Profile of Forensic Autopsy Practices in Small Towns and Cities in Rural Areas / 대한법의학회지

Forensic autopsy service in a metropolitan area of Korea is well established and optimized for high population density based on high social system and infrastructures. However, forensic autopsy in rural areas in our country might be affected due to their low population density, and inconveniences related to special and temporal limitations as well as cultural and traditional limitation. Therefore, for an advanced and optimized model of forensic autopsy service in rural areas, we performed a retrospective analysis on the profile of forensic autopsy based on the eastern part of our nation for 8 years between 2005 and 2013 and analyzed them by cause of death, manner of death, demographic data, toxicological results, and additional information. Through our study we presented the profile of forensic autopsy practice in rural areas and suggested that it can be affected by such regional characteristics.

What Happened to Him Using the Freight Elevator: Fall from Height or Caught Between? / 대한법의학회지

There has been an increase in the incidence of elevator-related accidents in the Republic of Korea. Every year, approximately 10~20 elevator-related fatalities are reported in the Republic of Korea. According to research from the United States, 'falls' were the most common cause of death, followed by 'caught in/between'. In such investigations, it is important to distinguish between the manners of death. Herein, we report an elevator-related fatality, which required careful forensic investigation to determine the cause of death. A thorough forensic autopsy and reinvestigation of the death scene by medical examiners were required to determine if the death was caused as a result of the deceased falling from from a height or being caught in between the elevator and the wall of building.

Usefulness of Serum Mast Cell Tryptase Analysis in Postmortem Diagnosis of Anaphylactic Shock / 대한법의학회지

Anaphylactic deaths are frequently observed at autopsies. Since death associated with medical practice has become social concern, the identification of anaphylactic shock is an important part of forensic medicine. However, autopsy findings of anaphylactic shock are usually non-specific; therefore, the diagnosis of anaphylactic shock must be inferred from collecting data on the past history of the deceased, circumstances of death, and negative autopsy findings. The analysis of serum mast cell tryptase level is a well-known, useful ancillary test for the diagnosis of anaphylactic shock, but is not widely used in daily practice in Korea. We recently encountered 2 autopsy cases of anaphylactic shock and confirmed that analysis of serum mast cell tryptase level was useful for the diagnosis of anaphylactic shock. In this report, we present these 2 autopsy cases of anaphylactic shock, with literature review of the usefulness and limitations of serum mast cell tryptase analysis.

Aneurysmal Rupture of the Internal Carotid Artery in a Presumed Neurofibromatosis Type I Patient / 대한법의학회지

Aneurysm of the internal carotid artery is a rare disease and is known to be associated with congenital arterial anomalies such as neurofibromatosis type I (NF-I). NF-I is an autosomal dominant neurocutaneous disorder characterized by a variety of manifestations that involve the central and peripheral nervous systems, skin, vascular system, and skeleton. In particular, the involvement of vascular abnormalities in NF-I is well known. Any vessel may be affected by this condition, although the renal artery is most frequently involved. The vascular abnormality can be occlusive or an aneurysmal degenerative change. Therefore, symptomatic presentations might assume an indolent pathophysiologic course such as hypertension, or manifest as a catastrophic event such as arterial rupture that could result in sudden death. We report a rare autopsy case of an aneurysmal rupture of the internal carotid artery in a woman with suspected NF-I, who collapsed in her home.

Death by Spontaneous Hemoperitoneum due to the Rupture of Capsular Vasculature in Hepatocellular Carcinoma Patient: A Case Report / 대한법의학회지

Hepatocellular carcinoma (HCC) is one of the leading causes of death in Korea. Chronic hepatitis, alcoholic liver disease and liver cirrhosis are predisposing factor of HCC. Bleeding tendency and hemorrhage resulting from reduced production of coagulation factors or portal hypertension are not uncommon in HCC, moreover spontaneous hemoperitoneum also can occur. Spontaneous hemoperitoneum is a complication of HCC, that is caused by the rupture of HCC mass which abuts on the hepatic capsule. However hemoperitoneum also occurs due to the rupture of vasculature of the mass. Emergency laparotomy is the recommended treatment, however these patients exhibit poor prognosis because of hemodynamic instability followed by combined liver disease. Herein, we report a case of spontaneous hemoperitoneum due to the rupture of subcapsular vessels with invasion of HCC in a 39-years-old man, whose tumor was left undetected.

