An autopsy case of miliary tuberculosis in a young adult

A 23-year-old woman who had worked as a hostess at a nightclub was found dead in her house. The cause of death was diagnosed as miliary tuberculosis from the findings of medico-legal autopsy. Recently, tuberculosis (TB) has re-emerged as a health problem due to recurrence in the aged, and infections among health care workers and young adults like the present case. Currently, the common source of TB transmission is recurrence in the aged, but global migration, difficulty to achieve permanent immunity by BCG vaccination, immunodeficiency such as HIV infection, and drug abuse and/or sexual intercourse are also thought to be associated with tuberculosis in young adults. Forensic pathologists should be aware of such connections with TB, and should take care not to become mediators of TB infections.     

Sudden death due to pulmonary aspergillosis

Sudden death due to respiratory pathology is not uncommon and tuberculosis with its complications is well known to cause death. We report a case of a male, train passenger, who started coughing out blood and died on reaching the hospital. Medicolegal autopsy confirmed the sudden unexpected death to be due to pulmonary aspergillosis in the person with past medical history of tuberculosis.     

Sudden death by laryngeal polyp: a case report and review of the literature

Sudden unexpected death in the context of bizarre or unusual behavior usually relates to acute drug intoxication or excited delirium. We report the case of a man who died suddenly while running naked on a public street. Although the initial death investigation was indicative of excited delirium or drug intoxication, autopsy revealed glottic obstruction by an inflammatory laryngeal polyp. Toxicologic studies were negative and investigation revealed presentation at a hospital the day before death with stridor. It is believed he developed airway obstruction while dressing at home and ran out on the street to find assistance. This case illustrates the importance of a thorough death investigation and a broad differential diagnosis when approaching a forensic autopsy.     

Tuberkulose

Due to a decline of tuberculosis infections in industrialized nations the disease has moved out of the line of focus. However, over 8 million people still get infected every year and multi-resistant mycobacteria have become more common. For autopsy staff the risk of infection is especially high due to the exposure to a high density of bacteria. Furthermore, the diagnosis of tuberculosis is often not known before a medico-legal autopsy. Thus, the mortuary staff carry a high degree of responsibility regarding the control of tuberculosis. Due to the decreasing number of tuberculosis infections in the western world, there is a lack of experience in case management in many medical institutions. This article focuses on aspects of protection from tuberculosis at autopsy and on the steps to be taken when reporting the cases to public health authorities and insurance companies according to German law.     

Prevalence of blood-borne infections in forensic samples: Epidemiology in areas of Chiba,Japan

ObjectivesTo statistically clarify the prevalence and risk factors of infections in forensic autopsy cases in Chiba Prefecture, Japan. The aim was to improve preventive measures against infection in forensic autopsies.MethodsWe retrospectively investigated the positive detection rates of five infections (hepatitis B, HBV; hepatitis C, HCV; human immunodeficiency virus, HIV; human T-lymphotropic virus, HTLV; Treponema pallidum, TP) using 1491 samples obtained in forensic autopsy at our facility from 2014 to 2018. In addition, risk factors related to infection such as methamphetamine and tattoos were analyzed. Pearson's chi-square test was used for statistical analysis, and the difference was judged to be significant at p < 0.05.ResultsAmong our samples, 9.0% of cadavers tested positive for infection, and the prevalence rates for HBV, HCV, HIV, HTLV, and TP were 1.0%, 6.7%, 0.3%, 0.7%, and 1.1% respectively. Statistically, cadavers linked to information about methamphetamine use had a 7.2 times higher rate of infection, and those with tattoos had a 5.6 times higher rate of infection, with HCV being the predominant cause.ConclusionsTo limit the risk of infection among autopsy workers, cadavers and samples should be handled on the presupposition that the bodies are at risk of infections. It is also important to obtain as much information as possible about the medical history and potential illegal drug use to help assess the risk of infection in a patient during forensic autopsy. We propose that all autopsy cases should be screened for infections whenever possible.     

Usefulness of postmortem computed tomography before forensic autopsy for alerting forensic personnel to tuberculosis infection

Since May 2009, we have performed multislice computed tomography (MSCT) prior to forensic autopsy for cases of suspicious death. In the present case, innumerable widely scattered nodules in both pulmonary fields on MSCT were indicative of miliary tuberculosis (TB). At autopsy, both lungs were submerged in formalin fluid immediately after removal from the body. Miliary TB was finally diagnosed based on microscopic findings. TB is a disease that autopsy room workers need to be aware of to protect themselves. Unfortunately, because little medical information about deceased individuals is usually available before forensic autopsy, the diagnosis of TB is frequently not made until autopsy. This leads to a much higher incidence of TB in autopsy room staff members even if they wear protective clothing. Therefore, MSCT before forensic autopsy may identify suspected cases of miliary TB in advance and thus help to prevent TB infection in forensic autopsy personnel.     

