Fatal retropharyngeal abscess: a possible marker of inflicted injury in infancy and early childhood

Retropharyngeal abscesses are serious infections of the deep tissues of the neck associated with significant morbidity and mortality due to their proximity to vital structures. The most common age range is 2–4 years, with neonates accounting for approximately 10% of cases. The following report demonstrates possible forensic issues that may arise in such cases. Case Report: A 10-week-old infant was found dead in her father’s arms an hour after feeding. At autopsy death was due to a large retropharyngeal abscess with disseminated Streptococcus pneumoniae sepsis. Other findings at autopsy of bruising and multiple fractures of the ribs and limbs indicated inflicted injury; this raised the possibility that the abscess had arisen from forceful foreign body insertion into the pharynx. The mortality and complication rates of retropharyngeal abscess remain high even with the institution of appropriate treatment; however, the wide variety of presentations often causes delays in diagnosis and treatment. When found at autopsy in infants and children the possibility of inflicted injury should be considered.     

Two autopsy cases with injuries to the stomach following cardiopulmonary resuscitation

We herein report two autopsy cases with gastric injury associated with cardiopulmonary resuscitation (CPR). Case 1 was a 36–year–old woman who was found in cardiopulmonary arrest possibly caused by a fall from a height of 8 m. She received continuous manual chest compression with artificial ventilation while being transferred to the hospital. Autopsy revealed bruises on her left upper arm with a fracture to the left humerus and advanced pneumohemothorax that was associated with laceration of the left lung due to fracture of the dorsal left costa. Furthermore, complete rupture of the gastric wall (25 cm) was found without hemorrhage. Case 2 was an 85–year–old man found unconscious on the road. He had a history of oral anticoagulant administration, cognitive impairment, and gait disorder. He also received cardiac massage and manual artificial ventilation during CPR. Autopsy revealed severe head injury, possibly caused by a backward fall. His stomach was markedly dilated by air and a fresh intramural hematoma had extended into all layers of the stomach and adjacent omentum; however, injury of the abdominal wall was not evident. Histopathological investigation of the brain revealed advanced Alzheimer’s disease and Lewy pathology, and the damaged neural tissue, which was positive for the amyloid precursor protein. We determined that the gastric injuries in both cases had been caused by CPR. We conclude that careful investigation is required for gastric injury cases to determine the etiology and correlation between gastric injury and cause of death when the victims receive CPR.     

Sudden death victims <45 years: Agreement between cause of death established by the forensic physician and autopsy results

PurposeThe goal of this study was to ascertain accordance between cause of death established by the forensic physician and autopsy results in young sudden death victims in the Netherlands.MethodsSudden death victims aged 1–45 years examined by forensic physicians operating in the participating regions which also underwent an autopsy between January 2006 and December 2011 were included (n = 70). Cause of death established by the forensic physician based on the external medicolegal examination was compared with autopsy findings using the ICD10-classification.ResultsAutopsy findings revealed that the majority of sudden death victims have died from a cardiac disease (n = 51, 73%). Most of the presumed heart disease related cases were confirmed by autopsy (n = 13, 87%). On the contrary, a large number of deaths caused by circulatory diseases were not recognised by the forensic physician (n = 38, 75%). In most of these cases, the forensic physician was forced to report an undetermined cause due to the lack of a solid explanation for death. Cause of death reported by the forensic physician appeared to be in agreement with the autopsy results in 12 cases (17%).ConclusionsCause of death determination in young sudden death victims is a difficult task for forensic physicians due to the limited tools available during the medicolegal examination. An effort should be made to standardize extensive post-mortem investigation after sudden death in the young. Autopsy can provide valuable information regarding the cause of death, which is of great importance in view of the identification of inheritable diseases among decedents and their families.     

An autopsy case of a homeless person with unilateral lower extremity edema

We present an autopsy case of a homeless person showing remarkable unilateral lower extremity edema, which was strongly associated with the cause of death. A 55-year-old homeless man without any past medical history was found dead in a flophouse. External examination showed evidence of malnourishment and remarkable swelling of the right, lower extremity. Putrefactive discoloration in the same area was evident at the time of autopsy (approximately 30 h post-mortem). The autopsy revealed focal pneumonia in the right lower lobe, dehydration and chronic pancreatitis. Dissection of the edematous extremity revealed massive abscess formation in the subcutaneous tissue and superficial fascia around the right knee joint. Histopathological findings were compatible with necrotizing fasciitis and blood chemistry results showed an elevation of HbA1c (6.3%). The cause of death is considered to be necrotizing fasciitis and secondary pneumonia/dehydration. This case suggests that necrotizing fasciitis should be differentiated during postmortem diagnosis, especially in cases showing lower extremity edema with early putrefactive changes. In addition, forensic pathologists should closely examine a lower extremity of such cases to detect a true cause of death, even if other pathological findings which can be a cause of death, such as pneumonia and dehydration, are observed in major internal organs.     

