The forensic spleen: Morphological, radiological, and toxicological investigations.

The spleen is only uncommonly investigated in the forensic setting. Thorough examinations are performed in some specific situations such as splenic trauma (including iatrogenic trauma from cardiopulmonary resuscitation attempts), anaphylaxis, drowning, and sepsis-related deaths. The aim of this review is to present the available literature focusing on a few selected splenic diseases as well as forensic investigations performed on the spleen in order to summarize the most frequent situations in which this routinely unexplored organ may merit more extensive examination.

Postmortem IgE determination in coronary artery disease.

Allergic, IgE-mediated inflammation is thought to play a role in atherogenesis and atherosclerotic disease progression. In this study, total IgE and mast cell tryptase were measured in a series of forensic autopsy cases including non-allergic cardiac deaths (14 cases with minimal or no coronary atherosclerosis, 14 cases with significant coronary artery atherosclerosis without acute coronary thrombosis, and 14 cases with significant coronary artery atherosclerosis and acute coronary thrombosis or myocardial infarction) and non-allergic non-cardiac deaths (21 cases with death due to hanging and 21 cases with death due to intracranial gunshot wounds), in order to correlate laboratory results with morphological findings and compare them to conclusions reported in the clinical setting. In cardiac death cases, postmortem serum total IgE levels were increased in 7 out of 42 cases and mast cell tryptase levels were increased in 3 out of 42 cases. In non-cardiac death cases, postmortem serum total IgE levels were not increased in 39 out of 42 cases and mast cell tryptase levels were not increased in any of these cases. These preliminary findings seem to indicate that a portion of coronary deaths characterized by coronary artery atherosclerosis of various severities are also characterized by increased total IgE and mast cell tryptase levels, thus corroborating the data previously reported in both clinical and forensic literature on this topic as well as the necessity of combining morphological investigations focusing on the heart and coronary arteries with biochemical analyses.

Virtual Autopsy as a Screening Test Before Traditional Autopsy: The Verona Experience on 25 Cases.

BACKGROUND: Interest has grown into the use of multidetector computed tomography (CT) and magnetic resonance imaging as an adjunct or alternative to the invasive autopsy. We sought to investigate these possibilities in postmortem CT scan using an innovative virtual autopsy approach. METHODS: Twenty-five postmortem cases were scanned with the Philips Brilliance CT-64 and then underwent traditional autopsy. The images were interpreted by two blinded forensic pathologists assisted by a radiologist with the INFOPSY® Digital Autopsy Software System which provides three-dimensional images in Digital Imaging and Communications in Medicine format. Diagnostic validity of virtual autopsy (accuracy rate, sensitivity, specificity, and predictive values) and concordance between the two forensic pathologists (kappa intraobserver coefficients) were determined. RESULTS: The causes of death at traditional autopsies were hemorrhage due to traumatic injuries (n = 8), respiratory failure (5), asphyxia due to drowning (4), asphyxia due to hanging or strangulation (2), heart failure (2), nontraumatic hemorrhage (1), and severe burns (1). In two cases, the cause of death could not be ascertained. In 15/23 (65%) cases, the cause of death diagnosed after virtual autopsy matched the diagnosis reported after traditional autopsy. In 8/23 cases (35%), traditional autopsy was necessary to establish the cause of death. Digital data provided relevant information for inferring both cause and manner of death in nine traumatic cases. The validity of virtual autopsy as a diagnostic tool was higher for traumatic deaths than other causes of death (accuracy 84%, sensitivity 82%, and specificity 86%). The concordance between the two forensic pathologists was almost perfect (>0.80). CONCLUSIONS: Our experience supports the use of virtual autopsy in postmortem investigations as an alternative diagnostic practice and does suggest a potential role as a screening test among traumatic deaths.

The forensic spleen: Morphological, radiological, and toxicological investigations.