Rare fatal effect of combined use of sildenafil and alcohol leading to Cerebrovascular Accident

Sildenafil is the first internationally approved drug for erectile dysfunction. Unsupervised and non-prescribed use of sildenafil among young Indian population has increased in last few years. Sildenafil helps in erection of penis by inhibiting the action of Phosphodiesterase-5 (PDE-5) enzyme, present in the vasculature of corpus cavernosum muscle and lengthens the duration of erection. Documented adverse effects of sildenafil are headache, flushing, nasal congestion, dyspepsia, and slight decrease in systolic and diastolic blood pressure.We present a rare case of sudden death due to cerebrovascular hemorrhage after sildenafil use and concomitant alcohol intake. The history is that a 41-year-old male with no significant past medical and surgical history was staying at a hotel room with a female friend; he had consumed 2 tablets of sildenafil (50 mg each) and alcohol at night. Next morning, he developed uneasiness following which he was taken to the Hospital where he was declared dead on arrival. The important autopsy findings include edematous brain with about 300 g of clotted blood in the right basal ganglia extending to bilateral ventricles, and in pons region. Other significant findings on microscopic examination were hypertrophic ventricular wall of heart, fatty changes in liver and acute tubular necrosis and hypertensive changes in the kidney.The findings are discussed in the light of the literature about the lethal complications of combined use of sildenafil and alcohol including cerebrovascular accidents. As a forensic pathologist it is the duty of the doctor to execute meticulous autopsy along with ancillary investigations including toxicological analysis and to correlate all these findings to determine the possible effects of drugs when present, so as to gather knowledge about potentially fatal drugs and further create public awareness regarding the same.     

Sudden death due to massive hemoptysis secondary to pulmonary tuberculosis – A case report

Forensic pathologists deal not only with criminal, accidental and suicidal deaths, but also with a wide range of deaths from natural causes. Natural deaths at times can be sudden, unexpected and unattended by the relatives or friends or eye witnesses. In such cases, even though there is no criminal element in their causation, the case has to be investigated and medico-legal autopsy has to be conducted to know the exact cause of death, thus putting an end to the allegations raised. A 55-year-old male was found dead lying in his room in a pool of blood without any obvious injuries under suspicious circumstances with disturbed furniture in his room. The case was investigated due to suspicious circumstances of his death and absence of history of significant medical illness. The autopsy revealed the death was due to asphyxiation as a result of massive hemoptysis secondary to fibro-cavitatory tuberculosis.     

Tales from the grave: Opposing autopsy reports from a body exhumed

We report an autopsy case of a 42-year-old woman who, when discovered, had been dead in her apartment for approximately 1 week under circumstances involving treachery, assault and possible drug overdose. This case is unique as it involved two autopsies of the deceased by two different medical examiners who reached opposing conclusions. The first autopsy was performed about 10 days after death. The second autopsy was performed after an exhumation approximately 2 years after burial. Evidence collected at the crime scene included blood samples from which DNA was extracted and analysed, fingerprints and clothing containing dried body fluids. The conclusion of the first autopsy was accidental death due to cocaine toxicity; the conclusion of the second autopsy was death due to homicide given the totality of evidence. Suspects 1 and 2 were linked to the death of the victim by physical evidence and suspect 3 was linked by testimony. Suspect 1 received life in prison, and suspects 2 and 3 received 45 and 20 years in prison, respectively. This case indicates that cocaine toxicity is difficult to determine in putrefied tissue and that exhumations can be important in collecting forensic information. It further reveals that the combined findings of medical examiners, even though contradictory, are useful in determining the circumstances leading to death in criminal justice. Thus, this report demonstrates that such criminal circumstances require comparative forensic review and, in such cases, scientific conclusions can be difficult.     

