic toxicology of trazodone

Trazodone is a popular antidepressant medication that has been available for approximately 30 years. It has a reputation as a safe drug with relatively few reported fatalities attributed solely to it. We review the pharmacology and forensic toxicology of trazodone and report toxicology and cause and manner of death in a series of 37 deaths in which trazodone was detected. Although the normal upper therapeutic blood concentration for trazodone is about 2 mg/L, fatalities are rarely attributed solely to it at blood concentrations below 9 mg/L. Considering the pharmacology of the drug, potential interactions between other drugs with serotonin reuptake properties need to be considered, as does the increased susceptibility to the toxic effects in patients with pre-existing heart disease. In the cases reviewed, none were attributed solely to trazodone, although trazodone was frequently present together with other serotonergic drugs, such as the selective serotonin reuptake inhibitors like fluoxetine and sertraline. Ten cases had blood trazodone concentrations above 2 mg/L. Of these cases, trazodone played a primary role in the death of three subjects, with blood concentrations all greater than 9 mg/L. We confirm the conclusions of others that trazodone is a relatively safe drug except in massive overdose, although its toxicity may be influenced by the presence of other drugs and underlying pathophysiology.     

Postmortem detection of hemp intoxication

The diagnostic tools applicable to the forensic medical expertise of cadavers in cannabinoid intoxication (CI) were evaluated. Histochemistry with incubation of stable blue "B" (SBB) were used for the detection of cannabinoids in the bronchi and lungs. Hyperemia and capillarostasis in the mucous tunics of the mouth and stomach as well as hyperemia and edema in the lungs and brain were histochemically detected in CI. The histochemical activity of aldehyde dehydrogenase (AlDG) was most essentially decreasing in the adrenal glands and brain of younger persons. The SBB reaction in the bronchial and alveolar epithelia was positive in 85% of cases. A high proof value of the CI diagnostics was pointed out in cadaver expertise.     

Postmortem tissue concentrations of venlafaxine

Venlafaxine is a phenethylamine antidepressant which inhibits both serotonin and norepinephrine reuptake and is structurally unrelated to the serotonin reuptake inhibitors (SSRIs). Its major metabolite, O-desmethylvenlafaxine (ODV), also inhibits serotonin reuptake. Although metabolized by the cytochrome P-450 (CYP) system, venlafaxine inhibits CYP 2D6 and 3A4 to a far lesser extent than do the SSRIs. Mechanisms of drug action are reviewed and evaluated in the investigation of 12 fatalities occurring over a 6-month-period where venlafaxine was detected.Venlafaxine and ODV were identified by liquid chromatography-mass spectrometry (LC-MS) using atmospheric pressure ionization (API) electrospray in positive mode following an n-butyl chloride extraction. Postmortem tissue concentrations studied in each of 12 postmortem cases for venlafaxine and ODV, were 0.1-36 and <0.05-3.5mg/l (peripheral blood), <0.05-22 and <0.05-9.9mg/kg (liver), <0.05-10 and <0.05-1.5mg/l (vitreous), <0.05-53 and <0.05-6.8mg/l (bile), <0.05-55 and <0.05-21mg/l (urine), respectively, and 0.1-200mg of venlafaxine in the gastric contents. Venlafaxine was typically present with other drugs, including other antidepressants, alcohol, and benzodiazepines. The potential for interaction with each drug is discussed. Over the 6-month-period of this study, there were no deaths ascribed solely to venlafaxine intoxication.     

Postmortem monocular indirect ophthalmoscopy

Postmortem monocular indirect ophthalmoscopy permits examination of the posterior fundus and peripheral retina even if there is less than perfect anterior segment media such as postmortem corneal clouding. Light directed through the decedent's pupil from a bright focal light source illuminates the fundus and reflected light from the retina is then projected out of the eye. An aspheric condensing lens positioned in front of the eye focuses the retinal image at the focal plane of the lens. The real inverted, laterally reversed image comprises a wide field of view permitting evaluation of the decedent's fundus for retinal hemorrhages and other lesions.     

Postmortem evaluation of barbiturate poisonings

The evaluation of barbiturate intoxication as the cause of death is often difficult when the concentration in body fluids and organs is not extremely high. The problem arises because of the great capacity of barbiturates to produce tolerance after chronic use, a property that is often unknown. Therefore, the most abused barbiturates were studied to assess whether chronic intake causes morphological liver changes or not. It was found that the chronic abuse of drugs containing seco-, cyclo-, brallo-, and/or pentobarbital produces hypertrophy of the smooth endoplasmic reticulum of hepatocytes corresponding to that of phenobarbital. Neither acute barbiturate overdose (without a history of abuse) nor chronic abuse of opiates causes similar liver changes. In conclusion, barbiturate tolerance can be evaluated postmortem by light microscopic examination of the liver.