Extracorporeal membrane oxygenation in the forensic setting: A series of 19 forensic cases

Extracorporeal membrane oxygenation (ECMO) employs vascular cannulation and a gas exchange circuit to provide support to patients with severely compromised cardiopulmonary function. ECMO is often the last intervention taken before death and thus presents a unique challenge to medical examiners. This study describes the characteristics of decedents on ECMO at the time of death, including clinical indications, types of circuit configurations, causes and manners of death, gross findings at autopsy, and therapeutic complications. Files of a regional medical examiner office within an academic medical center were searched for the period between 2013 and 2019. Nineteen cases were identified with a median age of 36 years. The circumstances surrounding the initial presentation included: sudden death, trauma, substance abuse, homicide, therapeutic complication, work-related injury, drowning, and hypothermia. The underlying causes of death included injury-related, as well as respiratory and cardiac-related natural diseases. The time spent on ECMO varied from less than 1 h to 10 months. Complications encountered due to ECMO included cannulation site bleeding, pneumohemopericardium, retroperitoneal hematoma, limb ischemia, clotting, and cannula dislodgement. The patient population likely to receive ECMO has significant overlap with death circumstances likely to be reported to the medical examiner. As ECMO therapy has become increasingly available, it is of importance for medical examiners and death investigators to be familiar with the procedure as well as its limitations. Familiarity with ECMO and its sequelae allows for the proper documentation of postmortem findings and fosters an informed determination of the cause and manner of death.     

Cor triatriatum sinistrum: a rare congenital cardiac anomaly presenting in an adult with chronic atrial fibrillation

Cor triatriatum is a rare congenital cardiac anomaly in which the left atrium is divided into proximal (dorsal or upper) and distal (ventral or lower) chambers by a fibromuscular septum. The upper chamber receives the pulmonary veins and the lower chamber contains the atrial appendage and the mitral valve. The 2 chambers communicate through a defect in the membrane. Cor triatriatum is often associated with other congenital cardiac anomalies. Most frequently, the upper chamber communicates with the right atrium through a patent foramen ovale or atrial septal defect, and the clinical symptoms simulate anomalous pulmonary venous return. Less commonly, the foramen ovale communicates with the distal chamber and the clinical features mimic mitral stenosis. When cor triatriatum is the only abnormality, the clinical findings are also similar to mitral stenosis with development of pulmonary hypertension and subsequent right ventricular hypertrophy and atrial enlargement. The diagnosis is usually made in infancy or childhood, and the lack of treatment results in death in 75% of patients.We report the case of a woman who presented much later in life. The patient was a 57-year-old female with a clinical history of chronic atrial fibrillation who presented to the emergency department because of a "funny sensation" in her chest, though she denied chest pain, nausea, vomiting, or diaphoresis. EKG revealed atrial fibrillation with a rapid ventricular response and a tachycardic rate of 157. She had a therapeutic level of digoxin, and cardiac enzymes were normal. The patient was admitted and placed on Cardizem drip. Serial EKGs remained normal and heart rate control was achieved. On hospital day 2, the patient became dyspneic and cyanotic. She went into cardiac arrest and died.Autopsy revealed cardiomegaly (610 g) with 4-chamber dilatation. A septum divided the left atrium into 2 chambers. The defect in the dividing membrane measured 1 cm in diameter. No other congenital defects were noted. The large size of the defect in the membrane likely accounted for the late onset of symptoms that allowed this patient to survive into adulthood without previous diagnosis or surgical intervention (which is usually required in childhood).     

Fatal poisoning due to ingestion of boiled oleander leaf extract

Nerium oleander is an ornamental evergreen shrub belonging to the family Apocynaceae. The Apocynaceae family includes the attractive evergreen shrub known as oleander. The cardiotoxic glycoside, oleandrin, is present in all portions of the common oleander plant. Oleander consumption can result in deadly situations accidentally or as a suicide attempt. After consuming kettle-boiled oleander leaf extract as part of a suicide attempt, an 80-year-old man was discovered comatose in his home and taken to our emergency room. The patient's heart rate was 30 beats per minute, and he had hypotension. Arterial blood gas analysis revealed remarkable metabolic acidosis and hyperkalemia (K: 7.7 mEq/L). An electrocardiogram showed a wide QRS wave, similar to a sine curve. The patient collapsed following cardiac arrest soon after hospital arrival. Veno-arterial extracorporeal membrane oxygenation was initiated; however, the patient eventually died. The serum level of oleandrin at hospital arrival, subsequently measured by LC–MS/MS, was found to be 33.4 ng/mL, far above the levels reported in previous fatal cases.     

