Is That Innocent to Touch the Adipose Tissue?: An Autopsy Case Series of Fat Embolism Syndrome.

ABSTRACT: Although fat embolism in the pulmonary or systemic circulation is usually associated with long bone fractures, it can also occur less frequently during surgical operations, such as liposuction, fat grafting, and joint repair. This study aims to present cases of macro fat embolism resulting in sudden death during the perioperative period. Three cases with a history of sudden death during the perioperative period were included in this study. The surgical operation histories, autopsy findings, and histopathological findings of the cases were evaluated. Fat globules were detected in the medium-sized vessel lumens in the lungs of the cases who died suddenly during surgery. Grade 4 fat embolism was observed in the capillaries, which stained positively with Oil-Red-O in all three cases. Fat embolism syndrome is a rare but life-threatening condition that should be considered in patients with respiratory distress and impaired neurological status in the postoperative period.

The Role of Immunohistochemical Markers in the Diagnosis of Early Myocardial Infarction.

INTRODUCTION:  Pathological diagnosis of acute myocardial infarction can be difficult if death from ischemic injury has occurred within a short period of time. In this study, we aimed to determine the role of immunohistochemical markers in the diagnosis of early myocardial infarction. METHODS:  The myocardium samples of 20 cases whose autopsies were performed at the Morgue Department of the Council of Forensic Medicine were evaluated. Hematoxylin and Eosin (H&E) stained slides and fibronectin, CD59, myoglobulin, troponin T, desmin, cathepsin S stained slides of 20 cases diagnosed with early myocardial infarction were retrospectively re-examined. The diagnosis of myocardial infarction was analyzed in two groups: Group 1: first eight hours, Group 2: 8-24 hours. The immunohistochemical staining patterns in these two groups were compared. RESULTS: Of the cases, 55% (n=11) had myocardial infarction consistent with the first eight hours, 45% (n=9) 8-24 hours with light microscopic examination. With fibronectin, 50% (n=10) of the cases showed Grade 1 staining, 5% (n=1) Grade 2, 15% (n=6) Grade 3 staining. The slides of three cases could not be reached. With CD59, 10% (n=2) of the cases showed Grade 1, 10% (n=2) Grade 2, 80% (n=16) Grade 3 staining. With troponin T, 50% (n=10) of the cases showed Grade 1, 45% (n=9) Grade 2, 5% (n=1) Grade 3 depletion. With cathepsin S, 10% (n=2) of the cases showed Grade 1 and 80% (n=16) Grade 3 depletion. The slides of two cases could not be reached. With desmin, 75% (n=15) had Grade 1 and 25% (n=5) Grade 2 depletion. Grade 3 depletion with myoglobulin was observed in all cases. CONCLUSION:  The diagnosis of early myocardial infarction, which may pose a problem for the forensic pathologist, may become easier with immunohistochemical methods. In cases where morphological findings are insufficient, it is more useful for diagnosis to be applied as a panel.

Natural Causes of Sudden Young Adult Deaths in Forensic Autopsies.

Objective The aim of this study is to define epidemiologic differences and the most common pathologies that cause nontraumatic sudden, natural death in people in the age group of 18-35 years. Identifying causes of sudden death in this age group is important for determining approaches for prevention. Methods We performed a descriptive statistical methodology, analysis, and interpretation using demographic and autopsy data of sudden deaths. A total of 4034 autopsies were reviewed and 66 cases of sudden death were included in this study.  Results We identified 58 (87.9%) subjects in whom the adjudicated cause of death was of potential cardiac etiology. The most common cause of sudden young adult death was ischemic heart disease associated with the atherosclerotic coronary artery (n=24, 36.3%), followed by ischemic heart disease associated with nonatherosclerotic coronary artery disease and dissecting aortic aneurysm. Conclusion We put forth that the main cause of sudden young adult death was cardiac (87.9%) in origin. Of these cardiac causes, ischemic etiology associated with atherosclerosis was the main reason for sudden young adult deaths. In order to reduce the incidence of sudden young adult deaths, major efforts should be directed to prevent atherosclerosis in this age group.

Forensic Microbiological Analysis of Soil and the Physical Evidence Buried in Soil Obtained from Several Towns in Istanbul.

