Value of stomach content in a case of fatal child homicide.

In death investigations, the volume of gastric contents may be useful concerning the time of death estimation, or to clarify the circumstances of death. Here, the case of a 4-month-old male infant who was found dead in his mother's bed is presented. SIDS was assumed as the cause of death after initial police investigations. Later, autopsy results revealed that this case was a homicide due to extensive abusive head trauma. The infant had three skull fractures on the back of his head with subdural hemorrhage and cerebral oedema. The survival time after feeding him formula and corresponding the time of death was determined to evaluate the mother's initial claims that the infant was alive several hours after feeding. In this case, the volume of stomach contents of the last meal was known. From the volume of milky fluid found in the stomach at autopsy, it was possible to estimate the time of death within a narrow time frame of less than one hour after feeding. The mother's claims could be ruled out, and she later confessed to having killed the child soon after feeding him. Even methods with low precision for estimating time of death, like examining stomach contents, can be essential for solving practical cases. To our knowledge, this is one of the first published cases in which an infant's stomach content was used successfully in the reconstruction of a homicide.

Sudden death of a 12-year-old boy with severe myocardial fibrosis due to inapparent chronic myocarditis.

Sudden death due to unknown cardiac disease in children is an unusual occurrence. An apparently healthy 12-year-old boy without any physical restrictions collapsed suddenly and died despite cardiopulmonary resuscitation. The main autopsy finding was extensive scarring of the myocardium, especially the interventricular septum. This extensive scarring was exceptional for the young age. Histologically, replacement-type fibrosis with patchy lymphomonocytic infiltrate and infiltration by macrophages were observed. The case was diagnosed as chronic myocarditis, which may have progressed to dilated cardiomyopathy with inflammation or inflammatory cardiomyopathy.

Expression of heat shock proteins (Hsps) 27 and 70 in kidney in cases of fatal hemorrhage.

The expression levels of intracellular heat shock proteins (Hsps), specialized chaperone proteins, increase in cases of cellular stress with protein misfolding and aggregation. In a previous study, we demonstrated that there is an extensive increase in intracellular Hsp27 and 70 expression levels in renal tissues in fire fatality cases. Hsp expression can be induced by not only heat, but also by tissue hypoxia. In cases of fatal hemorrhage, the individual suffers hypoxemia and consequently tissue hypoxia. Here, we examined 43 cases of fatal hemorrhage and a control group of 85 deaths not related to blood loss or temperature exposure. We evaluated Hsp27 and 70 protein expression levels in renal tissue using immunohistochemistry. The results revealed that no extensive Hsp27 or 70 expression is induced in the fatal hemorrhage cases. The renal Hsp levels were similar to those of the control group. Fatal blood loss does not cause relevant cell stress.

The prognostic value of the Frank sign.

Frank's sign (named after American pulmonologist Sanders T. Frank) refers to a diagonal skin fold between the tragus and outer edge of the earlobe. Gradation is based on the bilateral presence and/or degree of the earlobe fold. The presence of this sign, referred to as the diagonal earlobe crease (DELC), has been associated with coronary artery disease (CAD), independent of other cardiovascular risk factors. Corresponding studies are predominantly based on clinical or angiographic assessments, and few autopsy studies exist. The association of DELC with CAD, cardiovascular risk factors, and causes of death was investigated via retrospective and prospective evaluations. It was also investigated whether the degree of DELC correlated with the macroscopic severity of coronary heart disease. Furthermore, the influence of age on the appearance of DELC was analyzed and compared using two age groups. Additionally, binomial logistic regression analysis was performed to investigate the influence of age on the presence of higher-grade DELC and CAD. In cases related to a lethal cardiac event, the majority (78%) showed high-grade DELC. The DELC grade correlated significantly with CAD severity (rs = 0.474, p < 0.001) and with the severity of general atherosclerosis (rs = 0.606, p < 0.001) with medium and large effects sizes, respectively. Age was predominantly more suitable than DELC concerning the sensitivity, specificity, and positive prognostic value for preexisting cardiac disease and cardiac-related causes of death. In both DELC and CAD, age has a significant influence on the presence of higher-grade manifestation, but the influence of age in CAD appears to be even more significant than in DELC. The main results of previous autopsy studies and the prognostic value could have been confirmed, but these findings appear to be limited to younger patients.

Renal expression of Hsp27, 60, and 70 in cases of fatal hypothermia.

