Drowning versus postmortem submersion: Biochemical and histopathological examination and estimation of postmortem intervals (an experimental study)

Estimation of the postmortem interval (PMI) is a very essential task for forensic experts especially in criminal cases. drowning is still the most difficult tasks for forensic pathologists to be diagnosed and differentiated from a body disposed of in water following death especially after long post-mortem period. The objective of this study was to estimate the PMI in drowning in comparison to postmortem submersion using mRNA expression of AQP1 in addition to histological and immunohistochemical examination of caspase-3 in the adrenal and thyroid glands of adult albino rats. Adult albino rats were divided into 2 groups; group A (drowning) and group B (post-mortem submersion). Thyroid and adrenal glands were examined at different PMI. The results revealed significant differences at AQP1 levels between drowning and postmortem submersion at different PMI. Histological changes and caspase-3 expression immunologically in both glands were helpful.     

Feuerbestattungsleichenschau

Background

The external post-mortem examination of a corpse is an important task and errors can have serious medical, statistical and legal implications. In Germany death certificates issued on completion of such investigations form the source of population-based mortality statistics.

Methods

In a retrospective study 2,365 death certificates over a 6-month period were analyzed after an obligatory second external post-mortem examination of the corpse had been performed prior to cremation at the city of Essen crematorium. All these deaths were analyzed to ascertain the correctness and plausibility of the death certificates. The content of the death certificate was evaluated with respect to the findings of the second external examination.

Results

In 20.6% of cases unclear information had been given or severe errors made relating to the first external examination. In 4.5% of cases death was certified although no certain signs of death were recorded as being present. The term brain death was applied confusingly in 1.3% of cases. In a total of 277 cases (11.71%) the examining physicians stated that they had not investigated the corpses as thoroughly as legally required and in 1.1% of cases either no cause of death or insufficient information was given. In 26 cases the manner of death had been wrongly classified as“natural”, however, no previously unidentified murder cases were found. The autopsy rate was not surprisingly also very low (1.2%).

Conclusion

The quality of external post-mortem examinations of corpses in the Ruhr area around Essen needs to be improved as is known to be the case for Germany as a whole. The findings of this study demonstrate that in approximately 20% of all deaths severe errors occurred both while conducting the post-mortem examination and in filling out the death certificate. The best way to improve the mortality statistics and the quality of the first post-mortem examination of corpses in Germany is to significantly increase the frequency of autopsies.     

Limited post-mortem examination. An alternative and viable way to avoid full examination?

A complete post-mortem examination is required in most medicolegal investigation systems. Though uncommon, some jurisdictions allow limited post-mortem examination if it is adequate to fulfil the death inquiries. One such jurisdiction is the state of Queensland with the commencement of the new Coroners Act. It permits the Coroner to order limited post-mortem examination confined to a specific region or regions of the body based on the circumstances received from the investigating police. There is a paucity of literature comparing the completeness of limited post-mortem examination compared with complete examination. We aim to study whether limited post-mortem examination can partially replace complete examination in specific circumstances. Archival post-mortem reports with history are obtained. Cases where obvious complete post-mortem examination is required [e.g., sudden infant death syndrome (SIDS), homicide, medicolegal hospital cases, pregnancy deaths], decomposed and skeletonized cases are excluded from the study. The region or regions (head, neck, chest, or abdomen) most appropriate for examination are derived from studying the circumstances given. Three hundred and fifty-one cases were reviewed, of which 136 were found to be suitable to be incorporated into the study. Discrepancies were present in 17.7% (n = 24) of the cases (15 cases due to different cause of death, seven due to changes in interpretation, and two where pathology may be significant to the family). When classified according to mode of death, the percentages were 46.4%, 11.1%, and 9.3% for the accident, natural, and suicide groups, respectively. When compared to region examined, the discrepancies were 9 out of 18 for head, 1 out of 20 for neck, 5 out of 70 for chest, none of out 2 for extremities, and 3 out of 4 for abdomen. The study showed a significantly high percentage of discrepancies when limited post-mortem examination was performed. The missed information may impede medicolegal inquiries, police investigation, and interfere with the course of justice. Significant information about familial disease may be missed. Presented at the 18th International Symposium on the Forensic Sciences organised by the Australian and New Zealand Forensic Science Society (ANZFS) Fremantle, Western Australia, Australia 2–7 April 2006.     

