Lethal asphyxiating juvenile laryngeal papillomatosis. A case report with human papillomavirus in situ hybridization analysis.

Chronic, progressive, and recurrent laryngeal papillomatosis is an uncommon problem that primarily occurs in children and has been shown (in the pediatric age group) to be caused by human papillomavirus (HPV) types 6 and/or 11. Juvenile laryngeal papillomatosis is hallmarked by recurrences, necessitating repeated surgical procedures to maintain airway patency, and is rarely encountered cause of sudden and unexpected death. This case describes a 22-month-old girl who had been treated for laryngeal and pharyngeal papillomata that were diagnosed 3 months prior to her death, and who died in her sleep the night before she was to be again laryngoscoped and reevaluated. The autopsy disclosed exuberant, complex exophytic papillomata that essentially obliterated the laryngeal lumen. In situ hybridization analysis was performed on paraffin-embedded tissue, which revealed HPV type 6/11 positivity. This is the first time that in situ hybridization studies have been performed on autopsy tissues from someone who died suddenly and unexpectedly from upper-airway obstructive papillomatosis. The pathology and clinical characteristics of juvenile laryngeal papillomatosis are also presented and discussed.

Achalasia, the Valsalva maneuver, and sudden death: a case report.

A 48 year old woman with no significant prior medical history was found dead by her husband in their home. The autopsy disclosed no anatomic reason for her death; however, the length of the esophagus was found to be massively dilated, with stenosis of the cardiac sphincter, and contained swallowed food material. Her husband disclosed that she had experienced difficulty in swallowing for over 10 years, and had to "strain" to move food into the stomach, although she had never consulted a physician regarding the problem. No gross or microscopic anatomic cardiac abnormalities were identified. The death was ascribed to a cardiac arrhythmia arising from the Valsalva maneuver, which she used to move her ingested food across the stenotic gastroesophageal juncture. The Valsalva maneuver, which increases the intrathoracic pressure by forcing expiratory effort against a closed glottis, has been associated with cardiac arrhythmias and rarely, sudden death. Lethal cardiac arrhythmias should be considered when sudden deaths occur in individuals with esophageal motility disorders, as well as in other situations where the Valsalva maneuver may have been used, and where no other anatomic cause of death is identified.

The use of hydrogen peroxide to visualize tattoos obscured by decomposition and mummification.

Tattoos are distinctive, potentially important acquired identifying features that last for the life of the bearer, and persist into the postmortem period. However, the accumulation of decompositional pigments in the skin and subcutaneum will obscure tattoo designs. By treating the area with 3% hydrogen peroxide, the dark red-black decomposition products are temporarily removed, allowing underlying tattoos to be located, and photographed for identification purposes.

Scleral and conjunctival hemorrhages arising from a gunshot wound of the chest: a case report.

A young man committed suicide in the back seat of an automobile, witnessed by two law enforcement officers sitting in the front seat who had attempted to dissuade him from killing himself over an eight hour period. Death was caused by a contact gunshot wound of the anterior chest, which entered the midsternum and disrupted the anterior right atrium and ventricle of the heart, without involvement of either left ventricle or atrium. At the autopsy, bilateral fresh, confluent scleral and conjunctival sulcus hemorrhages were discovered, with no other evidence of facial or intracranial trauma. These hemorrhages are postulated to have arisen from a sudden pressure wave ascending through the superior vena cava, in a manner similar to the ocular findings associated with the retrograde venous blood flow that occurs during severe thoracic compression. These hemorrhages should not be mistaken for evidence that a decedent was beaten or otherwise involved in an assault episode.

Distinctive blunt force injuries caused by a crescent wrench.

Prompt recognition of patterned injuries by the forensic pathologist can greatly facilitate the investigation and resolution of injury and death cases. Careful observation and description of injuries may provide identification of an assault or murder weapon and contribute to the reconstruction of circumstances of injury. The two cases herein described manifest unusual and distinctive injuries resulting from multiple impacts by adjustable crescent wrenches. Detailed photographs and descriptions of these injuries are provided.

Tattoos and tattooing. Part II: Gross pathology, histopathology, medical complications, and applications.

Tattooing involves piercing the skin with needles bearing various pigments, to cause the permanent imprint of a design. The body responds to these incursions in specific and predictable ways, with initial sloughing of the overlying epidermis, variable dermal inflammation, and gradual assimilation of the pigment into macrophages. Eventually, much of the pigment is carried to the regional draining lymph nodes, with a residue staying within macrophages localized to dermal perivascular regions. The age of tattoos may be estimated, both grossly and microscopically. Tattooing can result in a variety of relatively uncommon complications and adverse reactions to the pigment, and certain infectious diseases may be inadvertently transmitted through tattooing when the instruments are inadequately sterilized, or when poor technique is used. This article, the second of three, describes the gross and microscopic pathology of both fresh and healed tattoos, and discusses the various complications (infectious and otherwise) that can occur. Tattooing has specific applications in both dermatology and plastic and reconstructive surgery, and these are also discussed.

