Sudden Unexpected Death in Epilepsy: A Retrospective Autopsy Study of 112 Epileptic Patients.

INTRODUCTION: Sudden unexpected deaths comprise the most important and worthy investigation case profiles in both neurology and forensic medicine. Epilepsy, which is one of the neuropathological causes of sudden unexpected deaths, is an important disorder having mysterious aspects. The aim of this study is to make common the points of view between neurology and forensic medicine experts and to discuss the features of the findings together with the related clinical hypotheses, leading to the differential diagnosis of sudden unexpected death in epilepsy (SUDEP) by presenting autopsy findings and available medical data of patients who had a prior diagnosis of epilepsy. METHODS: In Istanbul, the cases of 20334 autopsied patients who were referred to The Ministry of Justice Council of Forensic Medicine between 2007 and 2011 were identified from the complete forensic autopsy data of the city and were retrospectively reviewed. Patients who had a prior diagnosis of epilepsy were included. Both descriptive and inferential statistical analyses were performed through the parameters of demographical data, physical properties, incident features, macroscopic-microscopic autopsy findings, and cause of death initially for all cases and then separately for SUDEP cases. RESULTS: Among the 20334 patients, 112 were determined to have a prior diagnosis of epilepsy. A possible macroscopic and/or microscopic epileptic focus was present in 23 (20.5%) of these 112 cases. The cause of death was determined to be SUDEP in 40 (35.7%) cases, while it could not be determined in 28 (25%) cases. Among patients whose death cause was considered as SUDEP, the male-to-female ratio was 1.1:1, while the mean age was 31.5±13.9 years in males and 29.6±12.9 years in females. The presence of hypertrophy and myocardial scar tissue findings in the microscopic examination were significantly more frequent among patients determined to have died from cardiovascular diseases compared to patients in the SUDEP group (p=0.001 for each finding). Besides, in 40 SUDEP cases, 38 (95%) patients underwent toxicological analysis and no antiepileptic agent was detected in 21 (55.3%) of these. CONCLUSION: It can be concluded that there is equality in gender distribution among SUDEP patients, that the young adult population has a slightly increased risk for SUDEP, and that the inconsistent use of antiepileptic medicines is a greater risk factor for SUDEP than polytherapy. Besides, it is important to emphasize that all clinical and postmortem parameters together should be considered for the differential diagnosis of SUDEP, particularly with cardiovascular diseases.

Colchicine-Induced Rhabdomyolysis: An Autopsy Case.

Colchicine is derived from Colchicum autumnale and Gloriosa superba and is used to treat acute gout and familial Mediterranean fever (FMF). Musculoskeletal adverse effects range from myopathy to rhabdomyolysis. An 18-year-old woman, with a 2-year history of FMF treated with colchicine, took 9 colchicine pills (4.5 mg) to relieve severe abdominal pain. On the sixth day of hospitalization, the patient's condition worsened, and she died. As this was a case of fatal poisoning, a forensic autopsy was performed, and the cause of death was determined to be complications of muscle destruction due to colchicine intoxication with the findings of myocytolysis, positive antimyoglobin antibody staining kidney tubules. Colchicine toxicity begins with gastrointestinal symptoms. Multiorgan effects follow the gastrointestinal effects. Serious outcomes of colchicine toxicity are rhabdomyolysis, bone marrow suppression, and disseminated intravascular coagulation. In chronic diseases that require lifelong treatment with medications, adverse effects can arise with long periods of use. Our patient had been treated for FMF with colchicine for 2 years but took too many colchicine pills to relieve her severe abdominal pain. Warning patients about the effects of high doses of drugs and providing information about their toxic effects and what to do "in case" of overuse could be lifesaving.

Violence against women: A series of autopsy studies from Istanbul, Turkey.

