Death due to neurogenic shock following gastric rupture in an anorexia nervosa patient

We report a case of fatal gastric rupture discovered after death, which developed due to a bulimic attack of a 19-year-old woman suffering from anorexia nervosa. An autopsy revealed an acute gastric dilatation and rupture without commonly observed ischemic damage of gastric wall structures. However, it may be difficult to determine the cause of death despite the marked findings. The death as a consequence of neurogenic shock accounts for all the results of gross examination and histologic analysis. This case is the first reported case of fatal gastric rupture of an anorectic patient discovered after death.     

Mechanisms of unexpected and/or sudden death in Lafora disease

A 23-year-old male was found dead wedged between two chairs at his home address. His past history included a diagnosis of Lafora disease (a type of heritable progressive myoclonic epilepsy) at the age of 16 years. This had been characterised by the development of epilepsy and progressive motor impairment and mental deterioration. Diagnosis had been confirmed by demonstration of mutation in the EPM2A gene on chromosome 6q24. At autopsy, petechial haemorrhages were noted of the face and conjunctivae bilaterally. There were no other significant findings apart from gastric contents within the airways. Death was attributed to positional asphyxia complicated by aspiration of gastric contents. Although death in Lafora disease is usually predictable and often protracted, sudden and/or unexpected death may occur and involve status epilepticus, sudden unexpected epileptic death, choking, aspiration of gastric contents, and cardiac arrhythmias. In addition, the possibility exists of unnatural causes of death, such as accidents, provoked by epilepsy or physical inability of the victims to extricate themselves from dangerous situations, or homicides, provoked by difficulties in caring for individuals with significant and progressive disabilities.     

Postmortem transport of gastric contents?

For the determination of the time since death, the distribution of the last meal in the stomach and small bowel may be of great importance. It may be even more difficult to estimate the time if there is a possibility that postmortem peristaltic emptying of the gastric content occurs, as has been claimed. Radiological control immediately after death by means of applying barium sulfate to the stomach, however, revealed no evidence of peristaltic emptying of the gastric content after death.     

Wildlife forensic entomology: determining time of death in two illegally killed black bear cubs.

Forensic entomology is now commonly used to determine time of death in human death investigations. However, it can be equally applicable to wildlife crimes. This paper describes the use of entomology to determine time of death in the illegal killing of two young bear cubs in Manitoba, Canada. Two cubs were found shot, disemboweled, with their gall bladders removed. Natural Resource officers (Conservation Officers) and a Royal Canadian Mounted Police (R.C.M.P.) officer examined the remains, and the R.C.M.P. officer collected insect evidence. The only insects on the remains were adult blow flies coming to lay eggs and the blow fly eggs themselves (Diptera: Calliphoridae). The time of hatch was recorded and the insects were reared to adulthood. Time of hatch, together with species identification, macro and micro climate and lab developmental data were used to determine the time of death. The time was consistent with the time that the defendants were seen at the scene and was used in their conviction. This case illustrates that insect evidence can be equally as valuable in poaching cases as in homicide cases. However, in most cases Conservation Officers are unaware of this science. It is therefore, extremely important for more Conservation Officers to be educated about this field.     

Sudden death from hyponatremia and hypokalemia in a woman with Gardner syndrome.

The authors present the case of a 39-year-old woman with Gardner syndrome who died from marked hyponatremia and hypokalemia. Gardner syndrome is a rare variant of the familial adenomatous polyposis syndrome in which the affected individual develops thousands of polyps within the gastrointestinal tract, with a 100% risk of eventual malignant change. Individuals with Gardner syndrome also develop a variety of extra gastrointestinal abnormalities. In the case presented, a woman with a clinical history of Gardner syndrome who had previously undergone a total colectomy with ileorectal anastomosis presented to the hospital with a recent history of sore throat, fever, diarrhea, and abdominal pain. The symptoms were considered clinically to be due to a viral gastroenteritis. She was admitted to the hospital, where she had episodes of collapse believed to be vasovagal in origin. She suffered a cardiorespiratory arrest and died 24 hours after admission. After her death, electrolyte estimation performed on blood taken shortly before death revealed severe hyponatremia and hypokalemia. Postmortem examination showed the gastric mucosa to be virtually covered by innumerable adenomatous and hyperplastic polyps. Fewer polyps were seen within the small bowel. There was no evidence of malignancy. The features were consistent with Gardner syndrome. Hyponatremia and hypokalemia have been described in patients with villous adenomas and in familial adenomatous polyposis syndromes associated with numerous colonic polyps. The cause of death in this case was considered to be hyponatremia and hypokalemia associated with florid gastric polyps in a woman with Gardner syndrome. Viral gastroenteritis contributed to the death by causing further electrolyte depletion. To the best of the authors' knowledge, death in Gardner syndrome has not been described as attributable to such metabolic disturbance, in particular in those who have only gastric, small bowel, and rectal polyps remaining after total colectomy.     

