An autopsy case of infant death due to heat stroke.

We report an autopsy case of infant death due to heat stroke. On a winter day, a 52-day-old female baby was placed under a Japanese electric foot warmer with a coverlet (kotatsu) on an electric carpet warmer in a heated room at home. After about 5 h, the mother noticed that the baby was unconscious and took her to a hospital. Spontaneous respiration, however, was already absent, and the pupils were dilated. The trunk was hot; body temperature was 41.3 degrees C. The skin of the whole body was dry. Autopsy revealed second-degree burn injuries on the left side of the face and the dorsum of the left hand. Numerous marked petechiae and ecchymoses were found in the thymus (capsule and parenchyma), pleurae (visceral and parietal), pericardial cavity (internal and external surfaces), epicardium, and beneath the serosa at the origin of the aorta. In addition, there was congestion in various organs, edema in the brain and lungs, and hemorrhage in the lungs. Histopathologically, macrophages without hemosiderin granules were present in the alveoli. When the heating conditions at the accident were reproduced experimentally, the temperature in the electric kotatsu warmer rose to 50-60 degrees C. Thus, we concluded that misuse of the electric kotatsu caused heat stroke in this infant.     

2 fatalities due to hyperthermia in infancy. A contribution to forensic medicine case reports of death caused by heat

Two infants aged 4 1/2 and 8 months are reported to have been exposed to overheating by an electric blanket and a heating fan in bed for a period of up to approx. 19 hours. Dehydration complicated the effects of overheating. Due to the case history in combination with the autopsy and histological findings as well as the absence of toxicological findings the following diagnosis could be established: "Death from exhaustion as a consequence of long-lasting heat effect and dehydration." The necessity of thorough investigations in causes of death during infancy is shown by means of the two cases above. If possible, the rectal temperature should already be taken by the coroner. The public should get informed about the risks caused by the use of electric cushions, heating fans as well as floorboard heating.     

Fatal intravenous fentanyl abuse: four cases involving extraction of fentanyl from transdermal patches

The transdermal fentanyl system delivers a specific dose at a constant rate. Even after the prescribed application time has elapsed, enough fentanyl remains within a patch to provide a potentially lethal dose. Death due to the intravenous injection of fentanyl extracted from transdermal patches has not been previously reported. We present 4 cases in which the source of fentanyl was transdermal patches and was injected. In all of these cases, the victim was a white male who died at home. Case 1 was a 35-year-old with no known history of drug use, who was found by his wife on the floor of his workshop. Police recovered a fentanyl patch, needle, and syringe at the scene. Case 2 was a 38-year-old with a known history of drug use whose family claimed that he was in a treatment program that used fentanyl patches for unknown reasons. His brother found him dead in bed, and law enforcement officers found a hypodermic needle beside the body; a ligature around his left hand, and apparent needle marks between his first and second digits were also noted. Case 3 was a 42-year-old with a recent attempted suicide via overdose who was found dead at his home. An empty box of fentanyl patches, Valium, Ritalin, and 2 syringes were found at the scene. Case 4 was a 39-year-old found by his mother, who admitted to removing a needle with attached syringe from the decedent's arm. Medications at the scene included hydrocodone, alprazolam, zolpidem, and fentanyl patches. All reported deaths were attributed to fentanyl intoxication, with blood concentrations ranging from 5 to 27 microg/L.     

Death after anal "fisting"

A 45-year-old homeless woman was found dead at her usual sleeping place. Apart from traces of blood on the lower abdomen of the body, the police investigations did not produce any clues pointing to an unnatural death. At autopsy, it was found, however, that death had been caused by extensive disruptions of the intestine. After being confronted with the results, the sexual partner of the victim admitted manual anal penetration, but claimed that this had been done by mutual agreement. The court did not accept that statement and sentenced him to life imprisonment for murder. The frequency of such fatal outcomes of anal penetration, the relationship between the perpetrator and the victim and the special features at the scene are discussed.     

An autopsy case of malignant hyperthermia

A report is made of a 44-year-old female who died of malignant hyperthermia during general anesthesia for an operation of left subtrochanteric femoral fracture. Symptoms began with increases in heart rate and blood pressure after the introduction of anesthesia with halothane and were accelerated by the administration of succinylcholine, followed by muscle rigidity and high temperature. The typical wine red urine was observed. The oral temperature of 42 degrees C was recorded within 1 h after succinylcholine. The rectal temperature was 30 degrees C 22 h after death. Severe pulmonary edema and tubular necrosis of the kidney were found by postmortem examination. No latent myopathy was observed. The creatine phosphokinase levels in plasma obtained after the onset of malignant hyperthermia and at the time of autopsy were abnormally high and were 5632 and 34,854 mU/ml, respectively. Plasma myoglobin levels were 130,000 and 2.8 X 10(6) ng/ml, respectively.     

Rupture of an intracranial aneurysm--unusual complication of an electric shock.

