Fatal hypernatremia due to drinking a large quantity of shoyu (Japanese soy sauce)

We report a case of fatal salt poisoning in a 55-year-old woman who suffered from depression and drank a large quantity of shoyu (Japanese soy sauce). She presented with the highest ever documented serum sodium level of 187?mmol/L. This was associated with symptoms of cerebral damage which developed within hours after drinking the soy sauce. She died as a result of massive pulmonary edema, despite intensive medical treatment. Viewing the results of clinical and postmortem investigations together, her death could clearly be attributed to drinking a large quantity of soy sauce.     

An autopsy case of zinc chloride poisoning

Ingestion of large amounts of zinc chloride causes corrosive gastroenteritis with vomiting, abdominal pain, and diarrhea. Some individuals experience shock after ingesting large amounts of zinc chloride, resulting in fatality. Here, we present the results of an administrative autopsy performed on a 70-year-old man who ingested zinc chloride solution and died. After drinking the solution, he developed vomiting, abdominal pain, and diarrhea, and called for an ambulance. Except for tachycardia, his vital signs were stable at presentation. However, he developed hypotension and severe metabolic acidosis and died. The patient’s blood zinc concentration on arrival was high at 3030 μg/dL. Liver cirrhosis with cloudy yellow ascites was observed, however, there were no clear findings of gastrointestinal perforation. The gastric mucosa was gray–brown, with sclerosis present in all gastric wall layers. Zinc staining was strongly positive in all layers. There was almost no postmortem degeneration of the gastric mucosal epithelium, and hypercontracture of the smooth muscle layer was observed. Measurement of the zinc concentration in the organs revealed the highest concentration in the gastric mucosa, followed by the pancreas and spleen. Clinically, corrosive gastroenteritis was the cause of death. However, although autopsy revealed solidification in the esophagus and gastric mucosa, there were no findings in the small or large intestine. Therefore, metabolic acidosis resulting from organ damage was the direct cause of death.     

An autopsy case of spontaneous esophageal perforation (Boerhaave syndrome)

A 45-year-old male, an alcohol addict with asthma, was found dead in his home, after several days of continued drinking. A forensic autopsy was performed 3 days after the discovery of his death in order to specify the cause of death.A longitudinal perforation penetrating all layers of the esophagus measuring 1.8 cm was present on the left wall approximately 2.0 cm from the gastroesophageal junction. There were 1900 mL of greenish to brownish turbid liquid in the left pleural cavity and 150 mL of greenish viscous liquid in the stomach. Histopathologically, an infiltration of numerous neutrophils was evident in the submucosa layer, proper muscular layer, and serous membrane of the esophagus, corresponding to the esophageal laceration. The serum C-reactive protein (CRP) concentration was determined to be 3.1 mg/dL. The alcohol concentrations were determined to be 1.49 mg/g in the right cardiac blood, 1.31 mg/g in the left cardiac blood, and 2.48 mg/g in urine.Based upon the autopsy and histopathological findings, as well as the biochemical and toxicological analyses, we concluded that the cause of death was respiratory failure by pleural effusion, resulting from spontaneous esophageal perforation. This was the first report of a spontaneous esophageal perforation eventually causing respiratory failure.     

An autopsy case of commotio cordis from a motor scooter accident

A motor scooter carrying two 15-year-old boys collided with the back of an open, parked truck. The tailgate of the truck was down and in a horizontal position. At the autopsy of the driver, horizontal tramline bruises were found on the anterior chest, but the thoracic cage was intact. There was a transverse tear of the ascending aorta with adventitial hematoma, but significant bleeding was not found in the pericardial sac or the thoracic cavities. Therefore, it was obvious that cardiovascular collapse occurred immediately after the accident. Neither injuries nor diseases that would cause the instantaneous death were found on examination of the whole body. We determined that the driver died of commotio cordis due to blunt force to the anterior chest.     