Papillary hyperplasia of the lingual tonsil and sudden death in epilepsy.

Papillary hyperplasia of the lingual tonsils is a rare entity not previously reported at autopsy. We report a case that occurred in a 19-year-old man who died suddenly from his epilepsy, associated with aspiration of gastric contents. We describe the pathological features of this unusual condition, discuss the possible significance in this case and stress the importance of routine examination of the tongue and pharynx in every autopsy.     

Death following acute poisoning by moclobemide

A fatality due to ingestion of a reversible inhibitor of monoamine-oxidase A (MAO-A) is reported. Moclobemide is generally considered as a safe drug far less toxic than tricyclic anti-depressants. However, severe intoxications may result from interactions with other drugs and food such as selective serotonin reuptake inhibitors (SSRIs), anti-Parkinsonians of the MAOI-type (e.g. selegiline) or tyramine from ripe cheese or other sources. In the present case, high levels of moclobemide were measured in peripheral blood exceeding toxic values reported so far in the scientific literature. The body fluid concentrations of moclobemide were of 498 mg/l in peripheral whole blood, 96.3 mg/l in urine while an amount of approximately 33 g could be recovered from gastric contents. The other xenobiotics were considered of little toxicological relevance. The victim (male, 48-year-old) had a past history of depression and committed one suicide attempt 2 years before death. Autopsy revealed no evidence of significant natural disease or injury. It was concluded that the manner of death was suicide and that the unique cause of death was massive ingestion of moclobemide.     

Sudden unexpected death associated with atlanto-occipital fusion

A case of sudden, unexplained death in a 24-year-old male is presented. There were two previous spells of loss of consciousness. There was remarkable narrowing of the foramen magnum with indentation of the medulla. The atlas was partly fused with the occipital bone and a portion of abnormal bone compromised the foramen magnum from anterior reducing its anteroposterior dimensions to 16 mm (n 25-35 mm). Close clinical examination of this area in patients with acute intermittent symptomatology, or at the time of autopsy in cases of sudden unexpected death is stressed.     

Comparison between computed tomography (CT) and autopsy findings in cases of abdominal injury and disease

We report 10 autopsy cases involving fatal pathological changes in abdominal organs, for which findings of computed tomography (CT) on admission or after death were compared with autopsy findings. Two of the cases were death due to natural causes and eight were death due to traffic accidents. From the findings at autopsy, the causes of death were considered to be rupture of an aortic aneurysm in one case, gastrointestinal bleeding due to gastric cancer in one case, retroperitoneal bleeding in two cases, laceration of the liver in three cases, and traumatic rupture of the small intestine in three cases. CT findings revealed ascites or retroperitoneal bleeding in eight cases. However, in the cases of small-intestinal rupture, CT findings on admission revealed no free air. Therefore, ascites on CT should be regarded as a useful indicator of blunt abdominal trauma. Hepatic portal venous gas, known to be a post-mortem change, was significantly evident on post-mortem CT in cases of traumatic liver or intestinal injury, and was also seen in cases where the period between the accident and CT examination was long.     

Suicide by xylene ingestion. A case report and review of literature

A 27-year-old male committed suicide by ingestion of a large quantity of xylene. The presence of xylene in the tissues of the victim was confirmed by chromatographic and spectrometric techniques. High levels of xylene were detected in blood (11 mg/dl), gastric contents (880 mg/dl), and duodenal contents (3,300 mg/dl). Histological examination of the lungs showed severe congestion and acute pulmonary edema. Review of the relevant literature is presented.     