Autoerotic accident associated with self-applied ketamine

We present a rare case of an autoerotic accident involving a fatal combination of asphyxia by suffocation and intoxication with self-administered intravenous ketamine. Of note in this case is the fact that the victim was an emergency medical technician. Ketamine causes complete analgesia with superficial unconciousness and amnesia called “dissociative anasthesia”. Futhermore low anaesthetic doses of ketamine induce alterations in mood, cognition and body image and the substance is an emerging drug of abuse. We discuss the death scene investigation, findings at autopsy and the toxicological report. Received: 23 May 2001 / Accepted: 9 October 2001     

Death by ‘ice’: fatal methamphetamine intoxication of a body packer case detected by postmortem computed tomography (PMCT) and validated by autopsy

Fatal acute methamphetamine (MA) poisoning in cases of internal drug trafficking is rarely described in the literature. This case study reports an MA ‘body packer’ who died from fatal methamphetamine intoxication due to leaking drug packages in the alimentary tract. The deceased was examined by postmortem computed tomography (PMCT), and the results were correlated to subsequent autopsy and toxicological findings. The deceased was arrested by the police when he was found disoriented in the city of Kuala Lumpur. He was transferred to the emergency department on suspicion of drug abuse. The initial drug screening was reactive for amphetamines. Shortly after admission to the hospital, he died despite rigorous resuscitation attempts. The postmortem plain chest and abdominal radiographs revealed multiple suspicious opacities in the gastrointestinal tract attributable to body packages. An unenhanced whole body PMCT revealed twenty-five drug packages, twenty-four in the stomach and one in the transverse colon. At least two were disintegrating, and therefore leaking. The autopsy findings were consistent with the PMCT results. Toxicology confirmed the diagnosis of fatal methamphetamine intoxication.     

Asphyxia in a confined space: a case report

We describe a death in a hospital wardrobe of a 40-year-old male suffering from HIV infection and lobar pneumonia. On the basis of circumstantial evidence and autopsy findings we conclude that the cause of death was asphyxia in a confined space as a result of several pathomechanical factors. As well as establishing the cause and manner of death, the interpretation of the case involves the evaluation of the professional responsibility of the medical personnel. This report discusses different aspects concerning the cause, mechanism, and manner of death and illustrates various problems encountered in forensic pathology.     

A case of medical liability involving an unexpected systemic amyloidosis

The authors present a case of fatal amyloid cardiomyopathy, which was diagnosed only upon autopsy. A 57-year-old man was admitted to the hospital for scheduled percutaneous cardiac procedure of transcatheter radiofrequency ablation due to persistent atrial fibrillation and atrial flutter. Ventricular fibrillation was recorded in the monitor 2 h after the surgical procedure. Therefore, he was defibrillated and intubated, but he died for nosocomial pneumonia 26 days after being admitted. A judicial autopsy was ordered by the prosecutor due to an alleged medical malpractice. The autopsy confirmed the cause of death being pneumonia, but also revealed an occult restrictive cardiomyopathy with a thick and firm myocardium. Viscera samples were then collected for microscopic examination. Histopathologic analysis showed diffuse amyloid deposits in the myocardium, especially in the perivascular and subendocardial spaces. Amyloid deposits were also detected in all the other organs, except for the brain. Furthermore, immunohistochemistry for light chains was performed on the heart tissue sample, resulting to be positive. In the case presented herein, autopsy and histopathologic examination were crucial to diagnose an occult systemic amyloidosis (AL-type). In fact, it has been observed that the rarity of systematic amyloidosis and its unusual clinical onset were at first mistakenly perceived as a medical malpractice due to a technical error within the catheter ablation for atrial fibrillation. As a consequence, upon discussing the clinical and medicolegal implications concerning the case, the focus was placed on the undiagnosed systemic amyloidosis and on the causality between surgical procedure and the patient’s death.     

Chronisch fibrosierende (sklerosierende) Peritonitis als Ursache des „plötzlichen“ Todes

We report a case of a 43-year-old male who died suddenly of sclerosing encapsulating peritonitis (SEP) after a short interval of acute abdominal pain and vomiting. He was diagnosed HIV-positive 10 years prior to death. Only one case of HIV-associated SEP has been reported in the literature. The cause of death was unclear until autopsy where small bowel obstruction and mechanical ileus due to an adhesive process, encapsulating the jejunum and ileum was discovered. Histological examination led to the diagnosis of peritonitis chronica fibrosa incapsulata, or sclerosing encapsulating peritonitis. The etiology of this disease remains unknown but the occurrence is associated with abdominal operations, inflammatory processes of the peritoneum and several drugs. The causes of sclerosing mesenteritis as well as the treatment with mostly immunosuppressive drugs is discussed. Prognosis differs and in this case it is remarkable that SEP evolved despite immunological deficiency due to HIV and medical treatment. Under full retroviral therapy with a low virus count, the man died a few weeks after the first symptoms of ileus caused by sclerosing encapsulating peritonitis.     