Post-mortem MRI of the foetal spine and spinal cord

AIMS: To compare the findings of post-mortem magnetic resonance imaging (MRI) of the foetal spine with autopsy with a view to using post-mortem MRI as an alternative or adjunct to autopsy, particularly in foetal and neonatal cases. MATERIALS AND METHODS: The brains and spines of 41 foetuses, with a gestational age range of 14-41 weeks, underwent post-mortem MRI before autopsy. Post-mortem MRI of the brain consisted of T2-weighted sequences in three orthogonal planes and MRI of the spine consisted of T2-weighted sequence in the sagittal and axial planes in all cases and coronal planes in selected cases. RESULTS: Thirty of 41 (78%) foetal spines were found to be normal at autopsy and on post-mortem MRI. Eleven of 41 (22%) foetal spines were abnormal: eight foetuses had myelomeningocoeles and Chiari 2 deformities, one foetus had limited dorsal myeloschisis, one foetus had caudal regression syndrome, and one had diastematomyelia. The post-mortem MRI findings concurred with the autopsy findings in 10/11 of the abnormal cases, the disagreement being the case of diastematomyelia that was shown on post-mortem MRI but was not diagnosed at autopsy. CONCLUSIONS: In this series, post-mortem MRI findings agreed with the autopsy findings in 40/41(98%) cases and in one case the post-mortem MRI demonstrated an abnormality not demonstrated at autopsy.     

Three sudden deaths in men associated with undiagnosed chronic thyroiditis

Three cases of sudden death associated with undiagnosed chronic thyroiditis are described. All were young or middle-aged men who were found dead, and death appeared to have occurred suddenly. Two of them had not previously experienced any serious medical problems, the third suffered from well-controlled Addison's disease. None had been investigated or treated for thyroid disease previously. Microscopically all showed a severe chronic thyroiditis with parenchymal destruction and reactive hyperplasia of the acinar epithelium. In the first case elevated triiodothyronin (T3), thyroxin (T4) and low thyroid stimulating hormone (TSH) were present, in the second case low T3 and T4 and normal TSH, and in the third an isolated elevation of T3 were found. Anti-thyroid antibodies were found in two cases. The possible causal relationship between silent chronic autoimmune thyroiditis and sudden death is discussed.     

Diagnosis of fatal pulmonary fat embolism with minimally invasive virtual autopsy and post-mortem biopsy

We report a case of a 78-year-old female with a proximal femur fracture caused by an accidental fall who died suddenly 1 h after orthopaedic prosthesis insertion. Post-mortem computed tomography (CT) scan and histological examination of samples obtained with post-mortem percutaneous needle biopsies of both lungs were performed. Analysis of the medical history and the clinical scenario immediately before death, imaging data, and biopsy histology established the cause of death without proceeding to traditional autopsy. It was determined to be acute right ventricular failure caused by massive pulmonary fat embolism. Although further research in post-mortem imaging and post-mortem tissue sampling by needle biopsies is necessary, we conclude that the use of CT techniques and percutaneous biopsy, as additional tools, can offer a viable alternative to traditional autopsy in selected cases and may increase the number of minimally invasive forensic examinations performed in the future.     

Postmortale bakteriologische Diagnostik Entnahmetechnik,Untersuchungsmaterial, limitierende Faktoren,diagnostische Wertigkeit und Interpretation