Sniffing-associated deaths in Denmark

An account is given of 20 deaths, which occurred in association with sniffing during the period 1959 – 1978. The annual number of deaths was almost constant during the period. Most of the deaths occurred in males. Ether and trichloroethylene were the predominant toxic substances. The material was divided into two groups. Group A, 14 cases, included real sniffing deaths, the cause of death being poisoning by the substance inhaled. In group B, 6 cases, sniffing was a contributory factor to death: 2 cases of suffocation by obstruction, one case of carbon monoxide poisoning during fire, one case of septicemia/severe anemia caused by bone marrow depression, and one case of bleeding to death from stab wounds inflicted by a sniffer against a non-sniffer. The circumstances before and at the time of death are reported, together with the autopsy and toxicological findings when these were performed.     

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.     

Suicidal monointoxication with flunitrazepam. Further comment on coloration phenomena of the upper gastrointestinal tract

Fatal monointoxications with benzodiazepines, for instance with a suicidal intention, are exceptional findings. We report the autopsy case of an 82-year-old woman who died due to a suicidal monointoxication with Rohypnol 1 mg film tablets (therapeutical agent: flunitrazepam). 0.065 mg/L flunitrazepam and 0.34 mg/L 7-aminoflunitrazepam were detected in a postmortem heart blood sample and toxicological analysis revealed the metabolite 7-aminoflunitrazepam in gastric contents, too. At external examination, a bluish-turquoise coloration was seen around the woman's right nostril and within the oral cavity. At autopsy, similar coloration phenomena were seen on the mucosa of the distal esophagus and the stomach. Formerly, bluish stains on mouth and nostrils were considered indicative of intoxications with organophosphates such as parathion (E 605). More recently, case reports accumulate where an intoxication with Rohypnol 1 film tablets (containing the coloring agent indigocarmine in its core) have to be considered as a potential differential diagnosis of such coloration phenomena.     

Therapy-related café coronary deaths: two case reports of rare asphyxial deaths in patients under supervised care

Café coronary deaths, as initially characterized, denote fatal occlusion of the upper airway by food substances. Such fatalities typically occur in individuals who either are clinically inebriated or have clinically significant neuromuscular dysfunction. Both conditions impair mastication and deglutition. The authors review the accidental deaths of two neurologically compromised patients under supervised care. Both subjects underwent complete medicolegal autopsy. In one case, ingestion of a prescribed emollient laxative precipitated death; in the other, death was attributable to aspiration of a contrast medium during a diagnostic radiographic procedure. These therapy-related deaths, which are regarded as a variation of the traditionally described café coronary fatalities summarized in the discussion, represent adverse events occurring during medical care. The adverse outcomes reviewed here are potentially avoidable and require special attentiveness by the clinicians directed to the particular condition of each patient. Such true aspiration-related deaths are confirmed on autopsy examination and are to be differentiated from the findings of agonal aspiration of gastric contents commonly encountered by the autopsy pathologist investigating deaths due to a great variety of natural and traumatic causes.     

Scanning electron microscopy determination of string mozzarella cheese in gastric contents

As part of a suspected homicide investigation, a sampling of the gastric contents from the victim was forwarded to the U.S. Food and Drug Administration's Forensic Chemistry Center (FCC) for analysis of specific, selected components. The victim was known to have consumed string mozzarella cheese, as a snack, less than 24 h before his disappearance and the subsequent discovery of the body. The investigation sought to confirm or dismiss speculation the victim may have been fed a meal or eaten additional food prior to his death. Analysis of the stomach contents involved examination by stereoscopic light microscopy (SLM) and isolation, processing, and analysis of suspect materials by scanning electron microscopy (SEM). Several wax-like, off-white to cream-colored objects were noted by SLM examination and removed from the gastric contents. Through a series of fixation, sectioning, drying, and coating steps, these objects were prepared for analysis by SEM. Comparison of the suspect material with laboratory control string mozzarella cheese showed excellent correlation between the analyzed samples, confirming the suspect material from the stomach contents as string mozzarella cheese.     