Accidental carbon dioxide poisoning due to dry ice during a funeral wake: An autopsy case

We report the autopsy case of a male in his 60 s diagnosed with carbon dioxide (CO₂) poisoning caused by dry ice for cooling in a coffin during a funeral wake. He was last seen alive, clinging to his family member’s body with his head inside the coffin. The autopsy and histological findings did not indicate a specific cause of death. To confirm the concentrations of CO₂ and oxygen (O₂) in the coffin, an experiment was conducted to reconstruct the scene. Based on the experimental results, 9 h after placing dry ice, the CO₂ concentration at the estimated closest point to his head was 24%, a lethal level for CO₂ poisoning. Contrastingly, although the concentration of O₂ had fallen, it never reached a lethal concentration at any of the determination points during the experiment, thereby ruling out asphyxia as a cause of death. Based on our findings, we concluded that the cause of his death was CO₂ poisoning.Forensic pathologists tend to overlook CO₂ poisoning unless suspected, as it does not exhibit specific autopsy findings. For the diagnosis of CO₂ poisoning, it is essential to collect detailed information about the deceased and the scene of death. The toxicity of CO₂ itself is not well known, although dry ice is widely available to the public. In order to make its risk well known, it is necessary to inform people about the dangers of using dry ice.     

A curious autopsy case of accidental carbon monoxide poisoning in a motor vehicle

A 26-year-old man was found dead in his car. All doors and windows were locked inside. The ignition key was in the "on" position; but the engine was not running and the fuel tank was empty. His post-mortem lividity was cherry-pink, and marked congestion was observed in the lungs and brain macroscopically. Massive intracardiac blood containing a small amount of cruor was found in the heart. In histological examination of the heart, partial disarrangement or necrosis was found in the myocardium. The liver cells showed derangement and degenerative changes, with focal lymphocyte infiltration in the portal regions, although they were not severe. The chemical tests showed that the blood concentration of carboxyhemoglobin was 46.6%. Stimulants were also detected from his blood and urine; the concentrations of methamphetamine and amphetamine were 3.25 and 0.84 microg/ml, respectively, for his cardiac blood. Therefore, it seemed reasonable to judge that the cause of his death was carbon monoxide poisoning; the cardiomyopathy and the presence of stimulants in blood might facilitate his death. Upon careful investigation of his car, it was disclosed that exhaust gas, leaked from small holes of the exhaust pipe due to rust-through, invaded the interior through four holes on the floor of the car during parking with the engine being on for the purpose of air-conditioning of the interior. It is very common to commit suicide by introducing exhaust gas into an interior of a closed motor car, but the present accidental case of carbon monoxide poisoning in a car seems rare and worthwhile reporting.     

Cystic fibrosis of the pancreas: report of a Japanese autopsy case

Cystic fibrosis of the pancreas is considered to be rare in the Japanese population. Forty-five cases from the Japanese literature (1951-1983) are reviewed and one autopsy case added. The patient was a 17-year-old Japanese male with recurrent episodes of pulmonary infection. His sweat test was positive (sodium 332 mg/l, chloride 316 mg/l). No particular hereditary trait was identified. Autopsy findings showed cystic dilatation of pancreatic ducts and ductules with mucous hypersecretion. Acini of the pancreas were replaced by fibrosis, while islands of Langerhans remained. These findings were compatible with cystic fibrosis of the pancreas (mucoviscidosis). The lungs showed chronic hypertrophic bronchitis and acute obliterating bronchiolitis. Cystic dilatation and hypersecretion were seen in the esophageal glands, Brenner's glands, and enteric glands. Goblet-cell hyperplasia was seen in the enteric glands. Central fatty metamorphosis and focal bile duct proliferation were seen in the liver. No obvious intralobular cholestasis was present. The epithelium of the gall bladder was highly columnar.     

Carrier-free separation of Pd from a large quantity of Ru

Palladium activity produced in the (α, xn) reaction on ruthenium has been separated from a Ru metal target. Two methods have been followed for this carrier-free separation of Pd from Ru. The recovery of Pd has been found to be 60 and 90% in the two methods, respectively. Separated Pd was found to be free from any radiochemical and chemical impurities.     

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.     