The identification of bacteria can be of evidential value for the medico-legal expertise on the aetiopathogenesis to establish a causal relationship between infection (e. g. as a consequence of an accident, bodily harm, iatrogenic interventions) and fatal outcome. The most promising media for bacteriological cultures and reliable identification of bacteria are spleen and heart blood. In contrast, the results of post-mortem lung cultures are often unreliable due to false positives. As cultures from only one sampling site are of questionable diagnostic value, the collection of specimens from at least two different sampling sites should be the standard prodecure. Various factors such as the time interval between death and sampling of specimens for cultures, post-mortem distribution of microorganisms or antibiotic therapy prior to death may limit the diagnostic value of post-mortem culture results. However, in the majority of cases contamination of specimens originates from inadequate samping techniques, insufficient specimens for culture and use of incorrect transport media. In the majority of cases the contamination rate of post-mortem cultures increases when bowel manipulation occurs prior to sampling. Post-mortem contamination is also dependent on the anatomy of the sampling site and is often reflected in the occurrence of polymicrobial growth. Based solely on the outcome of post-mortem bacteriology, the proof of a local or systemic infection as the cause of death is difficult. Due to the fact that the correlation of histopathological and post-mortem bacteriological findings often leads to conclusive results concerning causality, micromorphological investigations should be performed in each case. Furthermore the previous history (as far as is known), autopsy findings, outcome of toxicological investigations and the detection of biochemical parameters of systemic inflammation must be included in the final interpretation.     

Forensic relevance of post-mortem CT imaging of the haemopericardium in determining the cause of death

The post-mortem diagnosis of pericardial tamponade is associated with several medical legal problems. Thus, we explored whether post-mortem computed tomography might provide useful and reliable information for the diagnosis of this relevant disease in combination with autopsy data.We retrospectively reviewed the post-mortem computed tomography and autopsy reports of 15 autopsy cases with haemopericardium detected at the Institute of Forensic Medicine in Berne from July 2005 to February 2010.Two computer tomography findings were examined in combination with autopsy results. The first was the “hyperdense armoured heart,” which has been previously described as post-mortem evidence of heart beating for a time after the initiation of intrapericardial bleeding. The second was the “flattening of the anterior surface” of the heart which has been previously observed in vivo as a sign of the compression effect of the haemopericardium on the heart.Our retrospective analysis showed the combined presence of both of these findings in all cases of autopsy evidence of pericardial tamponade with the exception of one case. In contrast, the concomitance of both of them was never observed in cases of autopsy death due to haemorrhage in which neither the flattening of the anterior surface of the heart was detected except for one case.In conclusion, these results should be considered a first step toward the potentially using post-mortem computed tomography in combination with autopsy data in the diagnosis of pericardial tamponade especially considering the possibility to detect sign as the flattened heart signal which cannot be assessed after opening the pericardium at autopsy.     

Discrepancies between clinical and post-mortem diagnoses of causes of death

Medical institutions unjustifiably 'walk in a fog of misplaced optimism', convinced of the accuracy of clinical diagnosis. They disregard the fact that the latest diagnostic research has not reduced the frequency of diagnostic inaccuracy. We reviewed the autopsy records from the archive of the Institute of Forensic Medicine of 921 decreased persons in 1997 and compared the clinical with the post-mortem diagnoses. Group 1 included cases of complete agreement between the clinical and post-mortem diagnoses, Group 2 cases of partial disagreement about the direct cause of death, Group 3 cases of disagreement about the basic illness, Group 4 cases of total disagreement between the clinical diagnosis and the post-mortem. Group 5 included cases of improper filling out of documentation according to the ABC international classification of diseases, injuries and causes of death, which has been accepted by the World Health Organisation in 10 revisions to date (WHO, 1992). The diagnoses were in total agreement in 48.87% of the cases, in partial agreement (disagreement about the direct cause of death) in 22.74%, and in disagreement about the basic illness in 13.5%. Of the cases, 9.68% were classified into Group 5.     

Post-mortem decapitation by domestic dogs: three case reports and review of the literature

Post-mortem animal depredation is not an uncommon phenomenon in routine forensic autopsies. We present three cases of complete post-mortem decapitation by domestic German shepherd dogs. In two cases, the head had been bitten off, defleshed and left lying near the body, while in one case it had been completely devoured by two dogs; only small skull fragments and crowned teeth could be found. Two of the three bodies were putrefied; all dog bite injuries had been inflicted after death. The cause of death was drug toxicity in two cases and fatal hemorrhage from ruptured esophageal varices in one case. These rare injuries due to post-mortem animal depredation are discussed in the light of earlier studies and case reports.     

