Medico legal investigations into sudden sniffing deaths linked with trichloroethylene

Sudden deaths attributed to sniffing trichloroethylene are caused by the abuse of this solvent which produces pleasant inebriating effects with rapid dissipation. In the event of repeated cycles of inhalation, a dangerous and uncontrolled systemic accumulation of trichloroethylene may occur, followed by central nervous system depression, coma and lethal cardiorespiratory arrest.Sometimes death occurs outside the hospital environment, without medical intervention or witnesses and without specific necroscopic signs.Medico legal investigations into sudden sniffing deaths associated with trichloroethylene demand careful analysis of the death scene and related circumstances, a detailed understanding of the deceased's medical history and background of substance abuse and an accurate evaluation of all autopsy and laboratory data, with close cooperation between the judiciary, coroners and toxicologists.     

Sudden death after isobutane sniffing: a report of two forensic cases

The intentional inhalation of a volatile substance (“sniffing”) causing euphoria and hallucinations is an under-recognised form of substance abuse in children and adolescents with a high morbidity and mortality. Sudden death can be caused by cardiac arrhythmia, asphyxia or trauma. Two fatal cases of isobutane sniffing of cigarette lighter refill containing isobutane are reported. Toxicological investigations revealed the presence of isobutane in the heart blood and brain tissue of both cases (case 1: heart blood 0.1 μg/g, brain tissue 2.3 μg/g; case 2: heart blood 4.6 μg/g, brain tissue 17.4 μg/g) and the presence of its metabolite 2-methyl-2-propanol in the heart blood of both cases (0.5 and 1.8 μg/g, respectively). The histological investigations of the inner organs showed similar results in both victims. Autopsy findings, results of the histological and immunohistochemical investigations, toxicological findings and analytical procedures are discussed.     

Heart rupture as an acute complication of cocaine abuse: A case report

The purpose of this study is to show a very rare complication of acute cocaine poisoning, namely heart rupture. In the present case report, acute cocaine intoxication caused massive myocardial infarction, resulting in heart rupture and cardiac tamponade. A crime scene investigation found a dead body on the street in a drug dealing district. Examination of the body showed no external injuries. A thorough autopsy was performed showing massive cardiac tamponade with 510 ml of blood within the pericardium and full-thickness tissue lesion at the posterior wall of the left ventricle of 3.5 × 3 cm. Histological examination in hematoxylin and eosin was performed and confirmed the interruption of the posterior wall of the left ventricle with the presence of blood. In fact, although the correlation between cocaine and myocardial damage is well established, the relationship between heart rupture and acute cocaine intoxication is an extremely rare event. Moreover, since there are, to date, few reports of similar deaths, our report provides useful information regarding sudden death in a cocaine abuser. It is, therefore, of crucial importance to report this case to the scientific community.     

Three sudden deaths in men associated with undiagnosed chronic thyroiditis

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

A fatal case of post-operative pulmonary thromboembolism with cosmetic liposuction

Pulmonary thromboembolism (PTE) has been regarded as rare in Japan. However, PTE has been increasingly recognised because either of increased incidence, diagnostic progress, or social recognition. Recently, 10 Japanese Medical Associations have submitted preventive guidelines for PTE in post-operative patients and the government decided to fund this, as results of the increase in cases and concern regarding medical negligence. A fatal case of PTE after liposuction is reported. A female patient was in the home toilet after two days of immobilization following day-surgery liposuction. Clinicians must be aware of appropriate methods for the prevention of post operative PTE with cosmetic surgery.     

