Secondary sclerosing cholangitis in critically ill patients after a traffic accident-a new entity that should be considered in death classification.

A 49-year-old female sustained a polytrauma after being hit by a vehicle in a traffic accident. Following the incident, the woman had various surgical interventions and underwent intensive care over a 6-week period. Eight months later, she died after developing secondary sclerosing cholangitis (SSC). Autopsy revealed liver failure and hepatic encephalopathy due to SSC caused by the polytrauma and the subsequent intensive care. Prior to the accident, there was no evidence of a pre-existing liver or biliary system disease. The death of the patient was classified as non-natural as a causal consequence of the traffic accident. SSC has been clinically described as a complication of intensive care. Since it has a high mortality rate, it is important that forensics and pathologists are aware of the condition.

Make-up and love bites: two reports about exceptional cases of self-inflicted "injuries".

Self-inflicted injuries and their differentiation from inflicted injuries may have severe legal implications. The detection of these injuries is an important task in clinical forensic medicine. We present two cases of skin discolorations caused by using make-up and suction of the skin which have only rarely been reported. In the first case a 19-year-old woman asserted she was punched against her left clavicle and her right eye by a perpetrator, and that during the following forced sexual intercourse she had been bitten on the neck. On medicolegal examination 3 days later dark blue, shimmering discolorations at her right eyebrow, the left side of the neck and the left clavicle were seen. At first sight these discolorations appeared as bruises; however, they could easily be removed by a simple wipe with a finger. In the second reported case a 23-year-old woman reported she had been assaulted by two men who forcefully pressed her against a wall, partially undressed her and forced her to touch and rub one man's penis. Medicolegal examination 32 h after the incident revealed several round to oval shaped, reddish to brown discolorations on both of her upper arms resembling so-called love bites created by suction. In both cases the preliminary investigation by the public prosecutor were closed. However, case 1 is still subject to legal investigations due to false incrimination. Self-infliction of injuries should always be considered in forensic examinations, even if they do not follow the classical pattern.

An autopsy approach to bolus deaths.

BACKGROUND: The term "bolus death" or "cafe coronary" refers to a misplaced larynx or laryngeal inlet by foreign bodies, in most cases by unchewed pieces of food such as meat, sausage, or fruit. The pathophysiologic mechanism of death is still debatable - sudden reflex cardiac arrests and asphyxial suffocations are implicated. In particular, children, alcoholics, and persons with brain-related damages belong to this risk group. A defective dentition is also associated with the risk of bolus deaths. AIM: The aim of the study was to supplement existing literature by evaluating cases of bolus deaths and determining the most likely mechanism of death in a large autopsy sample. MATERIAL: Among 31,647 autopsies, 59 cases of cafe coronary syndrome were identified and evaluated: 38 male adults and 21 female adults between the ages of 26 and 89 years. METHODS: A retrospective analysis of autopsies performed in the Institutes of Forensic Medicine in Rostock (1990-2014) and Munich (1990-1999) was conducted. Autopsy findings, circumstances of death, police investigations, preexisting conditions, dentition, and toxicological investigations were recorded. Then, based on the presence or absence of selected findings and surrounding circumstances, conclusions on the mechanism of death were drawn. RESULTS: In eighty-six percent (86%), boluses of meat and sausage or meat-like chunks were observed. Of the forty-nine victims, 22 (42%) had elevated blood alcohol levels (>0.5‰) with blood alcohol concentration (BAC) levels of >0.73‰ to <3.99‰. Of the nonalcoholized decedents, 63% had neurological disorders and 11% had preexisting cardiac conditions. CONCLUSIONS: Detecting potential bolus events upon autopsy and the resulting mechanism of nonnatural deaths are of great importance. Therefore, the medical history, resuscitation protocol, and detailed description of the scene of death are essential. Upon autopsy, the type and position as well as size and weight of the bolus and dental status of the victims should be documented in a standardized manner. Additional toxicological investigations are necessary.

Death within 44 days of 2,4-dinitrophenol intake.

We report the case of a 50-year-old obese man (115 kg body mass at 1.77 m height), who started taking 2,4-dinitrophenol (DNP) for weight reduction 44 days before his death. After 43 days of taking DNP, the man showed signs of intoxication with nausea, vomiting, and attacks of sweating. After admission to a hospital where the man concealed his DNP intake, sinus tachycardia, tachypnea, and general unrest were noted. The patient died 9 h after the onset of those symptoms. Upon autopsy, a yellowing of palms and soles was striking. The initially uncertain cause of death could only be clarified by the forensic toxicological examinations and subsequent police investigations. Finally, the man had a total intake of 12.3 g of DNP in 44 days which is relatively high compared to other lethal DNP intoxications.

Histologic spectrum of the cardiac conducting tissue in non-natural deaths under 30 years of age: an analysis of 43 cases with special implications for sudden cardiac death.

In the past, histological findings of the cardiac conduction system or its adjacent structures, such as filiform fibers at the transition from bundle of His to bundle branches, connective tissue at the apex of the ventricular septum, or fibromuscular alterations of the arteries has been considered as a cause of death. However, the prevalence of such findings in a healthy population has been rarely analyzed systematically. In the present study, the morphology of the cardiac conduction system of 43 heart-healthy individuals who died of non-natural causes (ages 0 to 30 years) was investigated. In a high percentage of cases, connective tissue at the apex of the ventricular septum (97.7%), filiform fibers at the transition from bundle of His to the bundle branches (27.9%), and fibromuscular proliferations of the sinoatrial node artery (41.9%), and the AV-node artery (39.5%) could be detected. Based on our observations, these alterations should not be considered as a pathologic entity or as a cause of death.

Fibromuscular dysplasia of cardiac conduction system arteries in traumatic and nonnatural sudden death victims aged 0 to 40 years: a histological analysis of 100 cases.

BACKGROUND: Since 1967, numerous case reports have described fibromuscular alterations of the sinus node artery and/or the atrioventricular node artery as a potential cause of death. However, the prevalence of these changes in a healthy population has only rarely been investigated systematically. METHODS: The arteries of the cardiac conduction system were studied systematically, by means of routine histology, in 100 cases of victims aged 0 to 40 years with a nonnatural cause of death. RESULTS: Microscopic alterations were seen in the walls of sinus node arteries in 52 out of 100 cases, in the walls of atrioventricular node arteries in 63/100 cases, and in the walls of small vessels in 60/100 cases. CONCLUSIONS: The results demonstrate that microscopically detectable findings of the cardiac conduction system arteries similar to fibromuscular dysplasia do not indicate a defined disease and should not be considered as a cause of death when there are no macroscopic findings in the coronary arteries.