Fatal methemoglobinemia in three suicidal sodium nitrite poisonings.

Nitrites are chemicals that are abundant in the environment, widely used as preservatives for meat, and in pharmaceuticals. Volatile products containing nitrites have been used recreationally for the euphoric effect associated with mild hypoxia. Dietary exposure to small amounts is considered harmless. Deaths by ingestion of nitrite salts are not common, but accidental exposure and as suicidal and homicidal agents have been noted. Death is a consequence of oxidation of hemoglobin ferrous (Fe+2 ) iron (Hb) to the ferric (Fe+3 ) form (methemoglobin, MetHb), causing a reduction in the oxygen-carrying capacity of the blood. We report three cases of ingestion of sodium nitrite in two college students (one mildly decomposed) and one adult in early middle age. All of the decedents in these cases developed fatal methemoglobinemia. Sodium nitrite in chemical form was found near the bodies. MetHb was detected in the postmortem blood of each decedent. The MetHb concentrations in the two decedents with a short postmortem interval were less than MetHb concentrations reported in the current literature. The MetHb concentrations reported in the mildly decomposed person were greater than for the other two, but still less than the concentration previously considered lethal. The data from these cases indicate that levels of MetHb can vary widely in fatal cases, and should not be used as the sole criterion for determination of a death caused by sodium nitrite. Following a discussion of the cases, there is a review of the pathophysiology of MetHb production and a current literature review.

Methanol Detected in a Subdural Hematoma as an Embalming Artifact.

Analysis of subdural hematomata has been used to suggest antemortem drug concentrations, with the assumption that materials within the hematoma are less subject to metabolism or degradation during any survival period and postmortem interval. We report the case of an 87-year-old woman whose death had not been reported to the coroner's office until postembalming. Autopsy revealed a traumatic brain injury with subdural hematoma causing a mass effect. Testing of the clot indicated a methanol concentration of 51.8 mg%. No additional analyses were detected. These findings suggest that methanol can be present in a postmortem hematoma sample, yet not represent a poisoning. Our findings also suggest that while the interior of hematomata do not necessarily represent completely "protected space" from postmortem diffusion of some blood constituents, such diffusion is not facile, and analysis may still provide useful indications of antemortem drugs present, if not actual concentrations.

Temperature Influence on Prevailing Necrophagous Diptera and Bacterial Taxa With Forensic Implications for Postmortem Interval Estimation: A Review.

The decomposition process of human (and other mammalian) remains is influenced by numerous factors such as the environmental temperature, relative humidity, precipitation, geographical location of the remains, as well as the medical conditions of and any injuries sustained by the deceased person. The decomposition process generally follows a consistent pattern (fresh, bloat, active decomposition, advanced decomposition, and dry stage). Understanding the time-span of each stage of decomposition and the influence of the biotic and abiotic factors involved is imperative when trying to estimate the time elapsed since death (postmortem interval [PMI]). Over the course of decomposition, the tissues are gradually consumed by necrophagous insects and bacteria. The environmental temperature and its variations influence how insects colonize the remains, having a significant impact on their presence and developmental cycle. Additionally, the bacterial community colonizing decomposing tissues is also greatly affected by variations in environmental temperature. Because both the rate of decomposition of human remains and the relative abundance of certain insects and bacterial species are all temperature-dependent, insect and bacterial colonization data are useful as key points for the PMI estimation. This article reviews the current literature documenting the data collected on the occurrence and development cycles of predominant necrophagous Diptera (Calliphoridae, Muscidae, Sarcophagidae) and bacterial taxa involved in the decomposition of various carcasses at different temperatures. This review will impact the forensic community by providing an overview on the temperature, insect and bacterial records for the PMI estimation, seeking to aid forensic entomologists, microbiologists, pathologists, and the legal community.

Spontaneous rupture of the gall bladder: an unusual forensic diagnosis.

Peritonitis secondary to spontaneous rupture/perforation of the gall bladder is a rare condition overall and is even less common in the forensic population. We report the case of a middle-aged man who died from generalized peritonitis from gall bladder perforation due to acute acalculous cholecystitis. This condition usually occurs in critical patients with systemic illness, and although the exact pathogenesis remains unclear, the development of acalculous cholecystitis appears to be multifactorial. Antemortem diagnosis is reliant upon clinical presentation, laboratory data, and radiologic studies. Surgery and appropriate antibiotics are mainstays of treatment; however, there is an emerging role for minimally invasive procedures. Histopathologic features show significant overlap with the calculous type. Although increasing numbers of acalculous cholecystitis have been diagnosed in the critically ill, the fatal presentation of a perforated gall bladder following an undiagnosed case of acute acalculous cholecystitis is unusual in a nonhospitalized and ambulatory man.

Observed characteristics of suicidal hangings: an 11-year retrospective review.

Many studies have been published regarding suicidal hanging deaths, and most forensic pathologists and coroners are very familiar with such causes of death. Forensic pathologists are challenged over their rulings regarding manner of death in part because the general public has a limited scope of knowledge. One such challenge centers on the question of whether a hanging can be a suicide if the individual is not fully suspended. The authors designed a retrospective study to review suspension in hangings and to analyze other criteria used to help in deciding manner of death. We examined 229 suicidal hanging deaths over an 11-year period (1997 through early 2009) using the data from two separate jurisdictions in Ohio. In conclusion, we found that the vast majority (83.4%) of people who hanged themselves were found partially suspended. Among other criteria analyzed, only the presence of petechial hemorrhages and acute neck injury was statistically significant.

The temporal fate of drugs in decomposing porcine tissue.