Death is the most severe consequence of violence against women. The purpose of this study was to determine the frequency of violence-related deaths among women and the general characteristics of fatal violence cases against women in Istanbul, Turkey. A total of 20,486 forensic autopsies performed between 2006 and 2010, in Istanbul, were retrospectively analyzed. Of these, 537 violence-related deaths among women were included in the study. The victims were investigated in terms of sociodemographic characteristics, exposed type of violence, and autopsy findings. Out of all female deaths (n = 4165), 12.9% were due to violence against women, which comprised 2.6% of all autopsies (n = 20,456) performed during the study period in Istanbul. The median age of the victims was 43 years, and a significant proportion of victims (49.7%) were between the ages of 21 and 40 years. The deaths occurred most commonly in private residences (51.2%, n = 275), whereas the street was the crime scene for 14.5% (n = 78) of cases. Firearm injuries (50.1%, n = 269) were the most common cause of death, followed by stab wounds (28.3%, n = 152) and strangulation (8.4%, n = 45). Among the identified perpetrators, 52.3% were victims' spouses or boyfriends. The perpetrators were female in 4.4% (n = 16) of cases. Istanbul is the most important and cosmopolitan city of Turkey, representing the country's cultural characteristics. Therefore, the data obtained in this study may be strong indicators of violence against women in Turkey.

Custody and prison deaths autopsied in Istanbul between 2010 and 2012.

The occurred death of a convict in prison, police custody cell or in a hospital always attracts public attention and can be considered as a complex phenomenon. The aim of this study is to evaluate the data obtained from autopsies performed to the custody and prison deaths in Istanbul and to discuss the possible solutions by comparing with the literature. It is also aimed to discuss the postponement of the sentence and presidential amnesty facts in Turkey. Deaths of inmates, which occurred in hospitals, prisons, prison medical rooms, police vans and police custody cells between 2010 and 2012 in Istanbul, Turkey were included in the study. Totally 125 cases were found and 98.4% of them were male. Natural deaths accounted for a great majority of deaths (83.2%). The most common natural cause was cardiovascular diseases. Unnatural deaths accounted for 15.2% of the deaths. Death reason cannot be determined for 1.6% of the cases. More than half of the cases (56%) were died at the hospital, 34.4% were died at the prison, 4% of them at the police van, 3.2% were died under police custody and 2.4% were died at the prison medical room. Moreover, twelve of these cases had applied to Third Specialization Board previously for postponement of the sentence or Presidential amnesty. Totally five of these cases found suitable for postponement of the sentence. Prison conditions should be improved, prisoners with chronic diseases should be examined periodically and if appropriate their sentences should be postponed until they heal.

Postmortem diagnosis of cytomegalovirus and accompanying other infection agents by real-time PCR in cases of sudden unexpected death in infancy (SUDI).

As an opportunistic pathogen with high mortality rates, Cytomegalovirus (CMV) may lead to fatal disseminated CMV infection of the premature and newborn; thus necessitating the demonstration of CMV-DNA with clinical history and/or histopathological findings of CMV infection and defining other bacterial and viral infection agents with real-time polymerase chain reaction (RT-PCR) in udden unexpected death in infancy (SUDI) cases as we aimed in this study. 314 (144 female, 170 male) SUDI cases were prospectively investigated from January 2013 to January 2015 in Istanbul Forensic Medicine Institution. The study includes 87 tissue samples of 39 cases for post-mortem histopathological examination of interstitial pneumonia, myocarditis, meningitis, encephalitis, hepatitis, colitis or tubulointerstitial nephritis and/or accompanying chronic sialadenitis. CMV-DNA was found positive in 35 (40.2%) salivary gland, 19 (21.8%) lung, 1 (1.1%) tonsil, and 1 (1.1%) brain tissues. CMV sialadenitis and/or CMV pneumonia associated with other viral and/or bacterial agents were detected in 23 (60%) of 39 infant cases. The demonstration of CMV-DNA would significantly clarify the cause of death and collection of epidemiological data in SUDI cases with clinical history and histopathological findings of CMV infection accompanying chronic CMV sialadenitis. Furthermore, CMV suppresses the immune system, and may predispose to other bacterial and/or viral infections in these cases. Post-mortem molecular investigations are useful in explaining cause of death in SUDI with a suspicion of infection in forensic autopsies.