External foam and the post-mortem period in freshwater drowning; results from a retrospective study in Amsterdam,the Netherlands

IntroductionDetermining the time of death of bodies recovered from water can be difficult. A feature of drowning is the presence of external foam. This study describes the presence of external foam in relation to the post-mortem period.MethodThe study utilizes a database of death reports dated between January 2011 and July 2016. For bodies recovered from fresh water, the presence or absence of external foam was noted.ResultsIn this study, 112 death reports are included. Of these reports, 18 mentioned external foam, which account for 16.1% of the entire study population. In the population with a post-mortem period of less than 24 h, external foam was detected in 27.7% of cases. All 18 incidents with external foam had an estimated post-mortem period of less than 24 h.ConclusionIn our study, external foam was only present in freshwater drowning cases with a post-mortem period of less than 24 h. Based on this finding, the presence of external foam may be useful as an additional indicator when estimating the time of death in freshwater drowning.     

Two forensic autopsy cases of death from unexpected lesions of the pituitary gland

Herein, we report the findings of 2 forensic autopsy cases, in which unexpected pituitary lesions were the underlying cause of death.Case 1: A 56-year-old woman was found dead at her home during a cold winter spell. Macroscopic autopsy findings included a difference in the color of blood that filled her left and right cardiac chambers (deep red and dark red, respectively), collapse of both lungs, atrophy of the thyroid gland, and a large tumor arising from the sella turcica. Microscopic examination revealed a pituitary adenoma along with extensive bleeding. The cause of death was considered to be hypothermia, resulting from dysregulation of thermogenesis due to the pituitary adenoma.Case 2: An 86-year-old man with a history of pollakiuria was found dead in a bathtub, with his face and chest submerged in bathwater and his legs positioned outside the bathtub. The macroscopic findings of the autopsy included hyper-inflated lungs, fluid collection in the thoracic cavity, and aspiration of gastric contents in the bronchi. The atherosclerotic changes of the man’s coronary and cerebral arteries were considered mild for his age. Microscopic examination showed a marked infiltration of lymphocytes and plasma cells in the posterior pituitary gland, as well as in the liver, pancreas, and submandibular gland. Considering the results of the autopsy and the findings from the investigation conducted at the death scene, we concluded that the man probably lost consciousness following a neurally mediated syncope, which was induced by diabetes insipidus (lymphocytic hypophysitis). After losing consciousness, the man likely fell in the filled bathtub and then drowned.These 2 cases highlight the need for a thorough post-mortem investigation, including a microscopic examination of the pituitary gland. In addition, forensic pathologists should carefully study the pituitary gland in cases where the cause of death is thought to be related to dysfunction of thermoregulation or osmoregulation.     

Micro computed tomography features of laryngeal fractures in a case of fatal manual strangulation

Cases of subtle fatal neck compression are often complicated by the lack of specificity of the post-mortem signs of asphyxia and by the lack of clear signs of neck compression.Herein we present a forensic case of a 45-year-old schizophrenic patient found on the floor of the bedroom of a psychiatric ward in cardiopulmonary arrest and who died after two days in a vegetative state. The deposition of the roommate of the deceased, who claimed responsibility for the killing of the victim by neck compression, was considered unreliable by the prosecutor.Autopsy, toxicological analyses, and multi-slice computed tomography (MSCT), micro computed tomography (micro-CT) and histology of the larynx complex were performed. Particularly, micro-CT analysis of the thyroid cartilage revealed the bilateral presence of ossified triticeous cartilages and the complete fragmentation of the right superior horn of the thyroid, but it additionally demonstrated a fracture on the contralateral superior horns, which was not clearly diagnosable at MSCT. On the basis of the evidence of intracartilaginous laryngeal hemorrhages and bilateral microfracture at the base of the superior horns of the larynx, the death was classified as a case of asphyxia due to manual strangulation.Micro-CT was confirmed as a useful tool in cases of subtle fatal neck compression, for the detection of minute laryngeal cartilage fractures, especially in complex cases with equivocal findings on MSCT.     

One small scan for radiology, one giant leap for forensic medicine - Post-mortem imaging replaces forensic autopsy in a case of traumatic aortic laceration

The questions of cause and manner of death are the most pressing ones in any forensic investigation. Traditionally, autopsy is the means to provide answers to these questions and despite the increasing use of CT and MR in the post-mortem setting, imaging has usually been an adjunct to forensic autopsy. Here we describe a case where post-mortem CT and MR were performed instead of autopsy, at the request of the responsible public prosecutor. The forensic conclusions derived from imaging, including cause and manner of death were accepted by the legal authorities, thereby setting precedence for future cases. This case represents a landmark in forensic medicine and is another step toward the full realization of minimally invasive forensic autopsy.     

