Fulminant sepsis due to anaerobic bacterial infection in immuno-compromised state

We experienced two autopsy cases of fulminant sepsis due to anaerobes. Case 1: A 67-year-old female with uncontrolled diabetes mellitus (DM) was admitted to a hospital because of sudden onset of mid-abdominal pain. She was diagnosed with infectious colitis and given a laxative and an enema. However, 9 h later, her blood pressure suddenly dropped with metabolic acidosis, and she died 20 h after admission. Autopsy revealed massive pneumohemia and a dark-brown colored mucosal surface from the terminal ileum to the sigmoid colon. Histopathological findings were compatible with marginal ischemic colitis. Anaerobes were positive in blood culture. Case 2: A 53-year-old male with alcoholic liver cirrhosis (LC) was found dead in his room. He had been alive 24 h before the discovery, but postmortem changes appeared to accelerate more rapidly than usual cases. Autopsy revealed severe LC with muddy ascites and many Gram-negative rods in several organs. These cases suggest the possibility of sepsis as causes of death, especially in immuno-compromised hosts when unexplained putrefactive changes are seen on forensic autopsy.     

Death attributed to amobarbital and levomepromazine intoxication

A 29-year-old man, possibly a schizophrenic patient, was found dead 9 h after admission to a hospital. Autopsy revealed neither significant injuries nor diseases except for congestion of all organs. Microscopic examination revealed severe edema in the lung and slight centrilobular necrosis in the liver. Since amobarbital and levomepromazine were detected by drug screening, the concentrations of these drugs in the victim's body fluids and tissues were determined using gas chromatography-mass spectrometry. The whole blood concentrations of amobarbital and levomepromazine were 9.02 microg/ml and 231 ng/ml, respectively. These levels exceeded therapeutic ranges, but are not so toxic or fatal. However, on the basis of the findings in the literature and of the severe lung edema and centrilobular necrosis in the liver, the cause of his death was judged to be amobarbital and levomepromazine intoxication.     

Sexual asphyxia by hanging--a case report and a review of the literature

A case of sexual asphyxial death by hanging is presented. A 35-year-old male, found dead lying on his face in a bed of a truck cab, had hanged himself from a window frame using a leather belt. He was completely naked. There were pornographic and sadomasochistic magazines beneath his face, opened to pages depicted nude photographs of a woman. Autopsy findings revealed a ligature mark on the neck and petechial hemorrhages in the conjunctivae, but there were no hemorrhages in the neck muscles or fractures of the hyoid bone or the thyroid cartilage. The alcohol levels in the blood and urine were 0.78 and 0.45 mg/ml, respectively. The circumstances suggested that his death was accidental, and due to asphyxia by hanging performed to enhance sexual gratification during masturbation. Sexual asphyxia is reviewed and discussed.     

Fatal intoxication with naftidrofuryl

A 52-year-old man was found dead in his bed. He had financial and psychosocial problems like separation from his wife and children or unemployment due to alcoholism. Under treatment of disulfiram he was presently abstinent from alcohol. As he had suffered from epileptic seizures and dizziness, he received valproic acid and the vasodilator naftidrofuryl, respectively. Autopsy showed no morphologic cause of death. Chemical analysis of blood revealed concentrations for valproic acid and disulfiram in the therapeutic and above the therapeutic range but far below the lethal level, respectively. No ethanol was found. However, the very high concentration of 7500 μg/L naftidrofuryl in whole blood was considered as cause of death, and the most probable manner of death seemed to be suicide. To our knowledge, this is the first reported case of a fatal poisoning with naftidrofuryl.     