Tattoos and tattooing. Part I: History and methodology.

Most medical examiners and pathologists who routinely perform autopsies identify tattoos on a daily basis. However, these dermagraphics generally are given only cursory inspection and description, if at all, although many pathologists photograph particularly unique, unusual, or bizarre examples. From a medicolegal perspective, these permanent skin designs are most often used as identification markers, especially in cases of unknown or questionable identity. The majority of pathologists and other physicians are not familiar with the way in which tattoos are applied, much less the history of this unusual art or the various aspects of tattoos that may provide even more complete information as to how, where, why, and when the tattoos were done. This article, the first of three parts, provides a brief but comprehensive history of tattooing from both the worldwide and Western perspectives, describes how professional tattooing is done, and illustrates the machines involved and the various constituents of the inks that are currently used. The second and third articles will explore the gross and histopathology of tattoos, methods of tattoo removal, medical applications and complications associated with tattoos, psychology and psychopathology of tattoos, and the importance of tattoos in forensic medicine.

Radiographic identification by mastoid sinus and arterial pattern.

A skull and some incomplete postcranial remains were discovered in two searches over a two-month period near Santa Fe, New Mexico. The discoveries could be demonstrated to be from the same person, and the remains were shown to be consistent with a specific missing person on the basis of anthropological analysis. Further work led to a positive identification on multiple grounds, including agreement of the details of the mastoid sinus and endocranial arterial patterns observed radiographically. These features may be useful for establishing positive identification from skeletal remains when antemortem radiographic studies for comparison are limited to lateral cranial vault studies.

Fatal ethanol intoxication from household products not intended for ingestion.

Fatal acute ethanol intoxication is frequently encountered in medicolegal practice. Although the vast majority of acute ethanol toxicity deaths follow the ingestion of conventional alcoholic beverages, ethanol can be obtained from a variety of commercial products, which often contain high levels of ethyl alcohol but are not manufactured or designed for consumption. Such products may be easily purchased in locales where statutory limitations restrict liquor availability on Sundays or during the early morning hours. Several acute ethanol fatalities have been encountered in New Mexico that were directly related to consumption of non-beverage ethanol-containing products, all of them occurring during times when alcoholic beverage sales were restricted. Despite the fact that manufacturers deliberately include compounds in these products that discourage ingestion, this policy apparently does little to deter individuals who are searching for a source of ethanol when no conventional beverages are available. The products that were consumed in these fatalities also contained other compounds which would be toxic at much greater concentrations, but which were inconsequential in their effects in comparison with the direct toxic effect of ethanol. Investigation of the scene and awareness that alcohol-containing products can be fatally abused are essential to detecting these unconventional ethanol sources.

Inadvertent clavicular fractures caused by "chiropractic" manipulations in an infant: an unusual form of pseudoabuse.

A nine-month-old child was found unresponsive in his crib, five hours after his last feeding. At autopsy, there were no external or internal signs of abuse or neglect, and a few visceral pleural and epicardial petechiae were consistent with the sudden infant death syndrome (SIDS). However, postmortem total body radiographs revealed healing, symmetrical clavicular fractures and a healing left medial humeral epicondyle fracture. The parents had no explanation for these injuries and denied causing any harm to the child. The location and nature of the fractures strongly suggested abusive origin, and the case was reported to the police and the district attorney's office as child abuse. During the investigation, information from the parents indicated that the child had undergone "chiropractic" manipulations by an unlicensed therapist, between three and four weeks prior to death, to correct supposed "shoulder dislocations." This time interval correlated with the histologic age of the injuries, and the history explained their unusual bilateral location and appearance. The parents were exonerated of abuse charges, and the death was ascribed to SIDS.

An elliptical incised wound of the breast misinterpreted as a bite injury.

Bite injuries upon homicide victims are most often initially identified by the forensic pathologist during the course of the autopsy examination. Following such recognition, the injury or photographs of the traumatized site are then referred to a forensic odontologist for his or her examination, further characterization, and subsequent comparison with any suspect's dentition. However, if the pathologist misidentifies an injury caused by another mechanism as a human bite, this mistake can potentially be perpetuated by the dental consultant, since relatively few dentists regularly examine traumatic injuries other than those arising from bites. To illustrate such an event, a case is presented involving an incised wound of the breast, which was originally identified as an avulsive bite wound. Detailed examination by two odontologic consultants confirmed the wound as having been caused by human teeth, and further, they related the "bite injury" to a specific individual. The bite injury interpretation represented the only scientific evidence implicating the suspect at a subsequent trial for capital murder. Later examination of the tissues and photographs by a forensic pathologist and another dental consultant revealed that the injury was not due to human dentition, but rather resulted from a sharp-edged instrument. These consultants conducted a unique experiment to reduplicate the injury and prove its causation. This information was presented to the jury during the suspect's trial and resulted in his acquittal on all charges.

Anterior thoracic wall trauma in elderly homicide victims. The "CPR defense".