Background The identification of bacterial species in the soil can be used for the differentiation of soil samples and physical evidence. This study aims to evaluate the importance of identifying microorganisms in the soil for forensic sciences. The study covered 20 regions identified and marked outside the settlement areas within the boundaries of Istanbul. Methodology Big and wide soil and forest areas were preferred. Four types of physical evidence samples were collected from the identified areas at the end of the first, second, and third months and then analyzed. The collected samples were physically embedded in the soil. In this study, 10 g of soil sample and four pieces of physical evidence (fabric, rubber, metal, and wood), sized 5 × 5 cm and buried 20-30 cm deep in the soil, contaminated with soil were collected for analysis and stored in sterile conditions. The microbiological identification analyses were conducted at the end of the predefined period and in the predefined order using first phenotypic (e.g., microscopic and macroscopic), followed by culture methods using advanced diagnostic analyses, such as API and matrix-assisted laser desorption/ionization-time of flight mass spectrometry. Results In the soil samples and the physical evidence samples collected, 83% bacteria and 17% fungus were identified. A database was set up for the study findings. Conclusions The presence of microorganisms in the soil and physical evidence samples contaminated with soil, which is crucial in the evaluation of criminal cases, was determined using microbiological analysis.

Postmortem pathological changes in extrapulmonary organs in SARS-CoV-2 rt-PCR-positive cases: a single-center experience.

BACKGROUND: Although the lung is seen as the main target organ affected by SARS-CoV-2, other organs are also damaged. AIM: We aimed to determine the extrapulmonary findings of autopsies performed on cases with positive results with postmortem polymerase chain reaction test. METHODS: Pathological changes in extrapulmonary organs were examined with light microscopy. RESULTS: Heart, liver, spleen, kidney, pancreas, and central nervous system samples of these cases were evaluated. About 80% of the cases were men, and 20% were women. In the examination of heart, 28 of the cases had scar, 14 had acute myocardial infarction, 6 had acute and previous myocardial infarction findings, 2 had myocarditis, and 4 had interstitial mononuclear inflammatory cell infiltration. In the examination of the liver, portal inflammation was observed in 84 of the cases, steatosis in 54, centrilobular necrosis in 9, and capillary endotheliitis in the portal area in 7 of them. In the evaluation of the kidney, 37 cases had chronic pyelonephritis, 36 had tubular damage, 15 had tubulointerstitial necrosis, 16 had subcapsular microhemorrhage, 10 had capillary endothelitis, and 9 had a microvascular fibrin trombosis in their glomerular capillaries. In the central nervous system, 8 cases had infarction and liquefaction, 56 had perivascular petechial hemorrhage, 54 had acute hypoxic ischemic change, 3 had parenchymal microhemorrhage, and 52 had capillary endotheliitis. CONCLUSION: Autopsies play an important role in systematically examining the damage caused by the virus in all organs in order to elucidate the pathogenesis of SARS-CoV-2 infection and contribute to the clinical management of infected patients.

COVID-19 autopsies of Istanbul.

BACKGROUND/AIMS: The aim of this study is to share autopsy findings of COVID-19-positive cases and autopsy algorithms for safely handling of suspicious bodies during this pandemic. METHODS: COVID-19-positive cases of Istanbul Morgue Department were retrospectively analyzed. Sampling indications for PCR tests in suspicious deaths, macroscopic and microscopic findings obtained in cases with positive PCR tests were evaluated. RESULTS: In the morgue department, 345(25.8%) of overall 1336 autopsy cases were tested for COVID-19. PCR test was found positive in 26 cases. Limited autopsy procedure was performed in 7 cases, while the cause of death was determined by external examination in the remaining 19 cases. Male-to-female ratio was found 3.3:1 and mean age was 60.0 ± 13.6 among all PCR-positive cases. Cause of death was determined as viral pneumonia in fully autopsied cases. Most common findings were sticky gelatinous fluid in cavities and firm and swollen lungs, varying degrees of consolidation. In microscopy, diffuse alveolar epithelial damage, type-II pneumocyte hyperplasia, hyaline membrane formation, fibrinous exudate, and fibrinous plaques in the alveoli were the most common findings. CONCLUSIONS: In COVID-19 autopsies, pulmonary findings were found to be prominent and the main pathology was pneumonia. Older age and findings of chronic diseases indicate that the cases were in the multirisk group in terms of COVID-19 mortality.

Evaluation of histopathological findings of cardiac deaths in forensic autopsies.

