Fatal Drowning Accident and Undiagnosed Hydrocephalus

Abstract: Bodies found in water present several diagnostic challenges for the forensic examiner, such as the identification of the time and mechanism of death, the postmortem submersion time, and above all the circumstances of drowning. We report the case of a 33‐year‐old security guard found dead in Venice, in the water of the lagoon, who at autopsy presented a previously undiagnosed hydrocephalus with macrocephaly. The victim remained asymptomatic until 2 months before death and had never undergone a neurological or radiological examination. In the article, we emphasize the need to perform a thorough autopsy in all suspected drownings, discuss the etiopathogenesis of the neurological disease and hypothesize a possible relationship between the hydrocephalus and the drowning accident. Finally, we discuss the major clinical and forensic implications of macrocephaly and hydrocephalus in adults.     

The Drowning Index: Implementation in Drowning,Mechanical Asphyxia,and Acute Myocardial Infarct Cases

Drowning is a diagnosis of exclusion based on circumstantial and autopsy correlation. Sugimura proposed a threshold value of 14.1 for the Drowning Index (DI), the ratio of lung and pleural fluid to spleen weight, as a surrogate marker to diagnose drowning. We questioned the use of DI in diagnosing drowning. We compared DI between three groups—drowning, mechanical asphyxia, and myocardial infarct—seen at Broward MEO from 2008 to 2009. Only 9.4% of 53 drownings exceeded the DI threshold of 14.1, while 30% of 10 mechanical asphyxias and 40% of 10 myocardial infarcts had DI >14.1. Sensitivity for the DI test was <10% and specificity 60–70%. Median DI values for all groups were <10. Mann–Whitney U‐test was not statistically significant between groups. The DI is neither sensitive nor specific and lacks any utility in the diagnosis of drowning.     

Death due to baclofen and dipyrone ingestion.

A fatal suicidal intoxication with unusual drugs is reported. A 56-year-old man was found dead in his house; near by the corpse several empty drugs boxes were found. An autopsy was performed and the biological fluids were submitted to a full toxicological work-up.The analytical results supported the hypothesis of a death due to the acute baclofen (4-amino-3-(p-chlorophenyl)butyric acid) and dipyrone (sodium [N-(1,5-dimethyl-3-oxo-2-phenylpyrazolin-4-yl)-N-methylamino] methanesulfonate) intoxication.     

Unusual results due to transfused blood.

During a murder enquiry, the forensic science investigation used PGM and EAP blood grouping systems and detected a mixture of blood on the deceased's jacket. The blood groups matched those of the deceased and accused. The results of DNA analysis, however, proved that only a single source of DNA, matching the deceased, was present. Supplementary information relating to the transfusion of the individual whilst still wearing his clothing led the authors to conclude that a mixture of transfused blood and the individual's own blood had effused from his body via a stab wound, and onto his clothing.     

Sudden death due to lymphoplasmacytic hypophysitis.

We report the case of a 37-year-old mentally retarded woman who died suddenly with premortem clinical signs of diabetes insipidus. At autopsy, her pituitary was infiltrated and destroyed by a lymphoplasmacytic infiltrate, affecting the posterior pituitary more severely than the anterior pituitary. Vitreous electrolytes showed a pattern of hypertonic dehydration, compatible with diabetes insipidus.     

A fatality due to propofol poisoning.

This report describes a suicide by self-administration of propofol in a 29-year-old female radiographer. This is the first published report of death by overdosage with propofol. Propofol was detected in tissues using high performance liquid chromatography. Post mortem femoral blood and liver concentrations of propofol were 0.22 mg/L and 1.4 mg/kg, respectively. The scene suggested that a dose of 400 mg was used.     