An unusual autopsy case of a victim stabbed during sadomasochistic prostitution

A 29-year-old male who lived alone was found dead with his back leaning against the wall of his room. He had been stabbed in his abdomen with a survival-type knife. The victim's mouth was plugged with a pink-colored glove and was sealed with packing tape. His wrists were tightly tied behind his back with the same type of packing tape. The cause of death was diagnosed as hemorrhage from the right common iliac artery and vein. Due to the strange circumstances of the crime scene, the police initially considered the possibility of homicide by a group of assassins. Two months later, the police arrested a male suspect who was a member of a vice racketeer. The victim was characterized as a masochist and bisexual. He often hired the male suspect to perform sadomasochistic activities. On the day of the crime, the victim prepared a survival-type knife and packing tape himself to experience fear and pain more strongly. The victim hoped to use the knife to increase sexual excitement. In this case of sadomasochistic prostitution leading to death, the legal issues of homicide for money, malicious request of injury by the victim and accidental death were involved.     

Death resulting from a mesenteric hemorrhage due to acute myeloid leukemia: An autopsy case

Acute leukemia causes hemorrhage in various sites throughout the body, such as the brain parenchyma, resulting in serious complications. Here, we present an autopsy case where the patient succumbed to a ruptured mesenteric hematoma caused by acute leukemia.A 58-year-old man, without a significant past medical history, was found dead at his workplace. An external examination showed subcutaneous hemorrhage on the left upper extremity. Macroscopic autopsy findings revealed a massive hemoperitoneum (1000 mL) and extensive hematoma in the mesentery. Histopathological findings showed monotonous cell proliferation not only in the mesentery, but in many organs, such as the liver, spleen, and kidney; aggregates of the infiltrating cells were also observed in the microvessels of various organs. Immunohistochemical staining indicated that the infiltrating cells showed variable myeloperoxidase positivity, and the cells were strongly positive for CD68 (PG-M1). From the autopsy findings and the immunohistochemical staining, we concluded that the underlying cause of death was acute myeloid leukemia (M5).This case was not only a rare presentation of acute leukemia, but provides a lesson to forensic pathologists regarding noting underlying hematological disease, particularly when a case of massive hemorrhage of unknown etiology is encountered.     

An autopsy case of fatal anaphylactic shock following fluorescein angiography: a case report

We present a rare autopsy case of fatal anaphylactic shock following fluorescein angiography. A 71-year-old Japanese woman undergoing retinal angiography to evaluate diabetic retinopathy died immediately after an injection of sodium fluorescein. Forensic autopsy and post-mortem biochemical analyses revealed an elevated serum level of tryptase which, in the absence of morphologic changes suggesting injury or disease, confirmed the diagnosis of fatal anaphylactic shock. Although serious adverse effects are rare after fluorescein angiography, patients should be observed, with appropriate resuscitation equipment available, for several hours after the administration of fluorescein.     

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.     

An autopsy case of a charred body which committed suicide after arson

A severely burned body was found lying on its right side at the scene of the fire in a 2-story wooden apartment house. The presence of a ligature (an electrical cord) running horizontally around the neck aroused suspicion of arson after homicidal strangulation (murder-arson). The entire body was severely burned and partly charred. The head and neck were severely charred, and the left temporal bone had been consumed exposing the brain. Around the neck was looped an electrical cord, which ran horizontally and canted downward toward the nape, leaving a furrow resulting from the knot being tightened up. No other injuries or pathologic lesions suggestive of the cause of death were noted. No drug, poison or alcohol was detectable in the blood or urine. The peculiar method of making a noose of the ligature around the neck is called clove hitch, which makes the noose tighten further with increased load. The fallen curtain rod had a bend with an acute angle, which was considered to have been the point of suspension in hanging. In addition, a lighter was found under the corpse, which was presumably used to ignite the gasoline that the deceased sprinkled. We speculate, therefore, that the deceased hanged himself by placing the electrical cord around his neck (by clove hitch), suspending it from the curtain rod, sprinkling gasoline in his room, igniting it with a lighter, executing suicidal hanging after the start of the fire. Probably the body was wrapped in flames while dangling, then fell to the floor together with the collapsing curtain rod.     

An autopsy case of sudden death in a patient with idiopathic scoliosis

A 38-year-old woman with idiopathic scoliosis (right convex thoracic scoliosis, 78 degrees; left convex lumbar curvature, 75 degrees) died suddenly. Forensic autopsy and histopathologic examination revealed chronic congestive oedema, numerous cavities and atrophic changes of heart. These changes, including both respiratory changes and biventricular failure caused by hypoplastic cardiac changes, were due to a deformed thoracic cage. This case illustrates that not only abnormalities of respiratory function and cor pulmonare, but also hypoplastic cardiac changes, may cause sudden death in a patient with untreated scoliosis.     