猝死型冠心病抑或J波综合征

目的：探讨无冠心病史而心脏性猝死患者病因及发病机制。方法：对我院2例典型患者,围绕其病史、发病时症状及相关检查化验,结合心肌电离子基础进行综合分析。结果：2例心脏性猝死患者1例生存,另1例死亡。但均不具备冠心病特征,发病后相关指标的异常应为心脏骤停及相关综合因素所决定。结论：无冠心病史而心脏性猝死患者本身可能存在心肌电紊乱基础,在特定的诱因下使心室外膜2期复极电位差的进一步增大出现折返诱发室颤而使心脏骤停,归属于J波综合征较为合理。     

Performance of an on-site urine multidrug test used by forensic physicians in determining the cause of death

Forensic physicians in the region of Amsterdam routinely collect blood and urine samples during external examinations. A rapid on-site multidrug test is used to screen the urine samples for the presence of commonly used drugs classes. Urine and blood samples are sent to the laboratory for additional toxicological analysis. This study aimed to investigate how the substances found in urine using the on-site multidrug test relate to the substances identified with laboratory methods. In 2018 and 2019, 465 cases underwent an on-site multidrug test as well as toxicological laboratory analyses and were included in this study. Fifty-three percent (n = 247) of these cases included a positive on-site multidrug test for at least one substance. The level of total agreement between the on-site multidrug test performed by the forensic physician and the laboratory analyses either in urine or in blood varied per substance groups, with the best results for barbiturates, cocaine, ecstasy and methadone. In conclusion, the on-site multidrug test appeared to perform well for certain substance groups and is an economical and rapid tool. However, the results from the laboratory analyses in blood occasionally provided additional insights concerning the circumstances that could be of importance in the cause of death.     

Digital 3D reconstruction of two parahissian accessory bundles in a case of Wolff-Parkinson-White syndrome

Three-dimensional reconstruction of digitized histological serial sections of the cardiac conduction system yielded two accessory pathways in a case of a 24-day-old male infant who died after a short period of illness with ECG findings of Wolff-Parkinson-White syndrome. In infants, the differential diagnosis of possible accessory pathways connecting the AV conduction system, atrial or ventricular septum includes dispersed conduction system tissue without connecting features. This is why three-dimensional reconstruction is necessary in order to refute or establish connectivity of cell groups as found in histological serial slice images.C. Steffen and W. Schweitzer contributed equally to this study.     

A case report of lethal post-viral lymphocytic myocarditis with exclusive location in the right ventricle

The inflammatory involvement of vital organs may represent a dangerous and life-threatening situation: in particular, the inflammation of the myocardial tissue of the heart may lead to severe consequences since the clinical history of the disease may be completely asymptomatic, any clinical sign may be lacking, thus preventing correct diagnosis and treatment. This may occur even in the case of myocarditis and may lead to unexpected death whose cause can be assessable only by means of a thorough histopathological examination. The article reports the case of 61-year old female who developed a flu-like syndrome with very few symptoms, followed by sudden death in three weeks. The autopsy and following histopathological investigations identified the cause of death in a post-viral lymphocytic myocarditis, probably related to the previous infectious disease, and alternative causes (as arrhythmic ventricular dysplasia, vasculitis, sarcoidosis and giant cell myocarditis) were excluded. The exclusive location in the right ventricle was a peculiar finding. The case highlights the importance of the myocardium of the right ventricle, a tissue which is often less considered even in histopathological surveys. The exclusive location of myocarditis in the right ventricle is a rare event but in this case fully responsible for death.     

Forensic issues in cases of fatal hemorrhage from arteriovenous dialysis access sites

Angioaccess sites to enable repetitive vascular punctures for hemodialysis include temporary or permanent indwelling catheters, port access devices, autogenous vessels in native arteriovenous fistulas, or non-autogenous material in prosthetic arteriovenous grafts. While complications such as thrombosis and infection are well recognized, lethal hemorrhage is much less commonly encountered. In this paper, selected cases are reported to demonstrate the range of situations that may be encountered at autopsy, including hemorrhage from a catheter in a case of suicide, and hemorrhage from an arteriovenous fistula and an arteriovenous graft. Predisposing factors to hemorrhage include coagulation abnormalities due to anticoagulant therapy or to underlying renal failure, stenosis or obstruction that has resulted in increased intraluminal pressure, local sepsis, repeated trauma from venesection and hypertension. An approach to such cases should include careful evaluation of the medical history and death scene, with dissection at autopsy of catheters, grafts and fistulas to demonstrate the condition of anastomosis sites, and the presence or absence of ruptures, perforations, stenoses, and/or thromboses. Histologic sampling of autologous fistula walls and surrounding soft tissues may reveal evidence of sepsis.     