Macromorphological findings can be missing in cases of fatal hypothermia when the agonal period is very short because of a large difference between environmental and core body temperatures. Expression of heat shock proteins (Hsps) increases under endogenous and exogenous cellular stresses such as thermal stress. These stress proteins can be revealed by immunohistochemical staining. Forty-five cases of death due to hypothermia and a control group of 100 deaths without any antemortem thermal stress were examined for Hsp27, 60, and 70 expression in renal tissue because renal tissue is sensitive to cellular stress. The results revealed no significant difference between Hsp27, 60, and 70 expression in both groups (28.8% positive staining in the study group and 19.0% positive staining in the control group), which is contradictory to a previous study on expression of Hsp70 in renal tissue in cases of fatal hypothermia. Hence, it is currently unclear whether immunohistochemical staining of Hsps supports a morphological diagnosis of fatal hypothermia.

Aquaporin 1 and 3 as local vitality markers in mechanical and thermal skin injuries.

Assessment of the vitality of an injury is one of to the main tasks in daily forensic casework. Aquaporins belong to the family of water channels. They enable the transport of water and of small molecules like glycerol through biological channels. So far, 13 classes of aquaporins are identified in vertebrates. The classical aquaporin channels 1, 2 and 4 are only permeable for water. The aquaporin channels 3, 7, 9 and 10 are also called aquaglycerolporins since they can also transport glycerol. Aquaporin 3 is expressed in epidermal keratinocytes. In the present investigation, the aquaporin 1 and 3 expression in mechanically and thermally damaged skin is investigated by immunohistochemistry. The study collective comprises 30 cases (63.3% male and 36.7% female) with an age range between 19 and 95 years (mean value 54.6 years). The skin injury comprises different kinds of blunt force, sharp force, strangulation marks, thermal injury, gunshot wounds and frost erythema. In all kinds of mechanical and trauma injury, an increased expression of aquaporin 3 in the keratinocytes of the epidermis was found. There is no correlation of the aquaporin 3 expression with age, sex, body mass index, duration of agonal period and postmortem interval. Concerning aquaporin 1, there were no differences between injured and uninjured skin. Aquaporin 3 is independently from the kind of skin injury and appears to be a valuable immunohistochemical parameter of vitality.

Fatal misuse of transdermal fentanyl patches.

Fentanyl is a potent synthetic opioid with a variety of possible applications. Transdermal fentanyl patches are regularly prescribed for patients with severe chronic or cancer-related pain. The potential for abuse is well-known and cases associated with illicit fentanyl intake are common. Fentanyl related fatalities due to unintentional misuse are relatively rare. This study focused on those instances and their identification in forensic examinations and adds new cases and consolidates the existing femoral blood concentrations in the event of fatal fentanyl patch misapplications. A total of 35 cases between 2010 and 2018 in which transdermal fentanyl patches were detected during forensic autopsies were identified and reviewed for the frequency of unspecific macroscopic signs of opioid intoxication. Furthermore, a detailed examination is presented for 11 cases in which toxicological results were available. The cause of death was eventually considered to be related to fentanyl patch misuse in 5 of these 11 cases. Co-administered drugs and signs of opioid intoxication, especially pulmonary edema, were frequently found. Lastly, it is advised to include norfentanyl and hair analysis in the interpretation of post-mortem fentanyl concentrations.

Differentiation of homicidal or suicidal strangulation.

Hanging can be suicidal, accidental, or homicidal, and these backgrounds must be discriminated by police and forensic pathologists. We herein report a case involving a 33-year-old man who was found dead on the floor behind the entrance door of an apartment house. The man's brother declared that he had found him hanging in the gap between the stairs on the top floor. When his brother tried to cut him down, the victim fell three floors down through the gap between the stairs. Autopsy was performed to confirm suicidal hanging and a postmortem fall into the narrow gap. In this case, however, a homicide was suspected, and the version of events told by the victim's brother was initially doubted. Homicidal hanging may be uncommon, but intensive scene investigation and thorough autopsy are necessary in hanging cases to rule out homicide.

Supravital expression of heat-shock proteins.

Heat-shock proteins (HSPs) are expressed during cellular stress, especially thermal stress, to support protein homeostasis. Extensive investigations have revealed that HSP27 is rapidly and intensively expressed in the pulmonary and renal tissues of most cases of death due to fire, contrary to cases without premortem thermal influences, which are negative for HSP expression. As such, HSP27 can be used as a marker of vitality in the investigation of fire-related deaths. Without positive HSP27 expression or only slight expression, one can conclude that the deceased was not alive at the time of heat stress. This is presented in two case reports of men who were shot and later burned. HSP espression could not be found in these cases. In the very early supravital period, particularly the latency and supravital periods, metabolic processes can continue after irreversible cardiac arrest. Extensive cellular stress can lead to an immunohistochemically detectable expression of HSP in this portmortem period. This is shown in the case report of a 49-year-old man who immediately died and burned following the massive detonation of an air mine. Immunohistochemical studies of recovered renal tissues have revealed HSP27 expression in the vessel walls as well as renal tubules, as presented in a third case report. This HSP expression can be considered as a phenomenon of supravitality. Heat stress induces massive cellular stress and the expression of HSP under global ischemic conditions. When vitality is to be determined in cases of suspected fire deaths, the possibility of supravital expression has to be considered.