The spleen is infrequently investigated in forensic pathology routine. Thorough examinations are performed in very specific situations such as splenic trauma (including iatrogenic trauma from cardiopulmonary resuscitation attempts), anaphylaxis-related deaths, drowning and sepsis. The purpose of this review article is to provide a general overview of available literature focusing on a few selected splenic diseases as well as available forensic investigation techniques performed on the spleen in order to summarize the most frequent situations of forensic interest in which this routinely unexplored organ may merit more extensive examination.

Usefulness of liver function tests in postmortem samples.

Liver function tests have been investigated in the forensic setting in several biological fluids collected at autopsy. Nevertheless, the results of these investigations have provided diverging information on postmortem stability of liver function markers and postmortem reliability of liver function assessment. The first aim of this study was to determine gamma-glutamyltransferase, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, total bilirubin, total proteins, and albumin in antemortem and postmortem serum samples in a series of cases that underwent forensic investigations and had both samples available. The second aim was to measure total bilirubin and gamma-glutamyltransferase in cerebrospinal fluid. Preliminary results indicated that femoral (and cardiac) blood postmortem serum concentrations of bilirubin, total proteins, and albumin, as well as femoral blood postmortem serum concentrations of gamma-glutamyltransferase, can be considered to reliably reflect antemortem serum concentrations, thus suggesting that postmortem values could be used as surrogates for antemortem levels. Measurable bilirubin levels were demonstrable in cerebrospinal fluid samples in both preservative-free and sodium fluoride tubes, though with levels varying widely and unpredictably, irrespective of liver disease severity.

Cardiac troponins and NT-proBNP in the forensic setting: Overview of sampling site, postmortem interval, cardiopulmonary resuscitation, and review of the literature.

The possible use of biochemical markers in the postmortem diagnosis of myocardial ischemia is well known in the forensic setting, though several issues have limited its widespread adoption. The study presented herein focuses of N-terminal pro-B-type natriuretic peptide, troponin T, and troponin I, and the possible influence due to sampling site chosen, postmortem interval elapsed, and cardiopulmonary resuscitation attempts. Comparisons were performed between antemortem serum levels of these markers and postmortem levels measured in pericardial fluid and postmortem serum samples obtained from different sampling sites (n=16). Levels of these markers were also compared in cases characterized by various postmortem intervals (n=48, consisting of 24 ischemic heart disease cases and 24 controls) as well as in cases with and without cardiopulmonary resuscitation (n=22, consisting of 14 cases of hanging and 8 cases of drug intoxication). Our results indicate that N-terminal pro-B-type natriuretic peptide, troponin T, and troponin I values determined in postmortem serum from femoral blood (collected up to 24h after death) do not differ significantly from those measured in venous blood antemortem serum samples (collected at the upper limbs). In addition, our results reveal that the time elapsed after death should always be taken into consideration when cardiac troponins are measured in postmortem samples. Lastly, our findings reveal the absence of statistically significant differences between levels of the tested biomarkers (in postmortem serum from femoral blood) in cases without cardiopulmonary resuscitation compared to cases with cardiopulmonary resuscitation (at least for postmortem intervals up to 24h).

Postmortem biochemical investigation results in situations of fatal mechanical compression of the neck region.

Biochemical investigations performed in cases of mechanical asphyxia have provided diverging information over time. The purpose of the study presented herein was threefold: to investigate the postmortem stability of a series of molecules (thyroglobulin, iodothyronines, calcitonin, and parathyroid hormone) in blood after death, to determine the same molecules in a series of cases of suicidal hangings for which antemortem serum samples were available, and to measure the same molecules in postmortem serum obtained from different sampling sites thereby evaluating the distribution of these molecules in the specific samples. Preliminary results indicated postmortem stability of thyroglobulin, calcitonin, and parathyroid hormone levels, decreasing total and free T4 levels, and increasing total and free T3 concentrations. Our findings also showed that antemortem mechanical force applied to the neck region (hanging cases) may be accompanied by increased thyroglobulin in peripheral (femoral) blood, though a certain number of cases with nonincreased thyroglobulin levels may be observed. Lastly, our results revealed that hanging, manual, and ligature strangulation cases may be accompanied by increased thyroglobulin, total T3, and free T3 values in postmortem serum specimens obtained from blood sampled at different sampling sites, even in the absence of microscopically identified thyroid gland tissue damage. Such increases are more constant and important in arterial and venous blood samples obtained from sampling sites located in close vicinity of the thyroid gland.