BACKGROUND: The vast majority of sudden and unexpected natural deaths are related to cardiovascular diseases, especially coronary artery diseases. AIMS: In this study, we aimed to reveal the epidemiological differences between men and women and to investigate the most common pathologies that cause cardiac deaths. METHODS: Five thousand seven hundred sixty-eight autopsy cases that were done in 2016 were reviewed for the autopsy information and histopathological findings. Of the 5768 autopsies performed, 866 were due to cardiac causes. Eight hundred thirty-two cases were reviewed due to lack of autopsy information in 34 cases. RESULTS: One hundred sixteen (13.9%) were female, and 716 (86.1%) were male. Coronary artery disease was detected in 760 of 832 cases. There were findings of acute or previous myocardial infarction in 595 (71.5%), perivascular and interstitial fibrosis in 159 (19.1%), myocardial rupture and tamponade in 31 (%3.7), valvular disease in 6 (0.7%), cardiomyopathy in 4 (0.5%), and congenital heart disease in 3 (0.4%). In the study, it was observed that the mean age of death due to cardiac pathology other than coronary artery disease was significantly lower than deaths due to coronary artery disease (p < 0.05). The presence of coronary artery disease in men was found to be significantly higher than in women (p < 0.001). CONCLUSION: In our study, it was found that deaths due to coronary artery disease are seen at an older age than cardiac deaths other than coronary artery disease. In addition, in line with current knowledge, it has been confirmed that the mortality rate of coronary artery disease is higher in men than in women.

Embolism of Cerebral Tissue to the Lung After Head Trauma: A Case Report.

Embolism of cerebral tissue to pulmonary circulation is a rare entity. It can be occur because of penetrating or closed head trauma at any age or during difficult vaginal deliveries at any age. We present a case of cerebral tissue pulmonary embolization after severe head trauma in a male adult. The autopsy revealed multiple skull fractures, subdural hematoma, subarachnoid hemorrhages, and contusions. Microscopically, we observed cerebral tissue inside the branches of the pulmonary arteries. Embolism of cerebral tissue to the pulmonary circulation is a rare condition. It should always be kept in mind in sudden unexpected deaths during delivery and head trauma cases at any age.

Postmortem Diagnosis of Myocardial Infarction Due to Butane Gas Intoxication in a Child: A Case Report.

Volatile substance addiction and toxic gas inhalation are now an important health problem. The pleasure-based inhalation of butane gas, also known as lighter refill gas, is especially prevalent among children and young people. The most important reasons for this situation are that they are cheap and easy to obtain and lack of legal supervision. The exhaled gas is absorbed through the alveolar surface and rapidly enters the bloodstream and leads to clinical signs. It can cause dizziness, nausea, vomiting, confusion, hallucinations, and euphoria in the acute phase. In severe cases, bronchospasm, hypoxia, ventricular arrhythmia, cardiopulmonary arrest, and death can occur. Our case is one of the rare cases in the literature that was diagnosed by postmortem histopathological examination. Our case is a 15-year-old girl who was found in front of a tobacco product store. On gross examination, there was a hemorrhagic area under the aortic valve that continued to interventricular septum. There was no coronary artery lesion. Histopathological examination revealed hypereosinophilia and contraction band necrosis in myocardial fibers, which was more intense in papillary muscle. Immunohistochemical studies also supported early myocardial ischemic changes. Upon toxicological examination, butane gas was detected in lung and blood samples.

Metastatic malignant melanoma of the urinary bladder: A case report and review of the literature.

Metastatic bladder tumors constitute <5% of all bladder tumors and metastatic malignant melanoma of the urinary bladder is very rare. We present a case report of a metastatic malignant melanoma of the urinary bladder. A 70-year-old woman without any apparent significant clinical history was admitted to the Department of Urology for gross hematuria. Microscopic findings of the transurethral resection specimen revealed fascicles, sheets, and diffuse areas composed of oval and fusiform cells with focal pigmentation. Immunohistochemical analysis revealed that the tumor cells were positive for human melanoma black-45, Melan-A, and S100, and negative for pancytokeratin. Subsequently, we contacted the patient and learned that she was admitted to the Department of Ophthalmology for painless and progressive visual field loss 15 years ago. She had been diagnosed with a primary ocular (uveal) melanoma. A detailed patient history coupled with histological and immunohistochemical findings were necessary to make the final diagnosis of metastatic melanoma.