Multiple injuries in suicide simulating homicide: Report of three cases

Multiple inflicted injuries in traumatic deaths usually indicate homicide. Three cases are reported where homicide was initially suspected due to findings at the death scene and the apparent nature of the injuries however, after investigation, involvement of any other individuals in the deaths could be excluded. Case 1: A 52-year-old male was found with multiple stab wounds. At autopsy, 36 stab wounds were identified, the majority of which were superficial. Only two stab wounds had penetrated deeply. Case 2: A 19-year-old female was found with three gunshot entry wounds to the right temple and a .22 calibre automatic rifle resting across her lap. Case 3: A 47-year-old female was found with numerous haematomas and three deep head wounds in keeping with trauma from impact with a blunt object. A high level of clozapine was detected on toxicological analysis of blood and a history of schizophrenia was reported. Although multiple self-inflicted wounds are most often caused by sharp objects such as knives, on occasion multiple gunshot wounds and rarely, blunt trauma may also be encountered. Careful integration of scene and autopsy findings may be required to avoid misinterpretation of the circumstances and manner of death.     

Sudden unexpected neonatal death due to late onset group B streptococcal sepsis—A case report

We report a case of sudden unexpected death due to late onset neonatal group B streptococcal sepsis. A male neonate weighing 2731 g was born at 35 week gestational age, and discharged at the age of 4 days after the birth. At 6 days after the discharge (10 days after the birth), because of consciousness loss and hypothermia, the neonate was conveyed to an emergency hospital, eventually followed by his death. Forensic autopsy revealed neither severe trauma nor cardiac anomaly. Both lungs were edematous. Histopathologically, a lot of bacterial clusters were found in the lungs and intracerebral vessels. Cerebrospinal fluid contained a lot of leukocytes. Streptococcus agalactiae was detected in the specimens from the feces and the blood. Collectively, we diagnosed that the cause of the neonate’s death was late onset group B streptococcal sepsis. In autopsy cases of neonates, careful macroscopic and microscopic observations and bacteriological/virological examination should be performed.     

Fatal aortobronchial fistula

Aortobronchial fistula is a rare condition characterized by the development of a communication between the aorta and a branch of the bronchial tree that results from processes that arise within the aorta, in the tissues of the mediastinum, or in the adjacent thoracic organs. Three cases are reported to demonstrate characteristic features. Case 1: An 82-year-old woman was found collapsed with blood clot in her mouth. At autopsy an atherosclerotic thoracic aortic aneurysm was found which had eroded into the underlying left main bronchus with filling of the larynx, trachea and main bronchi with fluid blood. There was no evidence of dissection. Case 2: A 30-year-old woman collapsed and died. At autopsy, coarctation of the thoracic aorta was found with a saccular aneurysm distal to this which was joined to the left main bronchus by a mass of necrotic tissue. The bronchus contained a cast of blood; blood was also present within the trachea and within the distal airways of the left lung. Case 3: A six-year-old girl collapsed with massive airway haemorrhage following bronchoscopy. At autopsy coarctation of the thoracic aorta was identified with a saccular aneurysm distal to this. A transverse tear of the thinned aneurysm wall communicated with a mass of necrotic friable tissue that extended through the wall of the left main bronchus. Distal airways were filled with fluid blood. All three deaths were due to haemorrhage from aortobronchial fistulas. The pathogenesis of aortobronchial fistulas involves a variety of mechanical, infective and neoplastic processes. Many cases will not be diagnosed until autopsy examination is performed.     