A case of fatal multi-organ inflammation following COVID-19 vaccination

A 14-year-old Japanese girl died unexpectedly 2 days after receiving the third dose of the BNT1262b2 mRNA COVID-19 vaccine. Autopsy findings showed congestive edema of the lungs, T-cell lymphocytic and macrophage infiltration in the lungs, pericardium, and myocardium of the left atria and left ventricle, liver, kidneys, stomach, duodenum, bladder, and diaphragm. Since there was no preceding infection, allergy, or drug toxicity exposure, the patient was diagnosed with post-vaccination pneumonia, myopericarditis, hepatitis, nephritis, gastroenteritis, cystitis, and myositis. Although neither type of inflammation is fatal by itself, arrhythmia is reported to be the most common cause of death in patients with atrial myopericarditis. In the present case, arrhythmia of atrial origin was assumed as the cause of cardiac failure and death. In sudden post-vaccination deaths, aggressive autopsy systemic search and histological examination involving extensive sectioning of the heart, including the atrium, are indispensable.     

Sudden death during exercise in a juvenile with arrhythmogenic right ventricular cardiomyopathy and desmoglein-2 gene substitution: a case report

One type of arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited disorder resulting in fatty replacement of the right ventricular wall and consequent fatal arrhythmias. It is a major cause of sudden death in young people. Mutations in the genes encoding desmosomal proteins have been identified as a cause of ARVC. We report a case of sudden death during exercise in a juvenile. This case showed fatty replacement of the right ventricular wall, which suggests that ARVC may have been associated with the cause of death. Further genetic analysis showed a novel homozygous R292C substitution of the desmoglein-2 gene (DSG2), which encodes a desmosomal protein. In addition to morphological examination, genetic analysis may be useful for diagnosis of ARVC-suspected autopsy cases.     

Sudden unexpected death in a toddler with Williams syndrome

We report a toddler with Williams syndrome (WS) complicated by congenital heart disease and a seizure-like episode who died suddenly several hours after uneventful cardiac catheterization. The cardiovascular anomalies and their association with sudden death as well as the clinical neurological and neuropathologic abnormalities identified in WS are delineated and discussed.     

Sudden death due to a novel nonsense mutation in Marfan syndrome

BackgroundMarfan syndrome is a hereditary connective tissue disease accompanied by autosomal dominant inheritance; that mainly arises from a mutation in the fibrillin-1 gene (FBN1). Aortic dissection and rupture are the common and lethal complications of MFS and may cause sudden unexpected death.MethodA man aged 34 was admitted to the hospital due to persistent pain in his abdomen 12 h post-drinking and suddenly died 10 h later. A forensic autopsy was performed to identify the underlying mechanism of death. Due to the high suspected of MFS, Sanger sequencing was performed, and a novel mutation was detected in the deceased. To clarify the underlying mechanism of this mutation, real-time quantitative polymerase chain reaction was conducted and Western blot analysis was performed in vitro.ResultsA novel PTC mutation c.933C > A in FBN1 was found. Through family history inspection and Sanger sequencing, other MFS patients in the present family were confirmed. The pathologic changes in the aorta in the present case showed media cystic degeneration, disordered arrangement of elastic fibers and a significant reduction in fibrillin 1 compared with the control. The mutation led to significant reduction inFBN1 mRNA and fibrillin-1 in cells in vitro, and overexpression of phospho-Smad2 was observed.ConclusionWe confirmed a novel pathogenic PTC mutation in the FBN1gene through Sanger sequencing, and the pathological changes and underlying mechanisms were also identified. The present work not only extends the pathogenic mutation spectrum of MFS, but also stresses the role of forensic autopsy, genetic analysis and functional validation of novel mutations in cases of sudden death associated with congenital diseases.     