Here we report about a 35-year-old electrical engineer who was found dead in his study. Postmortem examination revealed that death resulted because of subarachnoid and intraventricular hemorrhage caused by the rupture of an intracranial aneurysm. Right hand and left cheek revealed electrical marks with metallizations on skin, an electric shock was diagnosed to have preceded death. The close temporal correlation suggests that a sudden rise in blood pressure was caused by the electric current and was thus responsible for the rupture of the aneurysm.     

An Unusual Zip Gun Suicide—Medicolegal and Ballistic Examination

Abstract:  Home-made guns are imitations of typical firearms and usually have handgun characteristics. This article presents an unusual case of a suicide carried out by means of a fatal gunshot wound to the head using a home-made zip gun. A 49-year-old male, with a history of paranoid psychosis was found dead in the dwelling place of a family house. The investigation at the crime scene did not lead to suspicion of a gunshot wound because of the unusual nature of the firearm used. A medical examiner diagnosed an opened head injury as the primary cause of the victim's death. The autopsy findings provided immediate grounds for further inspection of the crime scene. Subsequently, a simple zip gun, which had been overlooked during the scene investigation, was discovered. An undeformed projectile recovered from the victim's head was consistent with the use of the home-made firearm. Following the completion of the investigations and autopsy, the death was classified as a suicide.     

Time of death of victims found in cold water environment

Limited data is available on the application of post-mortem temperature methods to non-standard conditions, especially in problematic real life cases in which the body of the victim is found in cold water environment. Here we present our experience on two cases with known post-mortem times. A 14-year-old girl (rectal temperature 15.5 degrees C) was found assaulted and drowned after a rainy cold night (+5 degrees C) in wet clothing (four layers) at the bottom of a shallow ditch, lying in non-flowing water. The post-mortem time turned out to be 15-16 h. Four days later, at the same time in the morning, after a cold (+/- 0 degrees C) night, a young man (rectal temperature 10.8 degrees C) was found drowned in a shallow cold drain (+4 degrees C) wearing similar clothing (four layers) and being exposed to almost similar environmental and weather conditions, except of flow (7.7 l/s or 0.3 m/s) in the drain. The post-mortem time was deduced to be 10-12 h. We tested the applicability of five practical methods to estimate time of death. Henssge's temperature-time of death nomogram method with correction factors was the most versatile and gave also most accurate results, although there is limited data on choosing of correction factors. In the first case, the right correction factor was close to 1.0 (recommended 1.1-1.2), suggesting that wet clothing acted like dry clothing in slowing down body cooling. In the second case, the right correction factor was between 0.3 and 0.5, similar to the recommended 0.35 for naked bodies in flowing water.     

Sudden infant death from atelectasis due to amniotic fluid aspiration

An infant girl, whose hands showed lobster-claw deformity, was found dead in her bed at 17 days of age. Macroscopic and microscopic examination of the lungs showed fatal atelectasis. The alveolar spaces were filled with fluid, epithelial cells, and squamous debris. These were the constituents of amniotic fluid aspirated before birth. The present case suggested that some sudden unexpected deaths in early infancy are delayed deaths caused by amniotic fluid aspiration.     

Traumatic rupture of intracranial vertebral artery due to hyperextension of the head: reports on three cases

In three cases of fatal basal subarachnoid hemorrhage due to rupture of the normal intracranial vertebral artery, the ruptures appeared to have been caused by overstretching of the vertebral artery from traumatic hyperextension of the head. In the first case, that of a 31-year-old male pedestrian who, while intoxicated, had been hit from behind by a car, symmetrically located bilateral complete and incomplete tearing of the vertebral arteries was found. In both of the other two cases, involving women aged 37 and 51 found dead after receiving fist blows to the face while intoxicated, complete rupture of the vertebral artery was found. The blood alcohol concentrations of the three cases ranged from 1.6 to 1.7 mg/g at autopsy.     

Entomological and Cardiologic Evidence of Time Since Death in Short Postmortem Intervals

Estimating the time since death of the deceased is a main goal in forensic investigations, but this can be challenging due to contradictory results derived from different investigations at the scene of death. We present a case of a 78‐year‐old woman, found dead in a small forest with broad‐leaved trees, whose husband had a history of domestic violence. Routinely performed investigations, such as postmortem rectal temperature and lividity, yielded inconsistent time since death results between only a few and longer than 20 h. This difficulty was most likely caused by high ambient temperatures of up to 38.0°C, which negatively influenced the informative value of the applied nomogram method. Additionally, performed entomological investigation of fly maggots (Lucilia illustris) recovered from the corpse and the assessment of heart pacemaker data revealed consistent and incontrovertible results. The presented case highlights the benefits of information provided by entomological investigations and data evaluation of cardiac implantable electronic devices and the combined use of the two techniques.     

The role of intestinal bacterial heat production in confounding postmortem temperature measurements

To assess the influence of anaerobic bacterial heat production in human stools as a confounding factor in postmortem rectal temperature measurements, in vitro experiments were carried out with human stools incubated at 37 degrees C for 6 h and at decreasing temperatures simulating a postmortem body cooling. Although a statistical significant heat production was observed, it was not relevant enough to explain a postmortem temperature plateau or a substantial rise in the postmortem body temperature. The experiments suggest that stools merely reflect the environmental thermal changes rather than producing bias and confounding by a bacterial heat production.     