Experiences with a compound method for estimating the time since death

The period since death was estimated at the scene in 72 consecutive cases using the temperature-based nomogram method as the primary method and supplemented by examination of criteria such as lividity, rigor mortis, mechanical and electrical excitability of skeletal muscle and chemical excitability of the iris. A case-oriented, computer-assisted selection of the non-temperature-based methods and integration of the results into a common result of the compound method was made following a special logistic. The limits of the period since death as estimated by the nomogram were improved in 49 cases by including the non-temperature-based methods and also provided results in 4 cases where the temperature method could not be used. In a further 6 cases the non-temperature-based methods confirmed the limits estimated by the temperature method but in 14 cases a useful result could not be obtained. In only one of the cases investigated was the upper limit of the period since death, as estimated by the criterion re-establishment of rigor (8 h post-mortem), in contradiction with the period determined by the police investigations (9.4 h post-mortem).     

Medico-legale Aspekte der (not-)ärztlichen Leichenschau

Between 2009 and 2012 (the evaluation period) 127,545 cases of death were registered in Berlin, while 111,457 cases were registered in Brandenburg (239,002 cases total). A death certificate (in accordance with the burial laws of Berlin and Brandenburg) had to be issued by a physician for each of the deceased.Due to the legislative powers of the federal states of Germany, each state bears responsibility for regulating burial and post-mortem examination laws. Thus, there are significant differences between Berlin and Brandenburg’s burial and post-mortem examination laws.Unfortunately, an unknown number of death certificates were issued by EMS emergency physicians. EMS emergency physicians are often caught in a conflict of obligations between their guarantor position (to save the patient’s life and health), the police and criminal investigation department’s possible interests, and the health authority’s interests. These conflicts might eventually lead to fine/penalty proceedings with the health authority.To determine the relevance of fine/penalty proceedings, all 12 local health authorities in Berlin and 18 local health authorities in Brandenburg were asked to complete a structured questionnaire regarding fine/penalty proceedings in the context of post-mortem examinations and/or the issuance of death certificates between 2009 and 2012.Within the evaluation period, only 15 fine/penalty proceedings were conducted (nine in Berlin and six in Brandenburg), which equals 0.0062?% of all cases of death in Berlin and Brandenburg. Serious shortcomings regarding post-mortem examinations were not found in this study, as only one emergency physician was affected in each state.Our results show that the emergency physician’s fear of being subjected to legal action due to incorrect certificates of death is currently minor.Nevertheless, the study in part revealed serious structural issues in regard to the execution of post-mortem examinations. It also shows that fine/penalty proceedings are not an appropriate means to assure quality, as health authorities can usually only formally review death certificates.     

Serum procalcitonin (PCT): a valuable biochemical parameter for the post-mortem diagnosis of sepsis

The aim of this prospective study was to investigate whether serum procalcitonin (PCT) can be used as a post-mortem marker of sepsis and to determine whether this biochemical parameter can be employed in the forensic elucidation of death due to sepsis. At least three blood samples were collected between 0.3 and 139 h post-mortem from sepsis-related fatalities (n = 8) and control individuals (n = 53, where death was due to various natural and unnatural causes). Additionally one ante-mortem blood sample was collected shortly before death from the patients in the sepsis group. In the sepsis group, serum PCT concentrations, determined by using an immunoluminometric assay, were elevated in all patients for the whole observation period, whereas in the control group serum PCT was not detectable in 94% of the cases. Measurement of PCT levels seems reasonable until at least approximately 140 h postmortem, depending on the ante-mortem levels. A linear regression model is presented that allows the serum PCT concentration of an individual at the time of death to be estimated on condition that at least two positive post-mortem PCT values have been determined. Ante-mortem PCT values correlated well with the predicted PCT values at the time of death in the sepsis group using the standardized PCT logarithms. According to the results of the present study, PCT is a valuable biochemical parameter for the post-mortem discrimination between sepsis and underlying non-septic causes of death. Received: 29 March 2000 / Accepted: 12 June 2000     