Postmortem diagnosis of hyponatremia: case report and literature review.

Hyponatremia is defined as a plasma sodium concentration less than 135 or 130 mEq/L (or mmol/L) and may be responsible for life threatening symptoms that can be observed in a variety of medical conditions. Cases of fatal hyponatremia have been reported in both clinical and forensic literature in situations of water intoxication due to psychogenic polydipsia, amphetamine derivative drug intake, high-endurance exercise, iatrogenic causes, and exceptional cases of child abuse by forced water intoxication. Vitreous sodium levels have been determined to be relatively stable during the early postmortem period and similar to levels found in normal serum of living subjects. Nevertheless, there are relatively few cases of fatal hyponatremia described in literature that underwent exhaustive postmortem biochemical investigations. A case of fatal water intoxication in a psychiatric patient who underwent medicolegal investigations, including postmortem biochemistry, was chosen as a starting point to a literature review of deaths by hyponatremia that may be encountered in the forensic setting.

Postmortem evaluation of cholesterol, triglyceride, and apolipoprotein levels.

Cholesterol and triglyceride levels have been analyzed in the forensic setting and their values correlated with atherosclerotic lesions found at autopsy and histology. Nevertheless, the results of these investigations have provided diverging information on postmortem molecule stability and postmortem measurement reliability. The aim of this study was to determine triglycerides, total cholesterol, low-density and high-density lipoprotein cholesterol, apolipoprotein B100, and apolipoprotein A-I in antemortem and postmortem serum samples in a series of cases (N = 10, including cardiac and noncardiac deaths) that underwent forensic investigations and had both samples available, measure the same molecules in postmortem serum from femoral blood and pericardial and pleural fluids (N = 39, including cardiac and noncardiac deaths), and evaluate whether different levels of these molecules could be observed in cases characterized by different degrees of coronary artery atherosclerosis (N = 39, including cardiac and noncardiac deaths). Preliminary results indicated that total cholesterol and low-density and high-density lipoprotein cholesterol levels in postmortem serum samples tended to be lower than those in antemortem specimens, whereas triglyceride levels in postmortem serum samples tended to be higher than those in antemortem samples. No relationship could be found between postmortem serum and pericardial fluid levels or between postmortem serum and pleural fluid levels of all tested biomarkers. Lastly, cases characterized by severe coronary artery atherosclerosis revealed higher postmortem serum levels of total cholesterol and apolipoprotein B. Globally considered, these data confirm that femoral blood postmortem serum levels of cholesterol and apolipoproteins may be considered suitable to estimate their antemortem values in forensic cases characterized by coronary artery atherosclerosis.

Endocan concentrations in postmortem serum, vitreous humor and urine in victims of lethal hypothermia.

Endocan is a soluble molecule secreted from vascular endothelial cells of various organs. Its exact function in humans remains to be elucidated, though it has been postulated that increased tissue expression or serum levels of this molecule may be an indicator of endothelial activation and neovascularization. In the realm of forensic pathology, studies pertaining to endothelial activation following exposure to cold exclusively focused on thrombomodulin, a transmembrane protein specific to endothelial cells. In the study herein described, endocan concentrations were determined in postmortem serum, urine and vitreous humor samples collected during autopsy in a series of cases that underwent medicolegal investigations. A total of 76 autopsy cases were selected and three study groups (hypothermia group, sepsis group and non-hypothermia/non-sepsis group) prospectively formed during the study period. The obtained results seem to indicate that exposure to cold and subsequent death is not distinguished by significant endothelial dysfunction causing enhanced endocan secretion.