Murder-suicide by carbon dioxide (CO2) poisoning: a family case from Berlin,Germany

This report demonstrates how carbon dioxide (CO₂) may be a potent weapon in murder-suicide, where the death scene offers virtually no clues as to the lethal modality and the autopsy findings are nonspecific. Four bodies were discovered in an apartment in midsummer 2012 in Berlin, Germany. The bodies were those of a father (a 69-year-old business consultant), his wife (aged 26-years), and two sons (aged 3 and 6 years, respectively). The police found the wife and two sons lying in their beds and the husband in a supine position on the floor with a plastic bag over his head tied loosely around his neck with a rope. A 500 g single-use CO₂ cylinder was standing on the floor. The container was almost empty and according to the label had been sold as a CO₂-fertilizer for aquarium plants. Two synthetic inhalation face masks and tubing were also found, which tested positive for the DNA of all four deceased family members. It is hypothesized that the husband placed an inhalation mask over the mouths and noses of his wife and children while they were sleeping. Inhalation of pure CO₂ ensured their rapid unconsciousness due to hypercapnia and severe anoxia. The rapid increase in CO₂ concentration would render a victim helpless, with no time to wake and defend themselves, or others. The proximate cause of death in all cases was attributed to CO₂ intoxication, based on the scene findings, the reconstructed sequence of events, the autopsy, and results of toxicological studies.     

An autopsy case of sudden death in a boy with primary pulmonary hypertension: a case report

We report a rare autopsy case of sudden death due to primary pulmonary hypertension. A seven-year-old boy, who had been diagnosed with primary pulmonary hypertension at the age of four years, died suddenly. Forensic autopsy and histopathologic examination revealed extensive obstruction of small muscular pulmonary arteries by plexiform lesions and concentric intimal thickenings, compatible with primary pulmonary hypertension. We concluded that plexiform lesions of pulmonary arteries produced right ventricular hypertrophy and dilatation, decreased the preload of the left ventricle and subsequently led to biventricular failure. This autopsy and histopathologic examination suggested a possible pathophysiologic mechanism of sudden death due to primary pulmonary hypertension in a child.     

An autopsy case of a stunt man who jumped into seawater riding a motorcycle: a case report

We report a rare case of the death of a stunt man who jumped into the sea driving a motorcycle on location for a TV drama. A special ramp had been constructed for the jump. The stunt man and a passenger drove up the ramp at a speed of 60-70 km/h and jumped into the sea from a height of about five metres. Both men swam up, but the driver fell unconscious at the surface. He was sent to hospital, but did not recover. The autopsy revealed a deep laceration of the right axilla with complete rupture of the axillary artery, bone fractures of the right ribs and the right pelvis, and a small laceration of the upper lobe of the right lung. Other visceral organs were not injured. We finally judged that his cause of death was exsanguination due to rupture of the right axillary artery on the basis of the presence of a small amount of blood inside the heart and ischemic organs. All injuries were probably inflicted by a collision with the motorcycle upon reaching the water surface; the axillary injury might be due to the left handlebar piercing into the part.     

Pseudoaneurysm originating from left ventricle aneurysm: An autopsy case and review of literature

Rupture of the free wall of the left ventricle is a catastrophic complication of acute myocardial infarction. Rarely, free wall rupture is contained by overlying adherent pericardium, producing a pseudoaneurysm of the left ventricle. In this report, a case of a left ventricular pseudoaneurysm due to a previous myocardial infarction is described. A 55-year-old woman had a severe chest pain 11 months prior to death. No cardiac investigation was performed. Three days prior to death, she suffered from fatigue and weakness, and had a witnessed sudden cardiac death. At autopsy, a 8.5 × 10 × 8 cm pseudoaneurysm of the left ventricle was found. There was severe coronary artery atherosclerosis. There were extensive adhesions between pericardium and pseudoaneurysm wall. The cause of death was attributed to heart failure and resulting arrhythmia. The case illustrates the rare event of left ventricular pseudoaneurysm first diagnosed at forensic autopsy.