A Case of Sudden Death Due to Persistent Severe Pulmonary Arterial Hypertension After Late Atrial Septal Defect Closure

Atrial septal defects (ASDs) are one of the most prevalent congenital cardiac anomalies in adults. These interatrial communications can produce changes in the right heart (remodeling and failure) and the lungs (pulmonary hypertension). Most adults with ASDs are surgically treated with excellent results. However, a small fraction of patients is at risk for postoperative complications, particularly the persistence of pulmonary hypertension. A case of a 47‐year‐old woman who was found unresponsive in the bathroom of her house and died despite resuscitative efforts is described. According to medical records, the woman underwent a surgical repair of an atrial septal defect at the age of 37. At the autopsy, macroscopic and microscopic signs of advanced pulmonary hypertension were detected, highlighting the importance for the forensic pathologists to recognize pulmonary hypertension as a cause of sudden death in adults with a history of late surgical closure of an atrial septal defect.     

Heart rate changes in response to mild mechanical irritation of the high cervical spinal cord region in infants

Alterations in the heart rate were monitored before, during and after the application of a unilateral mechanical impulse to the high cervical spinal cord region which was administered strictly in connection with the so called manual therapy (diagnosis= KISS). The investigation is based on a survey of 695 infants between the ages of 1 and 12 months. A notable change in the heart rate was evident in 47.2% of all examined infants (n= 695). In 40.1% of these infants, the change in heart rate was characterized by heart rate decrease of 15-83% compared to control conditions. Infants in their first 3 months of life responded more often with a severe bradycardia (50-83% decrease), older infants (7-12 months) more often with a mild bradycardia (15-49.9% decrease). This comparison revealed a significantly increased occurrence of severe bradycardia in the younger age group compared to the group of children >3 months (significance 0.0017). In 12.1% (n= 84) of the infants, the bradycardia was accompanied by an apnea. We discuss the hypothesis that mechanical irritation of the high-cervical region serves as a trigger that may be involved in sudden infant death (SID).     

An epidemiological study on alcohol/drugs related fatal traffic crash cases of deceased drivers in Hong Kong between 1996 and 2000

This study is designed to evaluate the correlation between fatal vehicle crashes (FVC) and consumption of alcohol and/or drugs among drivers. Between 1996 and 2000 in Hong Kong, a total of 197 FVC cases of deceased drivers were investigated. The blood and/or urine samples of the victims were examined for the presence of alcohol and drugs. The 197 cases were then classified into two groups: single-vehicle crashes (SVC) and multiple-vehicle crashes (MVC). Out of the 106 cases for the latter group, alcohol and/or drugs were detected in 22 cases (21%) while the remaining 84 cases (79%) were regarded as no significant finding. As for the 91 cases in SVC group, 51 cases (56%) were positive for alcohol and/or drugs. The findings indicate that a driver consuming alcohol and/or drugs has a higher risk of being involved in a FVC. The most frequently detected drugs for SVC group (11 cases) were: 46% central nervous system (CNS) stimulants (including designer drugs like MDMA); 36% cannabis; 18% benzodiazepines and 9% ketamine. The detected drug for the only case in the MVC group was a CNS stimulant. The number of cases with ketamine, methamphetamine and MDMA detected has increased in recent years as these party drugs have gained popularity in Hong Kong.     

Cardiovascular malformations and sudden death in infancy

BACKGROUND: We survey the postmortem findings of cardiovascular malformations in infants under the age of 1 year who died suddenly and unexpectedly, in a way that mimicked sudden infant death syndrome (SIDS), and evaluate the importance of the malformation for the fatal outcome. METHODS: Four hundred fifty-seven infants under the age of 1 year, who died between 1982 and 2001, were investigated at the Department of Forensic Medicine in Stockholm, Sweden. RESULTS: Cardiovascular malformations were found in 18 infants (3.9%). Only 6 of 18 malformations, mostly severe, were clinically diagnosed before death. In the other 12 infants, cardiovascular malformations were found, such as atrial or ventricular septal defects, coarctation of aorta, stenosis of the aortic or pulmonary artery orifice, and aneurysm of the membranous portion of the interventricular septum. In all instances, the heart weight was increased. CONCLUSIONS: The observation of undiagnosed cardiovascular malformations as the only explanation for the cause of sudden and unexpected death in apparently healthy infants may advocate more examinations of the infant during early life. It is also important to enlarge the debate of the cause of death in infants with cardiovascular malformations. Should they be included in borderline SIDS?     