Virological investigations in sudden unexpected deaths in infancy (SUDI)

Previous studies have implicated viral infections in the pathogenesis of sudden unexpected death in infancy (SUDI), and routine virological investigations are recommended by current SUDI autopsy protocols. The aim of this study is to determine the role of post-mortem virology in establishing a cause of death. A retrospective review of 546 SUDI autopsies was carried out as part of a larger series of >1,500 consecutive paediatric autopsies performed over a 10-year period, 1996–2005, in a single specialist centre. Virological tests were performed as part of the post-mortem examination in 490 (90%) of the 546 SUDI autopsies, comprising 4,639 individual virological tests, of which 79% were performed on lung tissue samples. Diagnostic methods included immunofluorescence assays (using a routine respiratory virus panel; 98% of cases), cell culture (61%), rapid culture techniques such as the DEAFF test for CMV (55%), PCR (13%), electron microscopy (10%), and others. Virus was identified in only 18 cases (4%), viz. five cases of enterovirus, four of RSV, three of HSV and CMV, and one each of adenovirus, influenza virus and HIV. In seven of the 18 cases the death was classified as due to viral infection, whilst of the remaining 11 cases, death was due to bacterial infection in five, a non-infective cause in one and unexplained in five. Virus was identified in 33% of deaths due to probable viral infections, but also in 6% of SUDI due to bacterial infections, and in 2% of SUDI due to known non-infective causes and unexplained SUDI. When predominantly using immunofluorescence, virus is identified in only a small proportion of SUDI autopsies, resulting in a contribution to the final cause of death in <2% of SUDI post-mortem examinations. Routine post-mortem virological analysis by means of an immunofluorescence respiratory virus panel appears to be of limited benefit in SUDI for the purposes of determining cause of death. Application of a broader panel using more sensitive detection techniques may reveal more viruses, although their contribution to the final cause of death requires further exploration.     

The role of post-mortem CT (PMCT) imaging in the diagnosis of pericardial tamponade due to hemopericardium: A case report

Hemopericardium (HP) is frequently found at autopsy, but it represents a challenge for the forensic pathologist when having to assess its etiopathological relationship in causing death, particularly in those cases where ante-mortem clinical and instrumental data are not available. The diagnosis of pericardial tamponade (PT), in fact, is based on signs, symptoms and instrumental evidence and not only on the presence of HP. Post-mortem imaging techniques are actually considered a useful and non-invasive method able to enhance traditional procedures in demonstrating critical forensic findings; consequently, post-mortem imaging methods have been widely introduced in forensic investigations. We report a case of death clearly due to PT caused by ruptured dissected aneurysm of the aorta, submitted to post-mortem CT (PMCT) and PMCT angiography prior to autopsy. PMCT imaging permitted to solve the case without performing autopsy.In the paper we identify PMCT findings suggestive of PT with the aim of verifying the possibility to use post-mortem evidence to retrospectively demonstrate an in vivo dynamic clinical condition, such as PT.     

Sudden adult death: a medico-legal series of 77 cases between 1995 and 2000

Among all the autopsies performed between 1995 and 2000 in our Department, 77 adult cases of sudden death were selected. Sex, age, place of death, circumstances of death, causes of death and heart weight were reported from these 77 post-mortem records. A complete forensic autopsy was performed in every case. Sudden death occurred more frequently in males at rest. Strenuous activity was rarely involved in sudden death and 72.7% of the cases died from cardiovascular disease, mainly coronary atherosclerosis. Non-cardiac causes were dominated by pulmonary and neurological diseases. Cardiomegaly was a frequent finding in cases who died from cardiac pathology. This study underlines the importance of complete medico-legal investigations in case of sudden death. Multiple heart samples are required in order to detect focal microscopic lesions, such as myocarditis and some forms of cardiomyopathy with minimal gross abnormalities. The post-mortem diagnosis of such cardiomyopathies is very important because the family of the deceased may undergo a possible screening. Toxicology is useful in the diagnosis of epileptic seizure and in identifying drugs like metamphetamine as a risk factor for some lethal cardiovascular pathologies such as aortic dissection. Molecular biology can also be helpful when limits of morphological diagnosis have been reached.