Sudden death during worker transportation due to massive pulmonary thromboembolism: a case report

This is a report on a 30-year-old black man who suddenly died in the worker transportation vehicle in which he had been quietly sitting for thirty minutes. No information about his medical or surgical history or any family history has been obtained. This case is intended to highlight the fact that forensic autopsy is a valuable tool to recognize the cause of death and that fatal pulmonary thromboembolism still remains a post-mortem diagnosis. In this case report, the autopsy found a fresh saddle pulmonary thromboembolus associated with partially organized thrombi of the inferior vena cava. Can a prolonged seated position encourage thrombus formation? We think that seat-related factors and especially patient-related factors intervene together in the development of thromboembolic events. In our medico-legal unit, having no means to search for these factors, we speculated on the various causes that could be involved in the occurrence of venous thromboembolism in our subject. We emphasize the importance of focusing research on genetic factors and the impact of traditional medicine in African people.     

Sudden death in a patient with idiopathic scoliosis

We report an autopsy case of sudden death in a 36-year-old craftsman with idiopathic scoliosis. The doctor identified his scoliosis at the age of thirteen, and he was under medical care for three years until he stopped consulting the doctor. He collapsed while walking at the station and was sent to an emergency room in cardiopulmonary arrest state, where he was declared dead in spite of more than an hour of CPR. Numbers of petechiae were seen on the bilateral palpebral conjunctivae and the lips were cyanotic. There were no particular injuries except for small abrasions observed on the face. The back showed right rib hump owing to midthoracic scoliosis (with 73 degrees of Cobb's angle) and right hemithorax was deformed showing an appearance of pectus excavatum in the front. The volume of the right thoracic cavity was significantly decreased. In the right lung, there was extensive stromal fibrosis, leaving almost no normal alveolar structures, and medial hypertrophy of pulmonary arteriolar walls. Hypertrophy of the right heart ventricle due to these pulmonary changes and the congestion of other organs suggested that the cause of death in this case was cor pulmonale due to pulmonary hypertension. This was a rare case of fatal outcome of advanced idiopathic scoliosis without medical care in spite of early detection through mass screening.     

Ibogaine related sudden death: A case report

Ibogaine is a naturally occurring alkaloid derived from the roots of the rain forest shrub Tabernanthe iboga. Deaths have occurred temporarily related to the use of ibogaine. However, although not licensed as therapeutic drug, and despite evidence that ibogaine may disturb the rhythm of the heart, this alkaloid is currently used as an anti-addiction drug in alternative medicine for detoxification purposes. We report the case of a man who died suddenly 12–24 h after ibogaine use for alcohol detoxification treatment. In the autopsy liver cirrhosis and heavy fatty infiltration was found. The concentration of ibogaine was 2 mg/l. The potential risks of ibogaine use, especially for persons with pathological medical background, are discussed.     

A case of fatal perimyocarditis due to a rare disease

Although myocarditis is caused by viral infections in about 50% of cases in European countries, various other causative agents are known. We report the case of a 51-year-old man who died several months after being diagnosed with asthma by his general practitioner. This diagnosis had been confirmed by a pulmonologist approximately 6 weeks before the man’s death. To rule out the possibility of medical malpractice the prosecuting authority ordered a forensic autopsy. At autopsy macroscopic indicators for perimyocarditis and pneumonia were found. Microbiological and histological examination of tissue samples confirmed a diagnosis of Churg-Strauss syndrome, also known as Eosinophilic Granulomatosis with Polyangiitis (EGPA). The cause of death was determined to be cardiac involvement in Churg-Strauss syndrome. The presence of this disease also accounted for the man’s recent medical history. There were no findings to indicate that a medical error had been made. The reported case illustrates why accessory histological and microbiological examinations should always be performed when macroscopic findings at autopsy suggest myocarditis. Determining the etiology of myocarditis is a necessary step to prevent overlooking rare diseases with inflammatory myocardial involvement, especially in the clarification of alleged medical malpractice.     

Nocardia osteomyelitis in the setting of previously unknown HIV infection

We present a case of primary Nocardia osteomyelitis in the setting of HIV infection. The clinical and radiographic manifestations of musculoskeletal nocardiosis are nonspecific and resemble those of Mycobacterium tuberculosis infection. To our knowledge no other cases of Nocardia osteomyelitis have been reported in the radiology literature.