Expression times for hsp27 and hsp70 as an indicator of thermal stress during death due to fire.

The expression of heat shock proteins (hsps) increases in cases of hyperthermal cellular stress in order to protect cellular structures. Hsps can be visualized with immunohistochemical staining. We examined 48 cases of death from fire and excessive heat and a control group of 100 deaths without any perimortem thermal stress, measuring both the hsp27 and hsp70 expressions in myocardial, pulmonary, and renal tissues. The results revealed a correlation between hsp expression and survival time. Hsps are expressed rapidly within seconds or minutes after exposure to heat stress. In particular, hsp27 is expressed fast in high levels, whereas hsp70 expression is higher in the pulmonary and renal tissue of long-term survivors. In the myocardial tissue, hsp27 expression dominated in both short- and long-term survival. The expression pattern is strongly dependent on the organ structure and the survival time, which should be considered in future postmortem studies on hsps.

Subarachnoid hemorrhage due to aneurysm rupture in a young woman with Alagille syndrome - A rare cause of sudden death.

The Alagille syndrome (AGS) or arteriohepatic dysplasia is a rare, autosomal dominant inherited disease with a prevalence of approximately 1:100,000. AGS was first described in 1969 and affects liver, heart, arterial blood vessels, skeleton and the eyes. The expression of AGS is variable. In severe cases a liver transplantation is required. Presented is the case of a 25-year-old woman with AGS. At the age of 7 and 8years she had liver transplantations. Other typical findings associated with Alagille syndrome (e.g. pulmonary or renal anomalies) were also present. The young woman apparently died suddenly and unexpectedly in a good health condition despite regular medical treatment. Cause of death was a subarachnoid hemorrhage with invasion of the hemorrhage into the ventricle system caused by a rupture of previously unknown large aneurysm in the terminal basilary artery. Intracranial vascular malformations are a common finding in patients with AGS and cause death in up to 16% of them. Life expectancy in AGS patients depends on the severity of changes of the affected liver. But AGS is also responsible for various vascular abnormalities in several other organs which can cause lethal complications. Due to the high rate of vascular complications and intracranial hemorrhage with the leading cause of mortality in patients with AGS, vascular screening by the use of noninvasive imaging techniques (CT or MR angiography) is required to avoid unexpected sudden death.

Coronal clefts in infants - rare differential diagnosis of traumatic injuries of vertebral bodies in battered children.

Accidental and nonaccidental spinal injuries are generally rarely seen in infants. If affected, vertebral bodies usually present compression fractures due to forced hyperflexion or hypertension. Radiographic examination of the infantile skeleton can reveal a radiolucent band running through a vertebral body. These so called vertebral clefts are mainly visualized in the lateral spinal radiograph. Usually they can be found in the 1st year of life. Radiological appearance of coronal clefts was compared to that of a traumatic vertebral compression fracture. Clefts were mostly localized in the lumbar spine and had a completely different radiological appearance comparing to a traumatic compression fracture. As coronal clefts can be seen as a result from a retarded ossification of the vertebral bodies in fetal development they are a physiological variant. Due to this different etiology they have to be distinguished from spinal signs of child abuse.

Expression of heat shock proteins (hsp) 27 and 70 in various organ systems in cases of death due to fire.

The expression of heat shock proteins (hsp) increases in case of variable types of endogenous and exogenous cellular stress, as for example thermal stress. Immunohistochemical staining with hsp antibodies can visualize these stress proteins. Fifty-three cases of death due to heat and a control group of 100 deaths without any antemortem thermic stress were examined regarding hsp27 and hsp70 expression in myocardial, pulmonary, and renal tissues. The results revealed a correlation between hsp expression, survival time, and cause of death. In cases of death due to fire, the expression of hsp is more extensive than in the control group, especially in pulmonary and renal tissues. The immunohistochemical investigation of an hsp expression can support the proof of vitality in cases of death related to fire.

Histological examination of the carotid bifurcation in case of violence against the neck.

The carotid body and carotid sinus are localized in the area of the carotid bifurcation and respond to pressure fluctuations in the arterial blood vessel system. In case of irritation or stimulation, nervous impulses can reflexively increase the ventilation or slow down the heart rate and blood pressure, respectively. The external stimulation of the carotid sinus by neck compression with subsequent bradycardia or asystolia, especially in pre-existing heart-disease, is discussed controversially in the literature. Histological examination of the tissue of the carotid bifurcation, particularly with regard to haemorrhage as an indication of tissue trauma, should be carried out in terms of simple and easy feasibility in routine diagnostics. In 20 cases of violence against the neck and additionally 82 cases of a control group without neck trauma and variable causes of death, the carotid bifurcations were examined histologically. Only in one case of violence against the neck haemorrhage was found, which suggested a direct trauma to the tissue of the carotid bifurcation, but evidence of lethal cardiac reflex was not found in any case.