授权立法正当性缺陷的矫正机制

授权立法的正当性缺陷主要表现为三个方面:一是人民性不足;二是导致立法权与执法权由同一机关行使;三是导致权力的被授予者再度将权力授出.对这些正当性缺陷的矫正措施包括:严格授权条件、严格授权明确性原则、加强授权立法程序的民主性、严格授权立法的功能限制、建立对于授权法和授权立法的司法审查制度.     

Increase of pulmonary density of macrophages in sudden infant death syndrome

A 1996 cytodensitometric study found increased cellular density in the pulmonary parenchyma of infants who died of sudden infant death syndrome (SIDS). The present study clarifies these results in quantifying the density of immunohistochemical subtyped inflammatory cells. Histomorphometry was used to compare the density of macrophages, granulocytes and T and B lymphocytes in the lungs of two groups of infants. From the post-mortem records of infant deaths between 1983 and 1995, 29 (mean age = 5 months) were randomly selected including 16 cases of SIDS and 13 who died of other non-pulmonary causes. Densities of immunoreactive cells were measured under blind conditions in the parenchyma. The mean density of macrophages was significantly higher in cases of SIDS compared with the controls (P = 0.0318), but there were no differences for the lymphocytes and the granulocytes. These morphometrical results must be interpreted within the methodological limits of this study, especially the non-uniform level of lung inflation between selected subjects. However, the differences in level of inflation are not sufficient to explain the observed increase of macrophage density. Indeed, the mean values of alveolar surface area, which represent an indirect measure of lung inflation, are not significantly different between the two groups. Increase of pulmonary macrophage density in SIDS agrees with three non-exclusive hypotheses: (1) an abnormal inflammatory reaction by expression of Th1 helper cell phenotype activation; (2) consequence of passive smoking; and (3) post-agonal mechanisms. Bacterial superantigens produced by toxigenic bacteria in the respiratory tract could play a role as a trigger factor that initiates a fatal cascade with overproduction of cytokines leading to death. The significant increase of pulmonary macrophage density would be the morphological expression of this potential mechanism of death.     

Sudden and Unexpected Death in Three Cases of Ehlers‐Danlos Syndrome Type IV*

Abstract: Ehlers–Danlos syndrome (EDS) type IV is a connective tissue disorder characterized by the inability to produce sufficient amounts of collagen or a defect in the structure of collagen. The most serious complications include a rupture of a viscus or vascular rupture with or without mural dissection. Death may result from internal hemorrhage. This report describes three cases of sudden and unexpected death caused by EDS type IV. Two cases involved hemothorax as a result of dissection of the subclavian artery and aorta, respectively. The third case represented spontaneous pulmonary rupture and hemorrhage. A detailed family history should be sought, and additional specimens collected to confirm the diagnosis, including skin fibroblasts for collagen testing and blood for DNA testing. The forensic pathologist should consider the possibility of EDS type IV upon discovery of spontaneous visceral or arterial rupture and should alert the family members of this hereditary and potentially fatal condition.     

Asphyxiating death due to basal lingual cyst (thyroglossal duct cyst) in two-month-old infant is potentially aggravated after central catheterization with forced positional changes

There are various causes of possible upper airway obstruction in infants. Particularly, large cysts on the base of tongue may cause severe airway obstruction by a mass effect on the hypopharynx and by displacing the epiglottis. Of these basal lingual cysts, thyroglossal duct cyst is rare but occasionally its remnants can be found at the base of the tongue. Although they are pathologically benign, basal lingual cysts may result in death by asphyxia. There are a few reported cases of asphyxia caused by basal lingual cyst. All died suddenly in the bed or cot while sleeping without any significant symptoms and signs. The authors experienced a unique case of death due to airway obstruction by basal lingual cyst (thyroglossal duct cyst), confirmed by postmortem examination, probably aggravated after central catheterization in 2-month-old infant who had open heart surgery for atrial and ventricular septal defect and report with a literature review.     