Viral Pneumonias in Forensic Autopsies: Evaluation and Classification of Histopathologic Changes With Microbiologic Correlation.

Lower respiratory infections are commonly due to viruses and are the third largest cause of death. Respiratory tract viruses have a tendency to target the specific regions in the lung and can harm the host via direct effect of the virus and the host's inflammatory response. In this study, relationships between morphologic changes in the lung and the viral agent type isolated in the lung by the polymerase chain reaction technique were investigated. This study was performed retrospectively at 113 autopsy cases in the Council of Forensic Medicine in Istanbul. Slides from the lung tissues diagnosed as interstitial pneumonia and detected viral agent in polymerase chain reaction were evaluated and reviewed under light microscope by 2 pathologists simultaneously according to predetermined bronchiolar, alveolar, and interstitial findings. Alveolar findings were detected in 108 cases (95.6%), whereas interstitial and bronchiolar findings were detected in 91 (80.5%) and 38 (33.6%) cases, respectively. Intra-alveolar edema was the most common alveolar finding. Some findings such as multinucleated syncytial cells and smudge cells can aid the search for etiologic agent. Interstitial inflammation was the most common histopathologic finding in the lung in viral infections and the most prominent clue to viral infections in the lung histopathologically without discrimination of viral agent type.

Incidentally Detected Lithopedion in an 87-Year-Old Lady: An Autopsy Case Report.

A lithopedion is a rare complication of pregnancy that occurs when a fetus in an intraabdominal location dies, and it is too large to be reabsorbed by the body. The case was an 87-year-old woman, and she was transferred to the morgue department in April 2014 to determine the cause of death. During autopsy, an intraabdominally located calcified dead fetus and a 12-cm diameter calcified cyst in the right ovary were incidentally detected. It was aged 25 to 29 weeks (according to femur and humerus measurements) with a size of 12.5 × 8 × 5 cm and a weight of 227 g. According to investigation reports, her husband died in 1990, and she had 3 deliveries, the most recent of which was in 1946. Because the menopause age of the case was not exactly known, the retention time of the lithopedion was supposed to be 24 to 68 years according to the date of the most recent pregnancy and the date of her spouse's death. It is the first case that has been incidentally detected and identified during an autopsy in Turkey and also one of the oldest cases in the literature.

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.

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.

Hydatid Disease Involved in the Heart, Liver, and Kidney That Caused Sudden Death: Case Report.

Hydatid disease is a parasitic infestation caused by ingestion of eggs of echinococcal species. For Echinococcus granulosus, the definitive host is the dog, and sheeps are the usual intermediate hosts. Humans are accidental intermediate hosts, infected by ingestion of food contaminated with eggs shed by dogs or foxes. The most common organs that hydatid disease encountered are the liver and lungs. Involvement of the kidney is rare and usually accompanies the other organ involvements. Cardiac involvement of echinococcosis is also very rare. We report the case of a 31-year-old woman with a 6-year history of asthma who collapsed after strenuous activity and died despite the interventions carried out. At autopsy, cystic masses were detected in the apex of the heart, in the right kidney, and in the liver. There were no macroscopic pathologic findings in the other organs. Microscopic examination revealed the diagnosis of hydatid cyst in the heart, right kidney, and liver besides medial hypertrophy of the lung vessels. Cause of death was attributed to hydatid cyst and its complications. Patients who have symptoms akin to asthma at clinical presentation have to be further investigated for organic cardiac and pulmonary diseases such as hydatid cyst, especially in endemic countries.

Detection of Human Bocavirus DNA by Multiplex PCR Analysis: Postmortem Case Report.

BACKGROUND: Human bocavirus (HBoV) is a virus belonging to the Parvoviridae family, which has been newly discovered to be associated with respiratory tract infections in children. There are many reports worldwide on the endemicity of this virus. Since it is relatively new, it is not routinely detected in clinical laboratory investigations. CASE REPORT: We demonstrated that HBoV infection caused the death of a 5-month-old girl with a history of high fever and wheezing. Human bocavirus (HBoV 1/2/3/4) was found in a nasopharyngeal swab, paraffin-embedded lung tissue and stool samples by multiplex PCR methods using postmortem microbiological analysis. CONCLUSION: This case suggests that lower respiratory tract infections due to HBoV may cause severe and life-threatening diseases. Postmortem microbiology is useful in both clinical and forensic autopsies, and allows a suspected infection to be confirmed. To our knowledge, this report is the first document of a HBoV postmortem case in Turkey.