Paradoxical undressing associated with subarachnoid hemorrhage in a non-hypothermia case?

Paradoxical undressing is a phenomenon characterizing some fatal hypothermia cases. The victims, despite low environmental temperatures, paradoxically remove their clothes due to a sudden feeling of warmth. In this report, we describe a case of suspected paradoxical undressing in a non-hypothermia case. The victim, a 51-year-old Caucasian man, was found dead wearing only sneakers and socks. All other clothing was found in his car. Postmortem investigations allowed the hypothesis of hypothermia to be ruled out and revealed the presence of a ruptured cerebral aneurysm that caused a subarachnoid hemorrhage, the latter responsible for the death. The absence of any elements suggesting a voluntary undressing or any third party's DNA profile or involvement along with the possibility that the subarachnoid hemorrhage might have determined a hypothalamic injury, somehow rendered conceivable the hypothesis of an inappropriate feeling of warmth due to hemorrhage-induced dysregulation of the hypothalamic temperature-regulating centers.

Vaccination and anaphylaxis: a forensic perspective.

AIM: To review the available literature pertaining to fatalities following vaccine administration and, in particular, cases of vaccine-related fatal anaphylaxis. METHOD: The MEDLINE database was systematically searched up to March 2016 to identify all relevant articles pertaining to fatal cases of anaphylaxis following vaccine administration. RESULTS: Six papers pertaining to fatal anaphylaxis following vaccination were found relevant. Mast cell tryptase and total IgE concentration was assessed exclusively in one case. Laryngeal edema was not detected in any of these cases, whereas eosinophil or mast cell infiltration was observed in lymphoid organs. In one case, immunohistochemical investigations using anti-tryptase antibodies allowed pulmonary mast cells and degranulating mast cells with tryptase-positive material outside to be identified. CONCLUSION: In any suspected IgE-mediated fatal anaphylactic cases, biochemical investigations should be systematically performed for forensic purposes. Splenic tissue should be routinely sampled for immunohistochemical investigations in all suspected anaphylaxis-related deaths and mast cell/eosinophil infiltrations should be systematically sought out in the spleen, myocardium, and coronary artery wall. The hypothesis of fatal anaphylaxis following vaccination should be formulated exclusively when circumstantial data, available medical records, laboratory investigations, and autopsy or histology findings converge in a consistent pattern. The reasonable exclusion of alternative causes of death after all postmortem investigations is also imperative in order to establish or rule out a cause-and-effect relationship between vaccine administration and any presumptive temporarily-related death.

Mediators of Inflammation in Asthma: A Forensic Perspective.

In the clinical setting, the role of systemic inflammation in patients with asthma has attracted increased attention, and some authors showed that increased IL-6 and high-sensitivity C-reactive protein characterized a group of asthmatic patients. In the realm of forensic pathology, a postmortem diagnosis of asthmatic death can be extremely challenging. The aim of this study was to determine the postmortem serum levels of C-reactive protein, IL-6, and tumor necrosis factor α in a series of severe acute bronchial asthma deaths that underwent medicolegal investigations. A total of 35 autopsy cases were retrospectively selected and included deaths in asthmatic subjects (related and unrelated to severe acute bronchial asthma, in situations characterized or not by systemic inflammation) as well as deaths in nonasthmatic individuals (in situations characterized or not by systemic inflammation). Our findings suggest that IL-6 is selectively increased in the systemic circulation of individuals with asthma, irrespective of whether the cause of death depends on a fatal asthma attack, compared with other biomarkers. Accordingly, postmortem serum IL-6 values in cases of death during severe acute bronchial asthma can be measured and considered of diagnostic relevance to estimate the magnitude of the systemic inflammation responses characterizing the disease.