Accidental death of elderly persons under the influence of chlorpheniramine

Older individuals are susceptible to accident, such as falls, some of which are fatal. In such cases, autopsies and toxicological analysis may be deemed unnecessary, especially if the critical injuries and manner of death can be determined conclusively based on information at the scene and an external investigation. Here, we report the results of two autopsies performed on elderly individuals who died accidentally under the influence of chlorpheniramine. These autopsies revealed valuable additional information.Case 1: A woman in her 70s, who was living alone, was found dead under the stairs in her house. She had no history of a condition that could have led to sudden death. The autopsy revealed a neck fracture, multiple rib fractures, and a coccyx fracture. The histopathological findings showed fat embolisms in numerous small vessels of the interalveolar septum. Toxicological analysis of blood samples revealed the presence of chlorpheniramine (0.41 μg/ml).Case 2: A woman in her 70s, who was living alone, was found dead in the bathtub in her house. There was no past medical history other than diabetes mellitus and vertigo. The autopsy revealed hyper-inflated lungs and brown–red fluids in the trachea, but there was no evidence of a pathology or injury that could have induced a loss of consciousness. Toxicological analysis of the fluids in the right thoracic cavity revealed the presence of chlorpheniramine (0.57 μg/ml).In both cases, re-examination of the scene after the autopsy revealed the presence of common cold medicine containing chlorpheniramine. The victim may have accidentally overdosed on common cold medicine. This overdose would have been compounded by anti-histamine-induced drowsiness. The present cases suggest that forensic pathologists should always notify physicians/pharmacists of findings pertaining to unexpected drug side effects. Such intervention would prevent many accidental deaths. In addition, each autopsy must be performed in conjunction with a detailed postmortem investigation. Such efforts would also increase the accuracy of the public health record’s mortality statistics.     

A fatal case of intoxication from a single use of eutylone: Clinical symptoms and quantitative analysis results

Eutylone is a synthetic cathinone that is becoming an increasingly popular drug in the US and Europe. This report describes a fatal case of eutylone intoxication. A 32-year-old man went into cardiac arrest after several minutes of abnormal behavior. Rectal temperature was 37.0 °C at 5 h after death. Autopsy revealed no remarkable injuries apart from several small abrasions and no signs of rhabdomyolysis. Toxicological examination revealed only aripiprazole in the therapeutic range and eutylone. The eutylone concentration in cardiac blood was 4290 ng/g. This case is valuable because it involved fatal intoxication from a single use of eutylone and quantitative analysis, whereas most previous reports of eutylone intoxication have involved a mixture of drugs with limited quantitative analysis.     

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.     

Post-mortem CT findings following intentional ingestion of mercuric chloride

Mercury is known to be associated with both acute and chronic poisoning. A 36-year-old man intentionally ingested mercuric chloride (HgCl₂) and died within 24 h. Post-mortem CT images showed oral, esophageal and gastric wall hyperdense “staining”. On toxicological analysis, the blood concentration of mercury was measured at 25.5 mg/L; a figure far higher than reported lethal levels. Autopsy was not performed in order to prevent potential inhalation of mercury vapor by pathology staff.     

A rare case of steering wheel injury causing coronal-plane pancreatic lacerations

The incidence of pancreatic injury after blunt abdominal trauma is extremely low. A timely and accurate diagnosis is important, as a delay could be life-threatening. In this case, a 70-year-old driver crashed a car into a concrete wall at low speed. He was transported to the emergency hospital but died about 9.5 h later with the cause of death unknown. An autopsy revealed that his pancreas was lacerated in the coronal plane and there was mesenteric contusion. Cause of death was determined to be blood loss resulting from pancreatic and mesenteric contusion. The mechanism of the injury was considered to be a very rare “degloving,” caused by the impact from the steering wheel. It is therefore important to keep in mind possible pancreatic damage when examining blunt trauma to the abdomen, especially in traffic accident cases.     