[An Autopsy Case of Sudden Death Caused by Cerebral Malaria Infection]. / Serebral Malarya Enfeksiyonuna Bagli Ani Ölümle Sonuçlanan Otopsi Olgusu.

Malaria is a lethal protozoan infection which is generally diagnosed antemortem and rarely diagnosed postmortem in a few cases. A fifty five year old, Turkish citizen male has been referred for autopsy. It has been found that he has gone abroad to work a month ago, however, quitted malaria prophylaxis before the intended end and brought into the emergency department in an unconscious state.Following quinine and clindamycin treatment with the initial diagnosis of cerebral malaria, the case was reported to have died due to his general condition got worsened at the end of the third day of therapy.Histopathological evaluation of postmortem tissues was revealed haphazardly arranged minor bleedings and central vascular necrotic foci in the cerebrum, cerebelum and brain stem; light brown pigment containing cells around vasculature; and pigment containing cells in the spleen and bone marrow. Cerebral malaria has a rapid course and is rare but one of the lethal complications of infections with Plasmodium. Although domestic malaria cases has been decreasing in our country, it should be kept in mind that the malaria infection can be seen in persons travelling abroad to high endemic malarial regions and an appropriate antimalarial prophylaxis should be recommended to those overseas travellers.

Evaluation of forensic deaths during the month of Ramadan in Konya, Turkey, between 2000 and 2009.

Ramadan is a holy month for Muslim people and includes long fasting periods. During Ramadan, practicing Muslims not only fast, but they also abstain from any kind of medication, smoking, sexual intercourse, and alcohol from sunrise to sunset. In the 10-year period between 2000 and 2009, it was determined that a total of 4881 death examinations and autopsies were performed at the Konya Branch of the Forensic Medicine Council (Turkey). All of the reports were retrospectively evaluated for demographic features of the cases and the manner of death. In the studied time period, a total of 491 deaths (10.1%) occurred in Ramadan. The manner of death was accident in 369 (75.2%) of the cases in Ramadan, 3107 (70.8%) of the other cases; suicide in 27 (5.5%) of the cases in Ramadan, 367 (8.4%) of the other cases; and homicide in 28 (5.7%) of the cases in Ramadan, 375 (8.5%) of the other cases. There was a significant statistical difference in terms of the manner of death between the deaths in Ramadan and in the remaining part of the year (P < 0.05). Our study suggested that there was an increase in accidental and natural deaths and a decrease in suicide and homicides in Ramadan.

Fatal injury by an unmodified blank pistol: a case report and review of the literature.

In this paper, we report a fatal neck injury of suicidal origin of a 29-year-old man. A 9-mm blank pistol and several blank cartridges in a plastic bag were discovered near the victim. There was an irregular and contuse oval contact-entrance wound of 25 mm × 20 mm with a muzzle imprint on its upper medial part on the right side of the neck. The cause of death was exsanguination due to injuries to the right external carotid artery and the right jugular vein. This case confirms that blank pistols, contrary to public opinion, are dangerous and may inflict potentially fatal injuries when fired at close or contact range. In addition, previously reported 18 fatal injuries by blank cartridges caused by unmodified blank pistols between 1990 and 2009 are reviewed and summarized. It is concluded that as blank pistols may cause fatal injuries even without any modification, it is necessary to develop new standards for their production.

Higher prevalence of toxoplasmosis in victims of traffic accidents suggest increased risk of traffic accident in Toxoplasma-infected inhabitants of Istanbul and its suburbs.