Medicolegal Review of Deaths Related to Propofol Administration: Analysis of 36 Autopsied Cases / 대한법의학회지

Propofol is a widely used anesthetic in anesthesia and sedation. Recent cases of propofol-induced death have been associated with adverse effects, abuse, or intoxication. However, there are few forensic reports of propofol-associated death. We reviewed and analyzed 36 cases of death related to propofol administration recorded by the National Forensic Service in 2000-2011. The number of women was 28 (77.8%). Subjects in their 20s and 30s accounted for 61.1% of cases. Cause included medical accidents, 16 (44.4%); suicides, 2 (5.6%); and undetermined, 18 (50%; suicide/accident). Of the 16 medical accidents, 8 were internal medicine cases (conscious sedation endoscopy), 3 surgical cases, 3 plastic surgery cases, 1 urology case, and 1 obstetrics and gynecology case. In 20 cases of suicide or undetermined (suicide/accident), the victims were nurses (9 cases), doctors (4 cases), hospital administrators (2 cases), homemakers (2 cases), bar hostesses (2 cases) and an office worker (1 case). The doctor included 2 plastic surgeons, an internist, and a resident anesthesiologist. The autopsy findings were nonspecific; congested parenchymal organs (34 cases), pulmonary edema (8 cases), cerebral edema (2 cases), pulmonary and cerebral edema (2 cases), putrefaction (2 cases), mucosal petechiae in the interior of the larynx (1 case), and cerebral ischemic necrosis and pneumonia (1 case). The blood propofol concentrations ranged between 0.007 mg/L (cardiopulmonary resuscitation) or 0.23 mg/L (no cardiopulmonary resuscitation) and 4.38 mg/L in medical accident cases, and from 0.12 mg/L to 108.3 mg/L in suicide or undetermined (suicide/accident) cases. Other drugs were detected in 17 cases and alcohol was detected in only 2 cases. Blood concentrations in cases of medical accident were lower than in cases of undetermined cause.

Hemorrhagic Infarction of the Small Intestine due to Transmesenteric Hernia in an Adolescent: A Case Report / 대한법의학회지

Transmesenteric hernia is so infrequent that sudden unexpected death due to this condition is a very rare occurrence. Because the disease usually occurs in pediatric populations, it is a very rarely observed in adolescents or adults. We report an autopsy case of transmesenteric hernia diagnosed postmortem in an 18-year-old boy who died suddenly after complaining of acute abdominal pains with nausea. Physical examinations, simple abdominal radiographs, and abdominal CT scans failed to provide a clear diagnosis of the illness for 37 h in the hospital. At autopsy, a small round defect of the small bowel mesentery was found, through which a long segment of the small intestine herniated, accompanied by hemorrhagic infarction induced by strangulation obstruction. We would like to present and review this rare autopsy case with medicolegal viewpoints.

Death due to Cardiac Metastasis after Treatment of Oral Squamous Cell Carcinoma: An Autopsy Case / 대한법의학회지

A 60-year-old man presented with electrocardiographic abnormalities after treatment for oral squamous cell carcinoma with surgical resection and radiation therapy 7 months ago. The patient died within 2 h without response to CPR after sudden arrest. Electrocardiographic changes 9 h before death included low QRS voltage and sinus tachycardia. Autopsy revealed cardiac metastasis with chronic active fibrinoid pericarditis accompanied by tumor cell infiltration. Although the frequency of cardiac metastasis in patients with oral cancer is reportedly low, clinicians should be aware that cardiac metastasis may exist if there are electrocardiographic changes in patients receiving follow-up care for primary malignancy. We report a rare medicolegal case of cardiac metastasis-related sudden death.

Death of a Severe Underweight Infant with Pulmonary Interstitial Glycogenosis / 대한법의학회지

Pulmonary interstitial glycogenosis (PIG) is a very rare interstitial lung disease in infants. It is poorly understood, but its pathological features are distinct; they include uniform alveolar septal thickening, caused by a group of oval to spindle-shaped cells containing abundant glycogen, without apparent inflammation or fibrosis. PIG is usually associated with a good prognosis. However, in the present report, we describe the case of a 5-month-old male infant who died due to PIG; he was severely underweight and not administered proper treatment or care. The pathology of PIG was determined following a medico-legal autopsy.

Pulmonary Hemorrhage with Progressive Massive Fibrosis in a Silicosis Patient: An Autopsy Case / 대한법의학회지

Progressive massive fibrosis (PMF) involves extensive fibrosis of the lung and is usually bilateral in nature. This lesion occurs in patients showing silicosis and other pneumoconioses, including asbestosis, coal workers' pneumoconiosis, or mixed dust fibrosis. PMF tends to exacerbate fairly rapidly and may continue to grow even if the dust hazard is removed. It is frequently associated with functional impairment, including reduction in lung compliance, lung volumes, diffusing capacity, and presence of hypoxemia. However, pulmonary hemorrhage is rarely observed along with PMF. We present an autopsy case of a silicosis patient who died as a result of PMF complicated with massive hemoptysis.