Endocan measurement for the postmortem diagnosis of sepsis

The vascular endothelium has been shown to play a pivotal role in the pathophysiology of sepsis through the expression of surface proteins and secretion of soluble mediators. Endocan (endothelial cell-specific molecule-1), a 50-kDa dermatan sulfate proteoglycan, is expressed by endothelial cells in lung and kidney and can be detected at low levels in the serum of healthy subjects. Increased concentrations were described in patients with sepsis, severe sepsis and septic shock compared to healthy individuals, with serum concentrations related to the severity of illness. In the present study, we investigated endocan, procalcitonin and C-reactive protein in postmortem serum from femoral blood in a series of sepsis-related fatalities and control individuals who underwent medicolegal investigations. Endocan was also measured in pericardial fluid. Two study groups were prospectively formed, a sepsis-related fatalities group and a control group. The sepsis-related fatalities group consisted of sixteen forensic autopsy cases with documented clinical diagnosis of sepsis in vivo. The control group consisted of sixteen forensic autopsy cases with various noninfectious causes of death. Postmortem serum endocan concentrations were significantly higher in the sepsis group, with values ranging from 0.519 ng/ml to 6.756 ng/ml. In the control group, endocan levels were undetectable in eleven out of sixteen cases. The results of the data analysis revealed similar endocan concentrations in the pericardial fluid of both studied groups. Endocan can be considered a suitable biological parameter for the detection of sepsis-related deaths in forensic pathology routine.     

Tonsillitis and sudden childhood death

Critical reduction in upper airway diameter may result from tonsillar enlargement due to infection or from associated abscess formation. Other potentially lethal complications include hemorrhage and disseminated sepsis. Two cases are reported to illustrate features of specific cases: Case 1: a 12-year-old girl who exsanguinated from a pharyngocarotid fistula caused by a retropharyngeal abscess due to acute tonsillitis, and Case 2: a 17-year-old girl who asphyxiated from an aspirated blood clot following tonsillectomy. While most cases of acute tonsillitis resolve without sequelae, occasional cases may be associated with a lethal outcome. Massive hemorrhage may occur due to erosion of tonsillar vessels or subjacent larger vessels, or it may follow surgical extirpation of the tonsils. The autopsy assessment of cases where there has been possible lethal tonsillar pathology requires review of the presenting history and possible operative procedures, with careful dissection of Waldeyer's ring, adjacent soft tissues and major vessels. Presentations may not be straightforward and there may be misleading histories of epistaxis, hemoptysis, hematemesis and even melena.     

Differentiation of antemortem pulmonary thromboembolism and postmortem clot with unenhanced MRI: a case report

We report a case of a 39-year-old woman who died of fulminant pulmonary thromboembolism (PE). Autopsy showed classical findings of fulminant PE with occlusion of the bilateral main stem pulmonary arteries. Ancillary testing revealed inherited thrombophilia (Prothrombin 20,210 G?>?A and MTHFR 677 C?>?T mutation). Pre-autopsy postmortem computed tomography was used to test whether virtual imaging studies alone (virtual autopsy) would be sufficient to detect PE. Our studies show that computed tomography (CT) can differentiate antemortem clots from a postmortem clot in certain cases, particularly when combined with magnetic resonance imaging (MRI), which is superior in the assessment of soft tissue. We show that postmortem CT and MRI can aid in the diagnosis of pulmonary embolism by virtual autopsy, especially when used in conjunction.     

Fatal postoperative malignant hyperthermia following rhinoplasty in a patient with one variant of the ryanodine receptor 1 (RYR1) gene

Malignant hyperthermia (MH) is characterized by a rapid rise in body temperature after using inhalational anesthetics and depolarizing muscle relaxants. A 19-year-old female had a rapidly developing fever up to 43.0 °C, after rhinoplasty surgery. Inhalational anesthetics and depolarizing muscle relaxants were used in general anesthesia. It was suspected that the patient died of MH. The medico-legal autopsy findings showed classical MH histopathological changes in the skeletal muscles, cardiac muscles, as well as lungs. Additionally, postmortem blood biochemical results indicated rhabdomyolysis. A combination of clinical records and autopsy revealed that MH might have caused the death. A diagnostic genetic testing was performed to confirm the existence of MH, and an MH diagnostic variant RYR1 c.7048G >A (p. A2350T) was detected. Eventually, the cause of death was determined as MH based on clinical records, autopsy, and genetic analysis. This case highlights that diagnostic genetic analysis plays a vital role in postmortem diagnosis of MH in routine medico-legal contexts.     