Death in head-down position in a heavily intoxicated obese man

Dying in a head-down position is rare, and autopsy may reveal no morphological findings which can sufficiently explain the cause of death. The authors describe a case of positional asphyxia of a 78-year-old man, found dead hanging in head-down position inside a blackberry bush. The subject was suspended by his left leg and wedged inside a thick blackberry bush, while his right leg was free and inflected. Investigation revealed that the elderly man had last been seen after lunch in the early afternoon (about 2.00 p.m.), two days before being found. The subject had no pre-existing physical or mental condition which might have explained his death. He was 164cm tall and weighed 90kg (BMI: 33.4). External examination of the body revealed abrasions on the head and multiple superficial scratch marks on the hands; no external signs of violence were observed. The deceased's head was cyanotic and revealed marked petechial haemorrhages of the conjunctiva. Rigor mortis was fully developed and reddish fixed livor was observed on the face, neck and upper chest. The distribution of livor was consistent with the position of the body at the scene. Autopsy revealed marked pulmonary and cerebral oedema; the liver showed fatty vacuolization with a mild increase of connective tissue and thickening of the walls of the central veins and centrilobular sinusoids. The heart was enlarged, particularly the left ventricle, with a slight, calcified, diffuse and increased thickness of the aortic and coronary arteries. The remains of meat and vegetables in the initial phase of digestion were found inside the stomach, and there was a strong smell of alcohol. The blood alcohol concentration, ascertained by GC (Gas Chromatography), was 2.10g/l. Toxicological assays for addictive drugs (cocaine, heroin, THC) yielded negative results. There were no features suggesting that the deceased had been the victim of an assault. The authors of this case report illustrate the main pathophysiological and diagnostic features of positional asphyxia and possible relevant co-causes of death, with an emphasis on the combined role of acute alcoholic intoxication and obesity in the hastened demise of a subject in the head-down position.     

Unexpected fatal outcome of laparoscopic inguinal hernia repair

In this paper we report the autopsy findings of a long-term warfarinized 60-year-old man who died unexpectedly 2 days after undergoing laparoscopic transabdominal pre-peritoneal (TAPP) inguinal hernia repair. In his medical records it was stated that the perioperative and postoperative period was uneventful with no sign of bleeding and he was discharged the day after surgery. Autopsy revealed massive bleeding in the pre-peritoneal space at the surgery site and a massive left inguinal canal hematoma spreading through the spermatic cord to the left scrotum. There was no evidence of retroperitoneal bleeding. No sign of traumatic injury to the abdominal wall, major abdominal and pelvic vessels was revealed. The cause of death was hemorrhagic shock. We believe that this is the first documented case of fatal outcome after TAPP inguinal hernia repair in Slovakia. Inguinal hernias account for approximately two-thirds of all abdominal wall hernias. The reported case demonstrates that routine procedures such as TAPP hernia repair can have a fatal outcome, not due to any surgical mishap but because of the altered health status of the patient.     

Fatal water intoxication in a schizophrenic patient--an autopsy case

We report a case of fatal water intoxication due to polydipsia. A 69-year-old schizophrenic male was found dead at his room of the hospital in which he had been admitted. Medico-legal autopsy was carried out to determine the cause of his death. The autopsy revealed no severe trauma leading him to the death. Internally, it was noticed that the stomach was vigorously expanded, including fluid contents. Intracardiac blood, being dark-red in color, seemed to be diluted. The both lungs ballooned aqueously, showing apparently edema. However, there was neither macroscopic nor histopathological lesion, being responsible for his death. Postmortem biochemical analyses revealed severe hyponatremia of 92 mEq/ml. In cases with short postmortem interval, serum sodium level almost similarly reflected antemortem level. According to his psychiatric doctor, he had been diagnosed as water intoxication due to polydipsia. Moreover, at 2 h before the discovery of his body, he had been found to drink much running water. It was concluded the cause of his death as fatal water intoxication.     

Akute myeloische Leukämie als Ursache des plötzlichen, unerwarteten Todes

A 52-year-old woman was found dead in her apartment. At initial inspection of the body, many haematomas were seen over the entire body. In order to exclude an act of violence as the cause of death, a legal autopsy was performed. Autopsy showed massive disseminated intravascular coagulation and the cause of death was massive cerebral haemorrhage. Due to the unknown risk of infection and to exercise reasonable care in the further proceedings, several differential diagnoses of haemorrhagic events had to be promptly excluded. The final diagnosis of acute myeloid leukaemia (AML) was determined through the histologic investigation. This case demonstrates that AML is a heterologic disease, which must be considered as a differential diagnosis in cases of sudden death.     