Spontaneous Coronary Artery Dissection: Report of 3 Cases and Literature Review Hormonal, Autoimmune, Morphological Factors.

The number of cases with spontaneous coronary artery dissection (SCAD) is considered to be being underestimated because of a large amount of SCAD leading to sudden death without previous diagnosis. Besides, not only in clinics but also in autopsy practice, correct diagnosis of SCAD is important to prevent forensic malpractice.The article is intended to discuss the pathological findings through the forensic point of view for improving the malpractice expertise in scope of clinicians' timely antemortem diagnosis according to risk factors and in scope of forensic pathologists' the cause of death determination ability according to macroscopical and microscopical findings of the autopsy.In 3 cases reported, the main characteristics were the female sex, pregnancy history and a sudden death without any trauma. However, although there are many women giving birth or using oral contraceptives, only some of them are facing with SCAD. This suggests the possibility of some hereditary factors, whereas hereditary characteristics may be understood in many different ways like hormone-releasing regulating mechanisms as well as immunity, morphology, or any other mechanism. For instance, autoimmunity has been also a hereditary underlying factor for vessel injury considered in presented cases.

[Comparison of two different real-time PCR systems in postmortem diagnosis of tuberculosis in paraffin-embedded tissues]. / Postmortem tüberküloz tanisinda parafi ne gömülü dokularda iki farkli gerçek zamanli PCR sisteminin karsilastirilmasi

Tuberculosis (TB) is one of those infections with high morbidity and mortality in all around the world. Hundreds of people died from this disease without diagnosed or due to resistant strains in Turkey. Therefore, it is important to identify postmortem cases who have died from tuberculosis. Molecular methods have been widely used as well as conventional methods in the diagnosis of tuberculosis. The aim of this study was to compare the two different real-time polymerase chain reaction (Rt-PCR) system in the postmortem diagnosis of Mycobacterium tuberculosis infections in paraffin-embedded tissues. A total of 40 paraffin-embedded tissue samples [lung (n= 35), brain (n= 2), heart (n= 2), lymph node (n= 1)] in which histopathologic findings consistent with TB (necrotizing granulomatous inflammation, gelatinous caseous pneumonia, necrotic fibrous nodul) obtained from 37 autopsy cases (31 male, 6 female; age range: 25-85 yrs) were included in the study. Paraffin-embedded tissues were deparafinized with xylene and ethyl alcohol and then DNA isolation was done with QIAsymphony DSP Virus/Pathogen Midi kit in the QIAsymphony device. DNA amplification process was performed by Rt-PCR using the kit Artus® M. tuberculosis RG-PCR in the Rotor-Gene® Q device (Qiagen, Germany). Likewise, after deparafinization process, samples placed in the cartridge and isolation and Rt-PCR was performed by Xpert® MTB/RIF (Cepheid, USA) system, simultaneosly. Seventeen and 20 out of the 40 paraffin-embedded tissues yielded positive results with Qiagen and Xpert system, respectively. M.tuberculosis DNA was found positive in 13 (32.5%) and negative in 16 (40%) of the samples by both of the systems, exhibiting 72.5% (29/40) of concordance. On the other hand, seven (17.5%) samples that were positive with Xpert system yielded negative result with the Qiagen, while four (10%) samples that were positive with Qiagen yielded negative result with the Xpert system. Of the 20 positive cases detected with Xpert MTB/RIF system, 15 were found rifampicin-susceptible, and three were rifampicin-resistant. In two samples in which M. tuberculosis DNA was low positive, rifampicin resistance could not be detected. The identification of M.tuberculosis infections in postmortem cases will contribute epidemiological data in Turkey. In these cases, effective sampling and diagnosing of M.tuberculosis infections by acid-fast stain and culture methods are crucial. However, in cases without microbiological sampling the detection of M.tuberculosis DNA in paraffin-embedded tissues with PCR, although there are differences between PCR systems has diagnostic value. In conclusion, our data indicated that Xpert MTB/RIF system is more favourable to detect M.tuberculosis DNA in paraffin-embedded tissues, with the advantages of determination of rifampicin resistance, and detection of more positive results within a shorter time.