Sudden Death from an Non-diagnosed Paraganglioma after Surgery: A Case Report / 대한법의학회지

Extra-adrenal paragangliomas and pheochromocytomas are rare but clinically important tumors, which produce, store, release, and metabolize catecholamines resulting in unexpected life-threatening effects. It is neither easy nor difficult to clinically diagnose these tumors despite the availability modern clinical methods because signs and symptoms such as recurrent episodes of paroxysmal hypertension and headache are nonspecific. Only a few cases of unexpected death in which the deceased had a non-diagnosed paraganglioma or pheochromocytoma have been reported. Death in these cases is usually sudden and occurs during emergency room care or during a major or minor abdominal operation, without prodromal symptoms. Death is considered to occur because of paroxysmal hypertension, cerebrovascular attacks, abrupt hemorrhage into the tumor parenchyma, or acute left ventricular failure. We report the case of a 73-year-old man who died 12 hours after undergoing decompression surgery for spinal stenosis. A medico-legal autopsy revealed that death in this case resulted from an undiagnosed paraganglioma around the abdominal aorta.

A Sudden Unexpected Death in an Epileptic with Cerebral Cavernous Angioma / 대한법의학회지

Cerebral cavernous angioma is a rare form of vascular malformations which is histologically composed of closely-packed, thin-walled blood vessels without neural tissue intervened. One of the most common symptoms is seizure, which is usually well-controlled by medication or surgery and known to be rarely intractable or fatal. Because sudden, unexpected death in epilepsy patients reveals generally its unclear death mechanism and negative autopsy finding in forensic pathology practice, particular attention should be paid. We recently experienced an autopsy case of 32-year-old woman who had suffered from epilepsy and showed cerebral cavernous angioma on autopsy. We report this case with literature review.

Review on the Use of Laboratory Information Sheet for Autopsy Practice / 대한법의학회지

The forensic medicine department of the National Institute of Scientific Investigation (NISI) designed a form of forensic laboratory information sheet for autopsy practice in 2006. The forensic laboratory information sheet consists of three parts of checklist; the first part concerns death circumstance-related investigatory facts, the second part displays a table of checklist regarding types of forensic scientific tests to be done, and the third describes brief presumptive results of forensic autopsy. This laboratory information sheet reminds forensic pathologists and other forensic medicine staffs to perform appropriate tissue sampling, helps reduce the probability of errors during interdepartmental flow of sampled tissues, and contributes to produce better forensic science results on the basis of good communication. We suggest that this communication form between forensic medicine and science departments should be now considered efficient and actuated especially in areas outside NISI.

Atherosclerotic Progression Attenuates the Expression of Nogo-B in Autopsied Coronary Artery: Pathology and Virtual Histology Intravascular Ultrasound Analysis

The relation of Nogo-B to atherosclerotic plaque progression is not well understood. Thus, the purpose of this study was to assess the expression of Nogo-B in fibroatheromas (FA) of different stages, classified using virtual histology intravascular ultrasound (VH-IVUS) analysis in 19 autopsied cases of non-sudden cardiac death. VH-IVUS imaging analysis was performed 30 mm from the ostium of each coronary artery. VH-IVUS revealed 11 early FAs (34.5+/-8.3 yr), 12 late FAs (42.6+/-16.6 yr), 8 thick-cap FAs (TkCFAs) (46.4+/-11.1 yr), and 6 thin-cap FAs (TCFAs) (51.8+/-6.8 yr). TkCFAs and TCFAs were defined as advanced FA. FA progression advanced with age (P=0.04). VH-IVUS analysis of small, early FAs showed smaller necrotic cores and relatively less calcium compared to more advanced FAs with large necrotic cores (P<0.001). Histopathology and immunohistochemical stains demonstrated that early or late FAs had smaller necrotic cores, less empty space of decalcification, and greater Nogo-B expression compared to advanced FAs (vs. early FA, P=0.013; vs. late FA, P=0.008, respectively). These findings suggest that FA progression is inversely associated with Nogo-B expression. Local reduction of Nogo-B may contribute to plaque formation and/or instability.

Analysis of Clavicular Periosteal Hemorrhages at the Sternocleidomastoid Muscle Origin in Hanging / 대한법의학회지

To evaluate the significance of clavicular periosteal hemorrhage at the sternocleidomastoid muscle origin in hangings, we performed prospective analysis on 62 hanging cases. Periosteal hemorrhages were observed in 40 of 62 (64.5%) hanging cases. Periosteal hemorrhages were found in only one or both at the origin site of the sternocleidomastoid muscle; 4, left; 14, right; 22 both clavicles. The analysis based on the hanging types showed that 13 cases were typical/complete hangings and 15, typical/incomplete, 12, atypical/complete, and 22, atypical/incomplete. Of 40 hemorrhage-cases, 19 cases had the hyoid bone and/or thyroid cartilage fractures. Although no statistical significance was observed between the periosteal hemorrhages and the knot locations, or the types of hanging, or the type of knot, hyoid bone and/or thyroid cartilage fractures was significantly correlated with the hemorrhage. We also analyzed 10 cases of manual and ligature strangulation. In only one of 10 cases, periosteal hemorrhage at both clavicles was observed. Compared with other inner cervical injuries in hangings, periosteal hemorrhage is the most common findings of inner neck lesion. Therefore, clavicular periosteal hemorrhage could be auxiliary feature in diagnosis and interpretation of hanging cases.