Reflexes of drivers who have toxoplasmosis have been shown to deteriorate from the actions of the parasitic cysts. The cysts can change the level of the neurotransmitters such as dopamine in the brain and by doing so extend the muscle response time and change personality profiles. In this study, we aimed to determine the frequency of the latent toxoplasmosis (LT) in the driver population who were either injured or died in traffic accidents reported in Istanbul and its suburbs. We compared the results with a control group and discussed the relationship between the LT and the traffic accidents. We included 218 (89.7%) non-fatal, 25 (10.3%) fatal cases in our study as study groups. A total 243 subjects, 234 (96%) male, 9 (4%) female (who were alcohol negative) compared with 191 (95.5%) male and 9 (4.5%) female subjects (control group) who had a traffic accident before but no history of toxoplasmosis were studied. Serologic tests, enzyme immunoassay (EIA) for IgG and IgM, and microimmunoflorescence (MIF) for IgG were used as the reference test, the Sabin-Feldman Dye test (SFDT) was used. According to serologic test results, LT seroprevalence in the study groups was 130 (53.5%) and in the control group 56 (28%) (p<0.0001). A LT was present in 126 out of 234 (53.8%) males in the study groups, and 54 out of 191 (28.3%) males in the control group (p<0.0001). In the 31-44 year age group, there was a significant difference with regard to toxoplasmosis between the study subjects and control groups (p<0.0001). This difference was statistically very significant in (recent and former) cases with middle-aged men (31-44 years old). The results of this retrospective study suggest that LT in drivers, especially those who are between 31 and 44 years might increase the risk for getting involved in a car accident. In a prospective study, Toxoplasma positive and negative subjects can be monitored before they are involved in a traffic accident to clarify the cause and result relationship.

Image analysis as an adjunct to sodium rhodizonate test in the evaluation of gunshot residues: an experimental study.

It is important to investigate the clothing, as well as the body, to determine the range of fire of entry wounds in firearm injuries. Clothing can affect the amount of gunshot residues (GSR) reaching the body and their distribution. The amount and distribution of the GSR also vary according to the distance between the firearm and the target. Sodium rhodizonate test provides valuable data when clothing is available for examination. In the absence of clothing, light microscopic examinations may add additional information regarding the range of fire. In this study, a sodium rhodizonate test was done on 80 garment samples containing the bullet entrance. The 80 calfskin samples were processed histologically and were stained using Alizarin Red S. These were also evaluated with computer-assisted image analysis. Gross residues were seen on military camouflage clothing in samples from < or = 45-cm group. White flannel undershirts under the military camouflage contained rhodizonate-positive particles only around the contact wounds. With image analysis, however, the residues could be detected also in the skin samples of the 2.5-cm- and 5-cm-range groups. We suggest that the image analysis can be combined with other techniques and it can provide valuable data in the determination of entry wounds and also in the estimation of firing distance.

Cardiac myxoma: an unusual cause of sudden death in childhood.

Primary tumors of the heart and pericardium are rare in autopsy series. Considering all age groups, the most common cardiac tumor is the myxoma. They may arise in any of the four chambers or, rarely, on the heart valves. About 90% are located in the atria, with the left-to-right ratio of 4:1. The majority of patients are usually in the age group of 30-60 years. Female predominance has been reported. In this report, we describe a six-year-old boy with right atrial myxoma. A 5x4x3 cm, polypoid, smooth-surfaced, brown-colored tumor was found in the right atrium. It was attached by the stalk to the atrial septum. Microscopically, the tumor had the typical appearance of a myxoma with spindle cells widely spaced by abundant myxoid matrix. The diagnosis was based on histopathological and immunohistochemical findings. Sudden death may occur in patients with atrial myxoma. Death is caused by coronary or systemic embolization or by obstruction of blood flow at the mitral or tricuspid valve.

Estimation of stature from upper extremity.

With the increasing frequency of mass disasters, identification of an isolated upper extremity and determination of the stature of the person it belonged to have created problems for investigation of the identity of some victims. Despite a need for such a study, there is a lack of systematic studies to identify fragmented and dismembered human remains. The purpose of this study was to analyze anthropometric relationships between dimensions of the upper extremity and body height. Analyses were based on a sample of middle class male (n = 202) and female (n = 108) Turks residing in Istanbul, Turkey. Five variables were entered into the analyses. For male subjects, forearm length was selected as the first factor, followed by hand length and finally upper arm length. For female subjects, upper arm length was selected first, followed by forearm length and finally hand length. There were also individually calculated formulae for some of these measurements that provided smaller R2 values. The study suggested that estimation of a living height could be made possible by using various dimensions of the upper extremity. One must consider differences between populations to apply such functions to other populations.