Use of postmortem computed tomography to reveal an intraoral gunshot injuries in a charred body

A 53-year-old man was found dead after a fire at his residence had been extinguished. Although a pistol was recovered beside the body, external examination was unable to indicate any gunshot wound because of severe charring of the body. Postmortem computed tomography (CT) scan performed prior to autopsy suggested an entrance gunshot wound in the posterior pharynx with loss of soft tissue and an internal bullet path through the right anterior and posterior parts of the occipital bone. Autopsy revealed an entrance gunshot wound with hemorrhage in the soft tissue of the posterior pharynx, massive contusion of the right occipital lobe, and subarachnoid hemorrhage in the right temporal lobe, both occipital lobes and the superior surface of the left cerebellar hemisphere, thus being consistent with the findings of postmortem CT. A carboxyhemoglobin concentration of 5% in blood from the cadaver was consistent with the lack of soot deposition from the larynx to the bronchus. These observations confirmed that death had been caused by an intraoral gunshot resulting in severe brain damage, before the body had been burned.     

Mitral valve prolapse and out-of-hospital sudden death: a case report and literature review

The emergency medical services were called to the workplace of a 25-year-old woman who appeared to be dead. The alarm was raised by employees who had found her unconscious at her desk. There was no semi-automatic defibrillator on the premises and no member of staff had received specific training in management of cardiac arrest. External cardiac massage was immediately started as advised by telephone by the emergency physician and ventricular fibrillation was diagnosed on arrival of the medical team. Despite continuous resuscitation, the victim did not revive. The death certificate was signed with a medicolegal objection to burial, leading to an inquiry. Several causes were suggested by the emergency physician who had been called to the patient, and who was unable to account for the death. Autopsy established the diagnosis of mitral valve prolapse. The authors stress that autopsy is imperative and detail the implications of such a procedure.     

Fatal accident caused by isoflurane abuse

A fatal accident after isoflurane abuse is presented in this report. A hospital employee was found dead in the operating area with a plastic bag over his head. In his locker an almost empty bottle of isoflurane was found. Autopsy revealed signs of asphyxiation and toxicological examination revealed nordazepam and isoflurane in non-toxic concentrations in the blood. Quantification of the anaesthetic was also carried out in urine, gastric contents, liver, kidney and brain samples, and in addition, oxazepam, prothipendyl and metabolites of midazolam and prothipendyl were found in the urine. Although the drug problems of the deceased were known before, no efforts had been made to restrict access to these drugs.     

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.     

Colloid cysts of the third ventricle with fatal outcome: a report of two cases and review of the literature

Two cases of sudden death due to colloid cysts of the third ventricle are presented with a review of the literature. In the first case, a 40-year-old woman suffered an acute onset of severe frontal headache after an intercontinental air flight. The next day, she was found comatous and died 7 h after admission to a hospital. In the second case, a 33-year-old man with a medical history of recurrent headaches was found dead in his car. Autopsy in both cases revealed a colloid cyst of the third ventricle and hydrocephalus involving the lateral ventricles. Received: 7 February 1997 / Received in revised form: 2 April 1997     

Fatal water intoxication during olanzapine treatment: A case report

A man in his twenties was diagnosed with schizophrenia in his late teens. The night before his death, his family reported he drank a large amount of water, vomited, collapsed, and snored loudly while sleeping, but they did not view the event seriously as he did it routinely. The following morning, he was found dead. Autopsy revealed hyponatremia by water intoxication as the cause of death. Water intoxication has various causes. In this case, 610 ng/mL olanzapine was detected in serum samples. Although this concentration is not as high as the fatal concentrations reported in past studies, it might have caused some adverse effects. Furthermore, the observation that excessive drinking behavior started after the dose of olanzapine was increased suggests a possibility that olanzapine aggravated water intoxication.     