Comamonas testosteroni meningitis in a homeless man

We report a case of meningitis caused by Comamonas testosteroni in a 54-year-old, alcoholic, homeless man. He, as a pedestrian, was struck by a car and suffered multiple fractures of the facial bones including the left frontal sinus. Over the course of 2-week hospitalization, he was clinically diagnosed with multiple cerebral and cerebellar infarcts resulting in altered mental status. He was pronounced dead 15 days after the injury. At the time of autopsy, diffuse purulent meningitis was found on gross examination. A swab culture of the brain surface was positive for C. Testosteroni, a saprophytic organism commonly found in soil and water. This is the first reported case of fatal meningitis caused by this micro-organism.     

Planned complex suicide: report of three cases

This article presents three planned complex suicide cases. The first case was a 46-year-old man, who had taken some antidepressant and antipsychotic drugs before cutting his right wrist and ingesting a large amount of concentrated hydrochloric acid. In the second case, a 34-year-old man was found dead in his home, hanging by his neck, with a suicidal stab wound on the left side of the chest. In the third case, a 22-year-old woman was found dead, hanging by her neck from a ceiling beam of her grandmother's a storage room, after taking of a solid rodenticide. The histories revealed psychiatric problems in all cases. The investigation of scene, the method employed, the autopsy findings and the interview with their relatives altogether pointed toward a suicidal etiology.     

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.     

Unexpected Human Fatality Associated with Bed Bug (Hemiptera: Cimicidae) Heat Treatment

Thermal insect treatments can be an effective method of controlling cryptic insect pests, particularly bed bugs, in residential settings. The treatments require high heat over a sustained timeframe. Residents are not present during treatment but return after completion. An unexpected death was investigated following heat treatment for bed bugs in the home of an elderly female, found with a postmortem axillary temperature of 106.2°F (41.2°C) approximately 8 h after returning home. The cause of death was classified as hyperthermia with a contributory cause of hypertensive cardiovascular disease. The manner of death was an accident. The decedent had medical history and medications that could have impaired her ability to dissipate heat. Furthermore, the air conditioning inside the residence was not functional following treatment. Recommendations including education regarding heat stroke and treatment, re‐entry timeframes, and/or temperature thresholds are suggested to reduce the risk of heat‐related injury or death in vulnerable populations.     

Hypothermia and undressing associated with non-fatal bromazepam intoxication.

A 42-year-old woman with a history of depression was found unconscious, lying near her car in an early autumn morning. The lower part of her body was undressed and there were multiple purple spots and excoriations on the body suggesting at first a sexual assault. On admission to the intensive care unit, she presented a hypothermia with a central temperature of 28.4 degrees C. The biological samples obtained at the hospital were analysed. Blood concentration of bromazepam was 7.7 mg/l, which is above the highest level reported till now in a case of fatal intoxication.     

Fatal penetrating abdominal injury by a metallic projectile

Penetrating abdominal injury is often a life-threatening condition, which is mainly associated with inflicted injuries. Fatal self-inflicted sharp force abdominal injuries too have been reported in the literature. Inadvertent penetrating abdominal injuries are a rarity and are caused by sharp objects of low-velocity and often nonmissile-type. A 27-year-old male factory worker was brought dead to the emergency department with an alleged history of sustaining abdominal injury by a sharp metal projectile while working on a metal cutting grinder. Autopsy observations were consistent with the history of inadvertent penetrating injury. Our case reports a fatal missile-type inadvertent sharp force trauma over the abdomen with intestinal perforation, a relatively uncommon scenario in occupational/workplace settings. The present case report describes the significance of the death scene visit and corroborating the medical findings with investigating agencies. This case further emphasizes on the need for adopting proper safety measures at the workplace.     

Environmental hyperthermic infant and early childhood death: circumstances, pathologic changes, and manner of death.

Infant and early childhood death caused by environmental hyperthermia (fatal heat stroke) is a rare event, typically occurring in vehicles or beds. The aims of this study were to describe the demographics, circumstances, pathology, and manner of death in infants and young children who died of environmental hyperthermia and to compare these cases with those reported in the literature. Scene investigation, autopsy reports, and the microscopic slides of cases from three jurisdictions were reviewed. The subjects in 10 identified cases ranged in age from 53 days to 9 years. Eight were discovered in vehicles and 2 in beds. When the authors' cases were grouped with reported cases, the profile of those in vehicles differed from those in beds. The former were older, were exposed to rapidly reached higher temperatures, and often had more severe skin damage. The latter were mostly infants and were exposed to lower environmental temperatures. Hepatocellular necrosis and disseminated intravascular coagulation were reported in victims who survived at least 6 hours after the hyperthermic exposure. The consistent postmortem finding among nearly all victims was intrathoracic petechiae, suggesting terminal gasping in an attempt at autoresuscitation before death. The manner of death was either accident or homicide. Recommendations for the scene investigation are made.