Unexpected Sudden Death due to Post-traumatic Apoplexy of Preexisting Pituitary Adenoma; Blunt Force to the Face / 대한법의학회지

Pituitary adenomas are frequent intracranial tumors with generally benign prognosis but acute hemorrhage into tumor with necrosis is a severe complication and can potentially result in fatal outcome, if not diagnosed or treated early. While many precipitating factors have been known, even a mild blunt force shown in this case could play a role in the catastrophic complication of the pituitary adenoma. We report a rare forensic case of post-traumatic apoplexy sustained in a preexisting pituitary adenoma with a mild blunt force to the face.

Description of the Surface Findings with Use of the Revised Korean Surface Anatomical Terms / 대한법의학회지

Forensic medicine doctors in NISI(National Institute of Scientific Investigation) have traditionally used handed-down or old anatomical terms when they put into words the external findings of dead body. And we have had no any traditional rule or accepted guide relevant to the description about the surface anatomy, especially in terms of our practice of forensic pathology and medicine. Korean association of anatomists has taken the head to revise the old anatomy terms mostly occupied with the old Japanese and banal Chinese types, and we have come to see the Hangeul anatomy terms. These new Hangeul anatomy terms are now used by younger forensic pathologists, newcomer forensic doctors, and present medical students. Present more experienced and older pathologists, however, still use the old terms. It is, therefore, no wonder that investigators, policemen, attorneys, judges and even laymen coming in contact with our autopsy reports might be confused with the terms expressed in that official and publicly trusted documents. We felt that it is time for appropriate guideline about describing the surface anatomy to emerge with the viewpoint of forensic medicine. So we explained and depicted what to designate the region which an external finding lies in and how to use the surface anatomy terms.

The plausible practicality of modern high-tech medical imaging devices to forensic medicine and scientific crime investigation / 대한법의학회지

CT and MRI are high-tech devices for medical diagnosis. Their electromechanical function has leaped forward such a fast step, so that their image quality is improved and the time for a whole body scanning is shortened as little as only several minutes. These essential diagnostic tools are tried to apply for the field of forensic medicine in favor of their noninvasiveness and great resolution. These merits could make our postmortem investigation system improve in the aspect of practicality. This presenting study was done for the purpose of expecting what the field of forensic medicine could get or lose, what is needed technically, and what kind of supports are required. In our preliminary study, we gave injuries to the pigs' heads with weapons, scanned the wounds with high-tech devices, and embodied the injuries and the weapons three-dimensionally. These high-tech methods would be expected to play a role in forensic medicine and scientific crime investigation as a new and powerful testimony.

Unexpected Death due to Massive Nontraumatic Intraabdominal Hemorrhage in association with Liver Cirrhosis / 대한법의학회지

We reports a woman's death caused by massive intraabdominal hemorrhage, who was in chronic alcoholic state with advanced liver cirrhosis and found dead in her room. No macroscopic source for the bleeding was found in her intraabdomen and there was no circumstances of traumatic forces to the individual's body around the death. The presenting unsuspected death could be consistent with the forensic pathological cases described as sudden, unexpected death due to massive nontraumatic intraabdominal hemorrhage in association with liver cirrhosis by DiMaio in 1987.

A Death caused by Increased Intraabdominal Pressure due to Spontaneous Intraperitoneal Bladder Rupture / 대한법의학회지

A 45-year-old female with psychosis complained urological symptom of urinary incontinence and voiding difficulty with abdominal pains and expansion during her psychiatric hospitalization and suddenly collapsed at the 14th day of the admission. At autopsy, the urinary bladder showed a focal perforation and the abdominal cavity was filled with massive urinary ascites. The both lower lobes and the right upper lobe of the lung were accompanied by atelectasis. The death mechanism of this case could be explained that an increased abdominal pressure produced by massive uroperitoneum with spontaneous bladder rupture led to respiratory failure. The so-called abdominal compartment syndrome was manifested by massive uroperitoneum and caused a death. This would be the first forensic medical case that an undiagnosed spontaneous bladder rupture resulted in death of a psychiatric illness patient.