Frequency of pulmonary hemosiderosis in Eastern North Carolina

Pulmonary hemosiderosis has been attributed to airborne fungi in water-damaged homes in studies of a cluster of cases in infants and children in Cleveland, Ohio, in 1997. We have searched for such emerging infectious agents in the Coastal Plain of North Carolina, which is subject to intermittent flooding. Pulmonary tissue from 206 infants and young children whose deaths had been investigated from October 1978 to September 1996 was retained at East Carolina University School of Medicine. Ages ranged from premature newborns to 49-months. One hundred and ten deaths were attributed to sudden infant death syndrome (SIDS). New sections were cut and analyzed using hematoxylin and eosin, Prussian blue for iron, and Gomori methenamine silver for fungal organisms. Twenty-three infants and children had iron-containing macrophages. Sixteen of these had underlying illnesses, but 4 were originally diagnosed as SIDS. Only one of these had sufficient hemosiderosis to be considered as having pulmonary hemosiderosis and no fungi were present. One case without iron had fungi and was not originally diagnosed as SIDS. The single case of pulmonary hemosiderosis found in this rural area is not similar to the cluster in Cleveland. The study identifies no fungal organisms as emerging infectious diseases in this area.     

Hypernatremia and subdural hematoma in the pediatric age group: is there a causal relationship?

Several researchers in the 1950's proposed that hypernatremia causes water to leave brain cells, shrinking the brain, thus tearing the bridging veins and resulting in subdural hematomas. Although the old literature suggests mechanisms linking the two in a cause and effect relationship, there is controversy as to whether hypernatremia leads to subdural bleeding or whether the reverse is true. This issue is important for forensic pathologists who must distinguish natural disease from trauma. An etiologic link between hypernatremia and subdural hematomas was suggested recently, and was proposed originally before Kempe's 1962 paper "The Battered Child Syndrome" which widely disseminated the concepts of child physical abuse, and of subdural bleeding resulting from non-accidental injury. Our study is a multifaceted investigation of infants which includes: a literature review, retrospective chart reviews of both living and deceased hypernatremic infants, a retrospective review of infants hospitalized with subdural hematoma, and a prospective collection of head injured, hypernatremic children. We conclude that hypernatremia, if present in association with subdural hemorrhage, is most likely secondary to intracranial pathology, and that hypernatremia often develops in critically ill infants suffering from a variety of medical conditions.     

A review of blunt force injury homicides of children aged 0 to 5 years in bexar county, Texas, from 1988 to 2009

ABSTRACT: It is essential that clinical physicians, medical personnel, medical examiners, and law enforcement agencies understand the types of injuries seen and demographics of children affected by intentional blunt force as this understanding can be crucial to the death and/or criminal investigations. An understanding of the injuries can also assist in drawing conclusions regarding how those injuries could have been sustained. This study discusses the types and patterns of injuries seen in blunt force homicides in children younger than 6 years. The study found that male infants are more often intentionally injured than are female infants and that fatal head injuries most frequently occur in the first year of life, whereas most fatal thoracoabdominal injuries occur in the first 3 years of life. In children with head injuries, subdural hemorrhage was the most common finding, followed by subarachnoid hemorrhage. In 2.5% of deaths due to head injury, concurrent neck injury was seen, a percentage far lower than previous literature would suggest if shaking was the primary mechanism of injury. Twelve legal confessions were also reviewed, none of which disclosed a pure mechanism of shaking the infant.     

Hazards of mattresses, beds and bedding in deaths of infants

Of 52 infants who had died suddenly and were referred to autopsy, nine had lain on adult water beds for the first time; five had died as a result of accidents; two had died on water beds; two were in beds with widely spaced slats; and one had died as a result of strangulation. Three deaths were due to overlying. Three other infants had been placed on sheepskin rugs for the first time and were found dead shortly thereafter. These infants ranged in age from 2 to 9 months, except for a severely mentally retarded nine-year-old with spastic paraplegia. We believe that a general warning should be issued concerning water beds and that soft bedding should not be used for infants. Infants should not be placed unattended or left to sleep on water beds; only beds recommended for infants should be used. Overlying of a young infant is most likely to occur on a water bed, or if the parent is obese or has consumed alcohol.     