Drowning deaths in toddlers and preambulatory children in South Australia

Infants who are preambulatory and toddlers who have only just learned to walk have particular characteristics that give them a unique susceptibility to drowning in certain circumstances. A study of drowning deaths in 32 infants and children <2 years of age in South Australia over a 35-year period from March 1963 to February 1998 was undertaken. The age range was 3 to 24 months (average, 15.4 months), and there was a male:female ratio of 21:11. Drownings occurred in home swimming pools (N = 10); baths (N = 9); waterways (i.e., rivers, irrigation ditches, sea; N = 5); buckets, bins, sinks (N = 4); and fish ponds (N = 3). Details were lacking in one case. Two cases raised questions regarding the manner of death and the possibility of inflicted injury. Specific problems that occur in the assessment of infant drownings include the vulnerability of infants to accidental and nonaccidental drowning, the absence of autopsy findings in inflicted drowning, and the lack of independent witnesses to the fatal episodes. Although the numbers of childhood drownings have declined in recent years, specific situations that remain dangerous for infants include unsupervised bathing and access to swimming pools, fish ponds, and industrial buckets containing water. Complete submersion does not have to occur for drowning to take place.     

溺死法医学检验鉴定方法评估与展望

综述近年来在硅藻检验、水中浮游生物叶绿素（A）检测、血液化学和组织化学检验等方面的最新文献报道,并对各种溺死检验方法的优缺点进行了评价：在硅藻检验中,硝酸乙醇法、破机罐法及微波消解法,可缩短检验时间,提高办案效率;酶消化法及PCR法硅藻检出率高,适用于可疑水样中硅藻密度低样品的检测。早期器官组织中浮游生物叶绿素（A）、血液和组织中其他生化指标,可作为鉴定溺死的重要参考;微量元素锶检测可用于鉴定海水中溺死;另外,硅藻及其他浮游生物遗传多态性片断PCR,可望成为新的、灵敏的溺死检测方法。     

Sudden death due to unsuspected coronary vasculitis.

Coronary artery vasculitis is a well-recognized complication of polyarteritis nodosa and is occasionally seen in other forms of systemic vasculitis. However, involvement of the major epicardial coronary arteries leading to myocardial infarction and death is uncommon. Isolated coronary arteritis is even more rare. We report three cases of sudden death due to myocardial ischemia associated with arteritis of the major coronary arteries. All three decedents were previously healthy young to middle-aged men who had died suddenly after complaints of chest pain and shortness of breath. The autopsy findings and differential diagnoses are presented. Such cases are of particular interest to the medical examiner because of the sudden, unexpected nature of the deaths. An approach to the correct diagnosis is discussed.     

Sudden death due to a laryngeal cyst.

A 68-year-old woman died suddenly at home; her body was found in an armchair in a sitting position. Autopsy revealed a laryngeal cyst of a dilated secretory gland, located above the vocal cords, which obstructed the glottis, causing asphyxia. A review of the literature with forensic implications is given.     

Death due to attack from chow dog.

It is estimated that between one and four million persons per year are bitten by dogs in the United States. While most injuries associated with the bites are minor, serious sequelae, and even death, may occur. Most victims of fatal dog attacks are children < 1 year of age or elderly women. The most frequent cause of death is hemorrhage and shock from major vessel damage. A case is reported in which an elderly woman was attacked by her pet Chow dog. The victim received multiple superficial abrasions, contusions, and lacerations from the dog attack. A large perforation of the right external pudendal vein and three perforations of the left superficial femoral vein resulted in exsanguination and death. Fractures of the left 2nd through 4th ribs with underlying pulmonary contusion were also found.     

Laboratory investigation of deaths due to anaphylaxis.

To establish a useful laboratory protocol to investigate possible cases of fatal anaphylaxis, we measured mast-cell-derived tryptase levels and allergen-specific immunoglobulin E (IgE) antibody levels in sera obtained prior to or within 24 h after death from 19 anaphylaxis victims. Elevated serum tryptase levels (range = 12 ng/mL to 150 micrograms/mL) were found in nine of nine Hymenoptera sting fatalities, six of eight food-induced fatalities, and two of two reactions to diagnostic therapeutic agents. Tryptase levels were normal (less than 10 ng/mL) in 57 sequential sera obtained postmortem from six control patients. Tryptase could not be measured in pleural or pericardial fluids for technical reasons. Serum IgE antibodies were elevated in five of the nine Hymenoptera sting fatalities and in eight of the eight fatal food reactions; assays were unavailable for the two diagnostic/therapeutic agents. If elevated, the victim's serum IgE antibodies to food could be used to identify allergens in uneaten portions of foods consumed shortly before the anaphylactic event. IgE antibodies were moderately stable during storage in a variety of anticoagulants at room temperature for up to 11 weeks. Elevated mast-cell-derived tryptase levels in postmortem sera reflect antemortem mast cell activation and may be used as a marker for fatal anaphylaxis. If assays are available for IgE antibodies to relevant allergens, such assays provide evidence for antemortem sensitization; these assays may be modified to identify allergens in foods consumed by victims of food-induced anaphylaxis.     