[Brainstem encephalitis in an 8-year-old girl]. / Hirnstammenzephalitis eines 8-jährigen Mädchens: Seltene Todesursache.

Encephalitis is often caused by viral infections and can affect various brain regions. The clinical symptoms are highly variable. Oligosymptomatic cerebral infections may remain undetected but there are also cases with very severe symptoms (e.g. paralysis, convulsions). This article presents the case of an 8-year-old girl who suffered from headaches and vomiting for several days following a harmless fall with impact on the back of the head. The health condition decreased rapidly and 7 days after the fall the girl was presented to a children's hospital. After a further foudroyant course of the disease the girl was hospitalized 2 days later. Resuscitation became necessary due to convulsions and pulmonary obstruction. Cranial computed tomography (cCT) revealed temporal hypodense areas and local edema. Cardiac echocardiography revealed a decreased left ventricular pump function so that encephalitis and myocarditis were suspected. Despite antiviral and antibiotic therapy the girl died 4 days after admission due to intravital brain death and multiorgan failure. This cause of death was confirmed by forensic autopsy. The fall had not led to any intracranial injury and predisposing diseases were not found. Histological examination revealed necrotizing brainstem encephalitis.

Histological examination of the pituitary glands in cases of fatal hypothermia.

Besides typical macroscopical findings in cases of death due to hypothermia (frost erythema, haemorrhagic gastric erosions) there are some histological changes (e.g. lipid accumulation in epithelial cells of renal proximal tubules) which can help to determine the cause of death. In the literature some changes of the pituitary gland are described in case of hypothermia, e.g. haemorrhage and hyperaemia of the anterior lobe of the pituitary gland (adenohypophysis) or a vacuolization of cells in the anterior pituitary. The validity of these morphological changes as hypothermia marker should be proved in our autopsy material. 17 pituitary glands in cases with verified fatal accidental hypothermia were examined histologically and immunohistochemically (HE, Ferric, Azan, LCA, C5b9) and compared with 61 pituitary glands of a matching control group (cases of natural and non-natural death without trauma and long agonal period). Autolytical changes complicated an evaluation but in 5.9% of the study group and 1.6% of the control group a vacuolization of cells could be verified. In none of the examined cases a distinct haemorrhage into the glandular tissue was detected. Histopathological characteristics which are described in the literature as pathogenetic for hypothermia could not be found. Differences concerning histological characteristics of the pituitary glands between cases of fatal hypothermia and the control group were not observed.

Unattended fatal haemorrhage due to spontaneous peripheral varicose vein rupture--two case reports.

Venous haemorrhage is a rare complication of varicose veins of the legs. Varicosis is found in 15-50% of the population. Haemorrhage from ruptured varicose veins of the legs can occur spontaneously or after a minor trauma. More frequent complications of varicosis include peripheral oedema of the ankles, skin pigmentation and skin ulcers. In case of venous haemorrhage simple possibilities of first aid can be applied, therefore fatal haemorrhage is a rarity. Two cases of fatal varicose vein rupture are presented. A 58-year-old man and a 76-year-old woman, both living alone, were found dead in the bathrooms of their apartments. Significant traces of blood were found in all rooms. Both corpses showed typical signs of death from exsanguination. No traumatic lesion was found. Cause of the haemorrhage was a small lesion of the skin of the lower legs of the victims with continuation to an underlying superficial varicose vein. Misinterpretation of life-threatening varicose haemorrhage, unconsciousnous, alcohol or drug influence, old age and dementia can promote the death. In case of fatal haemorrhage the death scene can simulate crime due to massive traces of blood and may focus primarily on a non-natural death. However, police investigations and autopsy will disclose the rare cause of spontaneous natural death.

Combined suicide by oxydemeton-methyl (Metasystox) ingestion and hanging.

A case of a combined suicide by oxydemeton-methyl (Metasystox) ingestion and hanging is reported. Dimethyl phosphate (DMP) proved to be a stable product of oxydemeton-methyl; for its determination a gas chromatographic/mass spectrometric procedure was performed. DMP levels were quantified in several liquids and tissue samples: measured concentrations were 103.31 microg/ml DMP in gastric contents, 0.10 microg/ml in blood, 1.40 microg/g in liver, 2.87 microg/ml in bile and 0.80 microg/g in kidney. No DMP was found in either urine or cerebrum. On the basis of the distribution of the poison in the organism, and particularly due to the fact that no DMP could be detected in the urine and that also an amount of DMP was found in the gastric contents, it can be assumed that there was a close temporal connection between ingestion of poison and hanging. Therefore, it is a case of a primary combined suicide.