Sudden Death by Occult Metastatic Carcinoma

A 33-year-old female collapsed and died suddenly after presenting with acute dyspnea and increasing cough over the preceding several months. Autopsy revealed poorly differentiated linitis plastica adenocarcinoma of the stomach. Microscopic examination of the lungs showed features consistent with pulmonary tumor thrombotic microangiopathy (PTTM). PTTM is a well-described complication in patients with adenocarcinoma. The typical presentation involves acute pulmonary hypertension, right-sided heart failure, and sudden death, often before the adenocarcinoma is discovered. The pathophysiology of PTTM remains elusive; it has been suggested that carcinoma cells may produce substances that influence pulmonary vasculature. Our patient had classic clinical and histologic features of PTTM in addition to prominent extravascular compression by intralymphatic tumor cells. These features undoubtedly caused her precipitous decline and lethal pulmonary hypertension, induced by underlying adenocarcinoma. This case demonstrates that sudden death can occur from pulmonary hypertension induced by metastatic carcinoma with remarkably little prior symptomatology.     

A new triplex STR system without irregular alleles by silver staining and its potential application to forensic analysis

In order to increase the discriminating power of DNA analysis in forensic science, we devised a new triplex STR system using three novel STR loci we previously reported, D14S299 (wglc5), D15S233 (wgldl), and 9q2h2. We designated this system a CDH triplex system. The CDH triplex system showed a high discriminating power, especially in Caucasians. This system is composed of three STR loci showing only regular tetranucleotide repeat alleles. We easily enlarged the databases mainly of Japanese, using this system, and compared them with those of Caucasian and Chinese. This CDH triplex system therefore appears to be useful for forensic practice.     

A contribution to a possible differentiation between SIDS and asphyxiation

The singular and combined appearance of conjunctival petechiae, of acute pulmonary emphysema and of signs of aspiration was evaluated in resuscitated and non-resuscitated children dying of SIDS (n=115), of other causes of natural death (n=17), of severe head injury (n=10) and of asphyxiation/strangulation (n=7). Conjunctival petechiae occurred in all of the asphyxiated victims and in five out of 10 children dying of severe head injury, but were exclusively found in four resuscitated babies and one baby with questionable resuscitation trials of the SIDS-group (4%), furthermore in one resuscitated child dying of a congenital heart defect. Acute pulmonary emphysema was detected in six out of the seven children of the asphyxiation/strangulation group, in two resuscitated children with head injury and in five resuscitated babies dying of SIDS. Both parameters were observed exclusively in the asphyxiation/strangulation group (71% of the cases) but not in the control cases. Therefore, it can be concluded that the simultaneous appearance of conjunctival petechiae and of acute pulmonary emphysema strongly indicates death by asphyxiation.     

Cardiac hydatid cyst rupture as cause of death

Echinococcosis is a frequent parasitic human infection in sheep-farming areas. It is caused by the larval or the cyst stage of a tapeworm, mainly Echinococcus granulosis. Humans can be infected by ingesting tapeworm eggs, from which cysts will be developed mostly in the liver and the lung. Cardiac involvement of echinococcosis is rare and its clinical evolution is silent till the complication stage. A young adult died suddenly. The autopsy showed a ruptured hydatid cyst hollowed on the right side of the interventricular septum, protruding in the ventricle. The left pulmonary artery contained white-colored fragments of a membrane, similar to the one found in the right ventricle, associated to small vesicles. All these elements were obstructing this vessel, extending to small pulmonary arterial branches. Dissection of the other organs did not show other locations. Microscopic examinations ascertained the diagnosis of echinococcosis. Death was imputed to a right ventricular hydatid cyst rupture with pulmonary artery embolism.     

H5N1型禽流感病毒感染致死的病理组织学改变——附1例尸检报告

本文报导1例经病毒血清学检验确诊为H5N1型禽流感病毒感染致死的尸体，其病理学改变主要特征为肺泡腔面形成厚层均质红染物，肺泡间隔增宽，内有炎细胞浸润。我们认为其肺部组织学改变可以为H5N1型禽流感病毒感染致死的法医学鉴定提供佐证。