Drug levels in decomposed individuals are difficult to interpret. Concentrations of 16 drugs were monitored in tissues (blood, brain, liver, kidney, muscle, and soil) from decomposing pigs for 1 week. Pigs were divided into groups (n = 5) with each group receiving four drugs. Drug cocktails were prepared from pharmaceutical formulations. Intracardiac pentobarbital sacrifice was 4 h after dosing, with tissue collection at 4, 24, 48, 96, and 168 h postdosing. Samples were frozen until assay. Detection and quantitation of drugs were through solid phase extraction followed by gas chromatograph/mass spectrometer analysis. Brain and kidneys were not available after 48 h; liver and muscle persisted for 1 week. Concentration of drugs increased during decomposition. During 1 week of decomposition, muscle showed average levels increasing but concentrations in liver were increased many fold, compared to muscle. Attempting to interpret drug levels in decomposed bodies may lead to incorrect conclusions about cause and manner of death.

Impacted foreign body in the sigmoid colon presenting as recurrent diverticulitis.

We report on a patient with left-sided abdominal pain thought to be caused by recurring diverticulitis. Computed tomography of the sigmoid colon revealed diverticulosis without the presence of a foreign body. During colonoscopy, a phytobezoar in the form of a vegetable stem was discovered transversely impacted within two diverticular openings in the lumen of the sigmoid colon. A localized inflammatory reaction was present without obstruction or perforation. After endoscopic removal of the phytobezoar, the abdominal pain resolved. The patient's presumed diverticulitis was an inflammatory reaction caused by the phytobezoar. This case highlights the importance of early detection and endoscopic removal of a colonic foreign body to prevent abscess formation, fistulas, obstruction, perforation, or peritonitis. Foreign bodies masquerading as colonic diverticulitis should be considered in the absence of more common diseases.

Evaluation of potential lactate/lactate dehydrogenase interference with an enzymatic alcohol analysis.

The Connecticut Department of Public Safety laboratory recently addressed a legal challenge to a hospital alcohol dehydrogenase (ADH)-based serum ethanol determination based on the suggestion of interference by lactate dehydrogenase (LDH)-catalyzed oxidation of lactate. Both ADH- and LDH-oxidations require NAD(+) (present in excess in the assay). NADH produced by LDH-catalyzed lactate oxidation in the assay is interpreted as derived from ethanol. Hepatic trauma was suggested as the basis for elevated levels of lactate and LDH. Clinical laboratory results were evaluated, specifically serum hepatic enzymes, ions, and anion gap. Aspartate aminotransferase (ASAT) and alanine aminotransferase (ALAT) were 229 and 144 U/L, respectively (approximately 8x and 4x reference range midpoint values). Na(+), K(+), Cl(-), and CO(2) levels were 143, 3.0, 112, and 20 meq/L, respectively, yielding an anion gap of 8 meq/L (ref. range 8-15). Serum lactate contributes to "unmeasured anions"; hence, the anion gap was inconsistent with a significant lactate elevation. Based on the slight elevation of ASAT and ALAT, LDH levels were estimated to be elevated to no more than 10-fold. Calculation of the amount of LDH and ADH present in the ethanol assay suggest an ADH/LDH ratio of 200:1. Hence, contribution by lactate oxidation to the serum ethanol concentration in this case would have been negligible.

Human identification from the ankle with pre- and postsurgical radiographs.

Fifty-four sets of presurgical ("premortem") and postsurgical ("postmortem") foot and ankle radiographs were retrospectively evaluated to simulate a postmortem identification. The entire foot and ankle was examined in a previous study. The present study evaluates only the ankle for positive identification. Results are consistent with our earlier investigation of pre- and postsurgical foot and ankle radiographic comparisons and indicate that surgical intervention with subsequent healing does not preclude positive identification. However, the ankle contains fewer skeletal features unique to an individual than does the entire foot. Hence, the ankle may be less useful than the foot for establishing positive identification from radiographic comparisons.

Forensic implications of the foot and ankle.

To clinicians, forensic medicine and the foot and ankle complex may appear to have little connection. However, if decomposed, burned, fragmented, or skeletonized human remains are recovered, the foot and ankle can provide information leading to identification and incident analysis. Furthermore, analysis of data collected at accidents can lead to safety modifications. This article reviews common elements of forensic medicine applied to the foot and ankle in 2 areas: establishing positive identification by using radiographic comparisons and analyzing aviation incidents. An understanding of these cases will enhance clinicians' awareness of the potential forensic value of the foot and ankle.

Using pre- and post-surgical foot and ankle radiographs for identification.

An evaluation of the effect of surgical intervention on foot and ankle radiographic comparisons was performed. In this study, 34 sets of pre-surgical ("premortem") and post-surgical ("postmortem") foot and ankle radiographs were retrospectively evaluated simulating a postmortem identification. In each radiographic set, the films were separated by a surgical event to reproduce the effects of an alteration in the anatomy. The radiographs included both matches and mismatches. This study also presents a numerical representation of the reliability of a radiographic match following a surgical procedure. Results indicate that surgical intervention with subsequent healing does not preclude positive identification in foot and ankle radiographic comparisons.

Identification of decomposed human remains from radiographic comparisons of an unusual foot deformity.

A case of positive identification from decomposed human remains using an unusual foot deformity is presented. Scrutiny of the decedent revealed foot deformities, which upon examination, prompted further inquiry. Radiographic comparisons and defleshing each foot established bilateral talipes equinovarus (TEV, clubfoot). Positive identification was based upon unique skeletal features present in the radiographs.