Death due to superficial soft tissue injuries.

A series of deaths due to multiple superficial injuries is reported. These cases represented 5% of a consecutive homicide series in the Northern Territory of Australia. All cases were characterized by extensive superficial injuries, particularly involving soft tissue, which were present over much of the body including the face, head, arms, legs, and trunk. Upper-limb fractures were present in some cases, as were fractured ribs. The internal organs and tissues were pale, but there was either little or no organ damage. No significant volume of free blood was found in any of the body cavities. In one case, fat emboli were identified in moderate numbers in the lung and kidney. Death due to multiple superficial soft tissue injuries has not previously been characterized in the literature.     

Sudden death due to a central neurocytoma.

The central neurocytoma is a common, usually intraventricular tumor with bland histologic features. We report a case of a 51-year-old man who died suddenly. At autopsy, a neurocytoma with acute hemorrhage filled the anterior left lateral ventricle. The tumor matrix and surrounding brain tissue contained accumulations of hemosiderin. Previously, 2 cases of central neurocytoma with associated hemorrhage have been reported. Hemorrhage appears to be a serious complication associated with these neoplasms.     

Acute fatal poisoning cases due to furathiocarb ingestion.

Seven cases involving acute fatalities due to ingestion of furathiocarb, a carbamate insecticide, are presented. Furathiocarb was detected in the gastric contents using thin layer chromatography (TLC) and gas chromatography/mass spectrophotometry (GC/MS), and quantified in the blood using a gas chromatograph equipped with a nitrogen-phosphorus detector (NPD). The fatal levels of furathiocarb in the blood ranged from 0.1 to 21.6 micrograms/ml.     

Sudden death in children due to mesenteric defect and mesenteric cyst.

Two cases of sudden death in young female children due to small intestinal volvulus are reported, which involved a mesenteric defect and a mesenteric cyst. Death due to small intestinal volvulus is uncommon, especially when complicated by either a mesenteric defect or cyst.     

气单胞菌aerA和hlyA两基因在溺死诊断中的应用

目的建立溺死尸体脏器气单胞菌气溶素(aerA)和溶血素(hlyA)两基因的PCR-CE检测方法,验证该方法的特异性和灵敏度,并探讨其在溺死诊断中的应用价值。方法设计气单胞菌(Aeromonas)特异性引物aer-A1和hlyA-1,构建PCR-CE方法;扩增52种标准株DNA;确定最低DNA检测浓度;检测16只实验猪和40例真实案件尸体组织样本,分别计算两对引物总阳性率。结果引物aerA-1可特异性扩增杀鲑气单胞菌和温和气单胞菌,产物片段为180bp,灵敏度分别为0.034、0.92ng;引物hlyA-1可特异性扩增杀鲑气单胞菌和嗜水气单胞菌,产物片段为150bp,灵敏度分别为0.94、0.034ng。利用aerA-1检测溺死实验猪和真实案件尸体组织样本,溺死阳性率分别为70.00%、78.38%;利用hlyA-1检测溺死实验猪和真实案件尸体组织样本,溺死阳性率分别为80.00%、83.78%。结论基于气单胞菌aerA基因和hlyA基因建立的PCR-CE检测方法进行溺死诊断,快速灵敏,特异性好,有良好的应用前景。     

A death due to ethchlorvynol abuse. A case report

A fatal case of ethchlorvynol abuse is reported with blood and tissue determinations.     

Death due to concussion and alcohol

We encountered 5 deaths following blunt trauma to the face and head in which the injuries were predominantly soft tissue in nature with absence of skull fractures, intracranial bleeding, or detectable injury to the brain. All individuals were intoxicated, with blood ethanol levels ranging from 0.22 to 0.33 g/dl. We feel that in these deaths, ethanol augmentation of the effects of concussive brain injury, with resultant posttraumatic apnea, was the mechanism of death.