Fatal intravenous injection of potassium: Is postmortem biochemistry useful for the diagnosis?

Fatal cases of potassium overdoses have traditionally been considered indemonstrable due postmortem biochemical investigation limits (mainly potassium determination in postmortem serum and vitreous humor). Nevertheless, some authors have expressed a divergent opinion over the years based on the results of their own investigations. In this study, we investigated left vitreous, right vitreous, postmortem serum from peripheral blood, postmortem serum from cardiac blood, urine, pericardial and cerebrospinal fluid potassium concentrations in 21 forensic autopsy cases. One of these was a case of accidental, fatal intravenous potassium injection in a hospitalized patient. The other twenty cases were subjects with various causes of death unrelated to potassium administration and comparable postmortem intervals. Our aim was to assess whether postmortem biochemical investigations performed in several biological samples may be useful in diagnosing exogenous potassium administration. No statistically significant differences were observed between the measured concentrations in the fatal case of potassium intravenous administration and the control cases in any of the tested samples. Potassium concentrations in the investigated case of exogenous potassium injection were within the range of those measured in the control cases, irrespective of the tested biological sample. Our findings corroborate the conclusions of former authors who highlighted that circumstantial evidence provides the greatest diagnostic contribution in situations of suspected potassium poisoning. This is due to the objective limitations demonstrated by postmortem biochemical investigations in such cases, even when potassium measurements are carried out in several biological samples of satisfying quality and within a relatively short postmortem interval.

Diagnosis of myocardial ischemia combining multiphase postmortem CT-angiography, histology, and postmortem biochemistry.

PURPOSE: The aim of this study was to assess whether the identification of pathological myocardial enhancement at multiphase postmortem computed tomography angiography was correlated with increased levels of troponin T and I in postmortem serum from femoral blood as well as morphological findings of myocardial ischemia. We further aimed to investigate whether autopsy cases characterized by increased troponin T and I concentrations as well as morphological findings of myocardial ischemia were also characterized by pathological myocardial enhancement at multiphase postmortem computed tomography angiography. MATERIALS AND METHODS: Two different approaches were used. In one, 40 forensic autopsy cases that had pathological enhancement of the myocardium (mean Hounsfield units ≥95) observed at postmortem angiography were retrospectively selected. In the second approach, 40 forensic autopsy cases that had a cause of death attributed to acute myocardial ischemia were retrospectively selected. RESULTS: The preliminary results seem to indicate that the identification of a pathological enhancement of the myocardium at postmortem angiography is associated with the presence of increased levels of cardiac troponins in postmortem serum and morphological findings of ischemia. Analogously, a pathological enhancement of the myocardium at postmortem angiography can be retrospectively found in the great majority of autopsy cases characterized by increased cardiac troponin levels in postmortem serum and morphological findings of myocardial ischemia. CONCLUSIONS: Multiphase postmortem computed tomography angiography is a useful tool in the postmortem setting for investigating ischemically damaged myocardium.

Postmortem serum levels of IgE and mast cell tryptase in fatal asthma.

The aim of this study was to characterize the concentrations of total and specific IgE as well as mast cell-derived tryptase in postmortem serum from femoral blood and evaluate the usefulness of their determination for diagnostic purposes in cases of fatal asthma attacks. 36 autopsy cases were retrospectively selected including cases of witnessed death in asthmatic subjects, deaths in asthmatics and atopic subjects with causes of death unrelated to asthma or allergic anaphylaxis as well as deaths in non-atopic, non-allergic individuals with causes of death unrelated to asthma or allergic anaphylaxis. Initial results indicated increased postmortem serum total IgE in atopic and asthmatic individuals, irrespective of the cause of death. Conversely, increased mast cell tryptase levels were noted exclusively in fatal asthma attacks. This suggests that mast cell tryptase measurement in cases of death potentially caused by severe acute bronchial asthma may be useful for diagnostic purposes.