Self-induced hemopericardium using a syringe needle: A rare method of suicide

This communication highlights a rare case of suicide by self-induced hemopericardium caused by a penetrating syringe needle. A 20-year-old male, diagnosed with ulcerative colitis, severe depression and hypochondriasis, was found dead at home. There was a 23-gauge 3 cm long syringe needle, connected to a 3 cc barrel, penetrating the left side of the chest. Autopsy revealed 3 fresh puncture marks on the left side of the anterior chest with subcutaneous hemorrhage underlying the puncture marks. The needle had penetrated through the 4th intercoastal space and entered the pericardial cavity causing superficial lacerations to the anterior wall of the heart. There were two anterior pericardial perforations. A hemopericardium of 235 ml was noted. Interventricular septal branches arising from the lower half of the left anterior descending artery were lacerated. Microscopy revealed multiple fresh hemorrhages into the myocardium at the site of myocardial injuries. Toxicological analysis of blood, urine and swabs from the syringe barrel was negative. The cause of death was given as hemopericardium due to laceration of the interventricular septal branches of the left anterior descending artery due to penetration by a 23-gauge syringe needle. The circumstance was concluded as suicidal. Suicide by stab to the chest using a 23-gauge syringe needle, resulting in hemopericardium where the source of blood was the coronary artery, has not been reported in the medical literature. A forensic pathologist must be vigilant and cautious in the interpretation of similar findings especially when cardiopulmonary resuscitation and/or therapeutic intracardiac injections have been administered.     

A case of fatal benzalkonium chloride poisoning

Five elderly persons with senile dementia accidentally ingested Hoesmin, a 10% aqueous solution of benzalkonium chloride (BAC). The condition of one patient, an 84-year-old woman whose lips and oral cavity became erythematous, gradually deteriorated. Although gastric lavage was performed, the patient died 3 h after ingestion of Hoesmin. Autopsy revealed corrosive changes of the mucosal surfaces of the tongue, pharynx, larynx, esophagus and stomach which may have come in contact with BAC. In addition, BAC was detected in the serum. We conclude that the patient died of BAC poisoning. Fatal BAC poisoning is rare and autopsy findings in only a few cases of BAC poisoning have been reported. Our findings emphasize the risk of oral ingestion of BAC. Received: 11 August 1997 / Received in revised form: 10 December 1997     

Autopsy case of a patient with 13q− syndrome

Partial deletion of the long arm of chromosome 13 results in 13q^? syndrome, and phenotypes of affected patients vary widely. We describe an autopsy case of the sudden, unexpected death of a 17-year-old boy with 13q^? syndrome. He had severe psychomotor retardation and had been receiving follow-up care. One day he was found dead in his house and autopsy was performed to elucidate the cause of death. Autopsy findings revealed lobulation anomalies of the lungs, hypoplasia of the adrenal and thyroid glands, and apituitarism due to hyperplasia of bone in the hypophyseal fossa. No other pathological lesions were observed. Chromosomal analysis confirmed interstitial deletion from the long arm of chromosome 13. Karyotype was 46,XY, del(13)(q14.3q32). We concluded that the patient died of multi-organ dysfunction due to apituitarism. Autopsy cases of 13q^? syndrome are rare. Furthermore, lobulation anomalies and apituitarism associated with 13q^? syndrome have not previously been described. This case report offers novel clues to elucidating critical regions of chromosome 13 associated with malformations of the lungs and pituitary gland.     

Fatal influenza A infection with<Emphasis Type="Italic"> Staphylococcus aureus</Emphasis> superinfection in a 49-year-old woman presenting as sudden death

A fatal case of influenza A infection with Staphylococcus aureus superinfection in a previously healthy 49-year-old woman presenting as sudden, unexpected death is reported. Autopsy revealed severe necrotizing tracheobronchitis and hemorrhagic pneumonia. Microscopic examination of the trachea and bronchi showed mucosal necrosis and a dense lympho-monocytic infiltration of all layers. The lungs showed focal hemorrhagic pneumonia. No pathological changes were detectable in the myocardium. Influenza A virus was detected in bronchi and lung samples obtained during autopsy by the polymerase chain reaction (PCR) and bacterial superinfection with Staphylococcus aureus was shown by culturing from tracheal, bronchial and pulmonary swabs obtained during autopsy. PCR assays for the detection of Panton-Valentine leukocidin performed from all samples were negative. This case demonstrates the need for an interdisciplinary approach towards an organism-specific diagnosis of potentially infection-related deaths undergoing a medico-legal autopsy. With improved diagnostic possibilities such as PCR and DNA sequencing, forensic pathologists can, in close association with the field of microbiology, make a significant contribution to the detection of highly infectious agents which must be notified to the authorities. This will increase particularly the knowledge about the influence of these agents on sudden, unexpected deaths in outpatients.