Sudden perinatal death due to rupture of congenital cardiac diverticulum. Pathological findings and medico-legal investigations in malpractice charge

Congenital diverticula of the left ventricle, very rare malformations, are determined by an abnormal embryonic development of the ventricular wall and can be isolated or associated to other cardiac anomalies. In most of the cases, these pathologies are not symptomatic and in some patients can be associated to ventricular arrhythmia, cardiac rupture with tamponade and sudden death.Authors are presenting the case of a sudden death in an 8-weeks-old newborn due to rupture of a cardiac congenital diverticulum of the left ventricle, discovered only at the moment of the autopsic examination. The parents of the victim pressed charges against the medical staff that was appointed to the cares, blaming them with malpractice.The missed diagnosis of a cardiac congenital diverticulum of the left ventricle, a rare pathology, reflects the trickiness of the medical management that can lead to medico-legal controversies and, even though such rare conditions must be always taken into consideration when investigating possible dysfunction causing the death, diagnostic difficulties, in the case in exam, justify the missed diagnosis intra-vitam of cardiac ventricular diverticulum.     

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.     

Integrated multidisciplinary approach in a case of occupation related planned complex suicide-peticide

The combined event of a suicide and the killing of a pet has been hardly explored in forensic literature, but it is not rare at all. In the reported case the dead corpse of a 60-year old mentally ill woman and the carcass of a dog were found on the bed of a private apartment. In light of death scene investigation, necroscopic examination and toxicological analyses death was attributed to licit drug intoxication and self-strangulation after lethal poisoning of the dog. Due to the presence of two lethal means (cervical noose and drugs), acting in chronological order, the event was classified as a secondary complex suicide. Moreover, the woman, although mentally ill, was a psychiatrist. Thus, her professional background, namely the easy access to psychiatric drugs together with her knowledge of drug composition and properties lead to suppose an occupation related suicide. The comprehensive analysis of all the available information, including death scene investigation, occupational, necroscopic and toxicological data, resulted of the utmost importance for a proper reconstruction of the events and are recommended in complex cases such as occupation related planned complex suicides combined to the killing of pets.     

Sudden death in case of syringomyelia

Summary Report of a case of sudden death in a 28 year old man, with known disease of the spinal cord. Autopsy showed hydromyelia, syringomyelia and a moderate intoxication by ethyl alcohol, which in combination are considered to have caused the death.

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Zusammenfassung Bericht über den plötzlichen Tod eines 28jährigen Mannes mit einer klinisch bekannten Erkrankung des Rückenmarks. Bei der Autopsie wurden eine Hydromyelie und Syringomyelie festgestellt. Es bestand eine mittelgradige Alkoholisierung. Die Kombination dieser Gegebenheiten wird als Todesursache angesehen.

     

Sudden death due to rupture of the right internal carotid artery in neurofibromatosis type 1: A case report

Vascular involvement is a well-recognized manifestation of neurofibromatosis type 1 (NF1) which has the potential to be fatal when disrupted. We here present a case of sudden death due to the fatal arterial rupture resulted from infiltration of the neurofibromas. A 42-year-old man who suffered from NF1 presented a 1-h history of sudden onset of pain in his right cervical region. His condition worsened and became unconscious on his way to the emergency room. Despite resuscitation efforts, he died 30 min later without regaining consciousness. Autopsy examination showed that a neurofibroma located around the right internal carotid artery, confirmed immunohistochemically with S-100, vimentin and CD34. Furthermore, proliferation of spindle cells positive for S-100 was seen in the wall of right internal carotid artery, which was disrupted and resulted in a hemorrhage. These findings suggest that the artery was disrupted by neurofibromas in the vascular wall, which led to fragility of the vessel. On the basis of these findings, we concluded that the cause of death was asphyxia resulting from airway obstruction compressed by the hematoma due to the arterial rupture. As the locality of the neurofibroma and hemorrhage were closed to the carotid baroreflex, we considered another possible mechanism of his sudden death, which could be cardiac inhibition induced by vagal stimulation. We hope this case will increase recognition of NF-1 vasculopathy when encountering any sudden death in NF1 patients.