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, unexpected death of a cannabis bodypacker, due to perforation of the rectum

A forty year old cannabis bodypacker was found dead in his flat in November 2000, two days after arriving back from a trip to Northern India. On his return he had complained to his family of feeling unwell, although he had refused to let them in or accept medical help. At post-mortem he was found to have 55 packages of cannabis resin in the large intestine, wrapped in cellophane. Subsequent search of the flat by the police revealed the presence of a further 133 similar packages in the fridge, suggesting that he had concealed 188 packages in total. The cause of death was given as peritonitis due to perforation of the distal large intestine caused by swallowing the packages.     

High blood mirtazapine concentration in a newborn – A case of suspected postpartum infanticide

We report a sudden death of an infant due to mirtazapine poisoning. A 15-day-old newborn boy was found dead when he was sleeping beside his mother who had suffered from panic disorder for approximately 1 year. After giving birth, she complained of palpitations and shaky hands, and was prescribed mirtazapine. The deceased newborn weighed 3,282 g and his height was 55 cm. There were no autopsy findings related to the death. The mirtazapine concentration as quantitated by liquid chromatography-tandem mass spectrometry analysis was 620 ng/mL in right heart blood, and was approximately 10 times higher than the therapeutic level in adults. Because transfer of mirtazapine into breast milk is low, mirtazapine was likely administered intentionally to the newborn. Based on the newborn’s immature renal, liver, and blood–brain barrier function, the cause of death was attributed to mirtazapine poisoning. Poison-related homicide in the infant is rare. We report the first case of intentional mirtazapine poisoning case in a newborn.     

Child death related to insulin omission by mother

A 4-year-old child was found dead in her house. She had been suffering from insulin-dependent diabetes mellitus (IDDM) for 3 years. She had been admitted to hospital three times, and attended the hospital once a month. Her glycaemic control remained poor. Autopsy findings revealed a remarkably fatty liver and lack of beta cells in the pancreatic islets of Langerhans. The laboratory reported ketoacidosis, ketonuria, glycosuria, and high levels of vitreous glucose and ketones. Her father had been absent for the 3 days before her death, and the mother should have fed her. Her mother was found drunk on the floor. No detailed history was available because of the mother's death, but the probability of the mother's omission of the insulin injection was suggested. Poor control of IDDM might have also been closely connected to general neglect by the mother. This case was considered child abuse.     

Fatal intoxication due to transrectal methamphetamine overdose: A case report

Methamphetamine (MA) abuse is common in Asian countries. The major ways of abuse include intravenous injection, absorption, and ingestion. Although two cases of survival after transrectal MA administration have been reported in the clinical field, to the best of our knowledge, there is no report of death due to intentional transrectal MA overdose. This is the first report of such a death. A single, 42-year-old male with a history of habitual MA use was found dead at his home. The police found numerous unused injectors in his closet. A rapid test of his urine was positive for MA. The cause of death was unclear, so a medicolegal autopsy was performed.ResultsAutopsy findings revealed a tubular plastic container without a lid in the rectum at the time of excision, with a small, open plastic bag inside. MA was detected in both the plastic container and the plastic bag. The MA concentration in the femoral vein blood was enough to cause death, and the cause of death was considered transrectal MA overdose. MA was absorbed through the lower part of the rectum, so the absorbed MA bypassed the liver and was transported directly to the systemic circulation. Since MA is largely metabolized in the liver, the absorbed MA was unaffected by the hepatic first-pass effect and may have caused more rapid and serious intoxication.     

Diffuse hepatic hemangiomas: percutaneous transcatheter embolization with detachable silicone balloons

Two infants with severe congestive cardiac failure secondary to diffuse hepatic hemangiomas were treated by percutaneous transcatheter embolization of the hepatic arteries using detachable silicone balloons. One infant experienced dramatic improvement of the cardiac failure and showed no impairment of hepatic function. The other infant remained in a low cardiac output state following the procedure and developed acute hepatic and renal failure followed by generalized sepsis and death. Autopsy examination revealed massive hepatic hemangioendothelioma as well as areas of necrotic and viable liver parenchyma. A review of reported patients with hepatic hemangiomas treated by hepatic artery ligation or embolization showed no others who had hepatic failure. These techniques were curative in 14 of 18 patients (78%), an improvement compared with the results of other available methods of therapy.