A case of death from prothiophos poisoning

A 62-year-old male, a farmer, who had ingested prothiophos (Tokuthion), died after 21 h of intensive care. Prothiophos in the tissues of the victim was extracted and purified by Extrelut column extraction. A gas chromatograph equipped with a flame photometric detector, and a gas chromatograph-mass spectrometer were used to detect prothiophos. The concentration of prothiophos was 10.9 micrograms/g in the brain, 8.6 micrograms/g in the kidney, 418 micrograms/g in the liver, 2.96 mg/g in the gastric contents and 4.69 mg/g in the intestinal contents. The case history and the distribution of prothiophos indicated that the cause of death was acute prothiophos poisoning.     

A fatal case of mercuric cyanide poisoning

A 57-year-old pharmacist was found dead 11 days after his disappearance. At the autopsy, samples of blood, urine, gastric content were obtained. Presence of ethanol, cyanide and mercury were detected in some samples. Cyanide and mercury were identified and quantified using high-performance liquid chromatography with diode array detector (HPLC) in fluorescence mode and ICP with mass selective detector (ICP-MS) respectively. Whole blood concentrations of ethanol was 1.72 g/L. Cyanide and mercury concentrations in whole blood were respectively 0.16 and 3.8 mg/L. Concentrations of cyanide (27 mg/L) and mercury (150 mg/L) in gastric contents prove a massive oral ingestion of mercuric cyanide or mercuric oxycyanide occurred. In this case report, the death was attributed to the combined toxicity of cyanide and mercury.     

Fatal outcome in a case of pontocerebellar hypoplasia type 2

Pontocerebellar hypoplasia (PCH) is a very rare congenital (autosomal recessive) condition with fetal onset. Only a few cases have been published on the basis of both clinical data (symptoms/neuroradiological imaging) and autopsy results. This paper reports on such a case involving a 1.5-year-old male infant. The child suffered from severe psychomotor delay, extrapyramidal dyskinesia and epileptic seizures, but did not exhibit signs of spinal muscular atrophy as related to PCH type 1. Magnetic resonance imaging (MRI) at the age of 6 months demonstrated olivo-pontine and bilateral cerebellar hypoplasia. The boy was unexpectedly found dead. Autopsy disclosed a severe aspiration of gastric contents as the final cause of death. The neuropathological examination confirmed PCH type 2 (according to Barth [Brain Dev., 15 (1993) 411-422]) with marked microcephaly and olivopontocerebellar hypoplasia. Histologically, decreased density of olivo-pontine neurons, reduction of granular and Purkinje's cell layers of the cerebellum, slight astroglial proliferation and fragmented appearance of the dentate nuclei were observed. The immunohistochemical expression pattern was determined using antibodies against glial fibrillary acidic protein, synaptophysin and neurofilament protein. Summarizing, typical features of PCH type 2 were present and proved by clinical course, MRI and autopsy. Despite severe symptoms due to a natural disease this rare neurogenetic entity can become of forensic interest, when sudden unexpected death occurs.     

A gastric artery aneurysm complicated by a dissection of gastric and hepatic arteries: possible role of adventitial inflammation and disruption of internal elastic lamina in splanchnic artery dissection

A 77-year-old woman was found deceased at home. An autopsy examination revealed a hemoperitoneum due to a ruptured false aneurysm of a branch of the left gastric artery. A long dissection extending from the aneurysm involved splanchnic arteries including the left gastric, common hepatic, right and left branches of proper hepatic, and intrahepatic arteries. An intimal tear was identified in the common hepatic artery. Neutrophils infiltrating in the adventitia may have been reactive and may have triggered the adventitial rupture of aneurysm or development of the dissection. Disruption of the internal elastic lamina, which has been proposed to cause dissection of intracranial arteries, was seen in the dissected arteries. Little is currently known about aneurysms or dissections of splanchnic arteries; however, observation of adventitial inflammation and internal elastic lamina may help disclose the etiology and pathogenesis.