During the course of medicolegal postmortem examinations, forensic pathologists often encounter the sequelae of cardiopulmonary resuscitation (CPR) that was administered by medical and paramedical personnel. A wide variety of CPR-related injuries have been described since the institution nearly 30 years ago of this now common-place emergency technique. The forensic pathologist must be aware of both typical and unusual CPR-related trauma patterns in order to differentiate between injury produced during emergency therapy procedures and injury sustained through other mechanisms (for example, during an assault or an accident). This article describes two recent separate and unrelated incidents in which an elderly woman was murdered. In each instance, bony injuries of the anterior thoracic wall structures were identified during the autopsy. Defense attorneys in each case attempted to use these injuries as proof that their accused clients had performed external cardiac massage on their victims, thus indicating that the homicides had not been intentional, and that the perpetrators showed remorse. These cases are presented, with a discussion of the typical features of CPR-related thoracic wall trauma as compared with willfully inflicted injury.

Toward a population-based assessment of death due to pulmonary embolism in New Mexico.

During a 5-year period (1981 through 1985), 586 of 46,512 (1.26%) deaths in New Mexico had pulmonary embolism (PE) listed on the death certificate. The frequency of death due to PE was mentioned more frequently in the autopsied than in the non-autopsied component of the study (2.4% v 1.1%). This observation, together with published data on the accuracy of clinical diagnostics among persons dying with autopsy-documented PE, suggests that the frequency of death due to this disease is considerably higher than previously thought. Among autopsied persons who died of PE, risk factors and associated diseases are not appreciably different for those who die in or out of the hospital. Important associations with respect to persons dying of PE include male gender, advanced age, serious medical or surgical disease, immobilization, and trauma.

Unexpected death as a result of infective endocarditis.

Thirteen cases of infective endocarditis (IE) diagnosed for the first time at autopsy or, in those patients with a previous diagnosis of IE, not thought to be active at the time of death, are presented. Of the six patients who died within 24 h of the onset of symptoms, two died of obstruction of a valve orifice, two died of sepsis, one died of sepsis and alcoholic cardiomyopathy, and one died of a coronary artery embolus. Of the five patients with symptoms lasting more than 24 h, three died of sepsis and congestive heart failure. One died from sepsis alone and one died from congestive heart failure (CHF). In two patients whose duration of symptoms is unknown, one died of sepsis and CHF, and in the other the mechanism of death is unknown. Predisposing factors present in 11 of 13 patients included alcoholism (three), intravenous (IV) drug abuse (three), prosthetic valves (three), aortic stenosis (two), past rheumatic fever (one), and nonstenotic congenitally bicuspid valves (two). The reasons for no antemortem diagnosis were a missed or incorrect clinical diagnosis in three patients seen by a physician shortly before death, no signs or symptoms or found dead (four), non-specific signs and symptoms (three), refusal of medical treatment (one), and a solitary lifestyle (one); there was insufficient information about one patient. Individuals with needle tracks, generalized petechiae. Osler's nodes, splinter hemorrhages, intravenous catheters, pacemaker wires, and infected aortic-valve (A-V) shunts are at risk of IE. Blood and the vegetations should be cultured. The attending physician should be notified of the diagnosis in such cases.

Fatal intraoperative hemorrhage during spinal fusion surgery for osteogenesis imperfecta.

Osteogenesis imperfecta (OI) is an uncommon inherited systemic disorder of the connective tissues characterized primarily by varying degrees of bony fragility. Consequently, individuals affected by this condition frequently suffer severe skeletal injuries from otherwise innocuous traumatic events. This syndrome has other associated abnormalities, including hydrocephalus and brain stem compression on the basis of cranial developmental defects (platybasia), cardiac and vascular problems, respiratory disease from spinal deformities, vascular fragility, a bleeding disorder caused by an apparent platelet function abnormality, and anesthesia-related hyperpyrexia. A case is presented here of a young girl with advanced OI in whom intraoperative death occurred as a consequence of inadvertent rib fractures, with subsequent uncontrollable hemorrhage. OI may also potentially be mistaken for child abuse by an inexperienced examiner.

Suicide by intravenous injection of cocaine. A report of three cases.

Death as a consequence of cocaine abuse is continuing to increase in all parts of the United States. Cocaine use may cause the development of psychosis, with subsequent expression of suicidal ideations, and potentially even successful suicide. Cocaine dependence may also cause depression in the individual who is unable to control his or her craving for the drug, and suicide may be perceived as the only solution to a desperate problem. Despite the dramatic escalation of cocaine abuse and the potential toxicity of this drug, there have been no reports within the United States of cocaine being used as the agent to accomplish a suicide. Herewith are reported three cases in which depression and desperation over cocaine dependence were the motivations for successful suicide, which was accomplished through the intravenous injection of cocaine to the point of death. True cocaine suicide is probably only identified through the presence of objective scene information that unequivocally proves suicidal intent, such as notes or letters which contain information to this effect. A careful search of the scene of death in cocaine fatalities is mandatory, and diligent application of routine scene investigation principles may reveal that suicide through the use of cocaine is more widespread than first appearances would suggest.