Determination of gunshot residues with image analysis: an experimental study.

In firearm injuries, assessment of the firing range and determination of entrance and exit wounds are important. For this reason, evaluation of the amount and distribution of gunshot residues (GSRs) is necessary. Several methods and techniques for GSR analysis have been developed. Although these methods are relatively sensitive and specific, they may require expensive dedicated equipment. Therefore, a simple, easily applicable, more convenient method is needed. A total of 40 experimental shots were made to calf skin from distances of 0, 2.5, 5, 10, 20, 30, 45, and 60 cm. Eighty samples were taken from the right and left sides of the wounds, and Alizarin Red S dye staining was performed. The amounts of GSR particles were measured with image analysis. GSRs were detected in all shots. The mean size of the distribution area of barium and lead elements around the wound had a significant negative correlation with increasing shooting distance (r = -0.97, p < 0.001). As the distance increased, the amount of GSR decreased, and this decrease rate was nonlinear. Variance analysis suggested significant differences between data groups depending on range (p < 0.001). The image analysis method may solve some of the standardization problems for evaluation of GSRs. GSR detection with the image analysis method does not require experienced personnel and may be a suitable method for scientific studies and for routine purposes.

Estimation of stature from body parts.

Anthropometric technique commonly used by anthropologists and adopted by medical scientists has been employed to estimate body size for over a hundred years. With the increasing frequency of mass disasters, the identification of an isolated lower extremity and the stature of the person it belonged to has created problems for the investigation of the identity of some of the victims. In spite of a need for such a study, there is a lack of systematic studies to identify fragmented and dismembered human remains. The purpose of the paper is to analyze anthropometric relationships between dimensions of the lower extremity and body height. Analysis is based on a sample of middle class male (N=203) and female (N=108) adult Turks residing in Istanbul. The participants are mostly students and staff members of a medical school, and military personnel. Measurements taken are stature, trochanteric height, thigh length, lower leg length, leg length, and foot height, breadth, and length. Of the five variables entered into the regression analysis, all but foot breadth participate in the analysis with leg length as the first and followed by thigh and foot lengths, and finally foot height in males (R(2)). There were also individually calculated formulae for some of these measurements which provided smaller R(2)-values. Student's t-test to assess if there was any intraobserver error in measurements take by individual anthropometrist did not show such any statistically significant difference. In conclusion, the study suggested that estimation of a living height can be made possible using various dimensions of the lower extremity. One must consider differences between populations in order to apply functions as such to others.

Fatalities due to methyl alcohol intoxication in Turkey: an 8-year study.

The aim of this study is to examine methyl alcohol poisoning cases from the medico-legal point of view. The records of the Morgue Department of Council of the Forensic Medicine were reviewed retrospectively for all methyl alcohol poisonings for the period of 27.10.1992 and 30.05.2001. The victim's age, sex, death year, death place, methyl alcohol blood levels, the source of methyl alcohol, accompanying laboratory results and histopathologic tissue changes were recorded. The number of deaths due to the methyl alcohol poisoning was 271 during that period of time. Two hundred and forty-two of the (89.3%) total 271 methyl alcohol fatalities were men and 29 (10.7%) of were women. The largest age group was 36-40 years old, followed by 41-45. The methyl alcohol blood concentrations ranged widely from 50 to 755 mg for per 100 ml. There were 222 cases (81.9%) with the methyl alcohol blood concentrations over 100 mg/dl. Twenty-nine (10.7%) victims were poisoned through the consumption of cologne and three of them with alcoholic beverage named "Raki". Consumed products were not known in all other cases because of insufficient patient history and data. As a conclusion, regarding the distribution according to years, mortality due to methyl alcohol intoxication in our country have been proceeding on a certain level. In order to decrease the mortality due to methyl alcohol intoxication, some precautions should be developed that could prevent the production and consumption of alcoholic beverages illegally produced.