American Journal of Forensic Medicine and Pathology - Vol 32, No. 1, March 2011

REVIEW ARTICLE State of the Art in Forensic Investigation of Sudden Cardiac Death Antonio Oliva, MD, PhD,* Ramon Brugad...

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REVIEW ARTICLE

State of the Art in Forensic Investigation of Sudden Cardiac Death Antonio Oliva, MD, PhD,* Ramon Brugada, MD, PhD,Þ Ernesto D_Aloja, MD, PhD,þ Ilaria Boschi, PhD,* Sara Partemi, MD,* Josep Brugada, MD, PhD,§ and Vincenzo L. Pascali, MD, PhD*

Abstract: The sudden death of a young person is a devastating event for both the family and community. Over the last decade, significant advances have been made in understanding both the clinical and genetic basis of sudden cardiac death. Many of the causes of sudden death are due to genetic heart disorders, which can lead to both structural (eg, hypertrophic cardiomyopathy) and arrhythmogenic abnormalities (eg, familial long QT syndrome, Brugada syndrome). Most commonly, sudden cardiac death can be the first presentation of an underlying heart problem, leaving the family at a loss as to why an otherwise healthy young person has died. Not only is this a tragic event for those involved, but it also presents a great challenge to the forensic pathologist involved in the management of the surviving family members. Evaluation of families requires a multidisciplinary approach, which should include cardiologists, a clinical geneticist, a genetic counselor, and the forensic pathologist directly involved in the sudden death case. This multifaceted cardiac genetic service is crucial in the evaluation and management of the clinical, genetic, psychological, and social complexities observed in families in which there has been a young sudden cardiac death. The present study will address the spectrum of structural substrates of cardiac sudden death with particular emphasis given to the possible role of forensic molecular biology techniques in identifying subtle or even merely functional disorders accounting for electrical instability. Key Words: sudden cardiac death, autopsy, ventricular tachyarrhythmia, cardiac arrest, risk factor, cardiomyopathy, molecular autopsy, postmortem genetic analysis (Am J Forensic Med Pathol 2011;32: 1Y16)

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udden cardiac death (SCD) is the leading mode of death in all communities of the United States and of the European Union, but its precise incidence is unknown. Internationally accepted methods of death certification do not include a specific category of SCD. Estimates for the United States range from 250,000 to 400,000 adult people dying suddenly each year due to cardiovascular causes with an overall incidence of 1 to 2/1000 population per year.1Y3 A task force of the European Society of

Manuscript received November 15, 2008; accepted May 27, 2009. From the *Institute of Forensic Medicine and Laboratory of Forensic Genetics, Catholic University, School of Medicine, Rome, Italy; †Cardiovascular Genetics Center, School of Medicine, University of Girona, Girona, Spain; ‡Institute of Forensic Medicine, Cagliari University, School of Medicine, Cagliari, Italy; and §Arrhythmia Unit, Cardiovascular Institute, Hospital Clinic, University of Barcelona, Spain. A.O. and R.B. have contributed equally to this study. Supported by Fondi di Ateneo Linea D1Y2008, Universita` Cattolica del Sacro Cuore, Roma. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.amjforensicmedicine.com). Reprints: Antonio Oliva, MD, PhD, Research Scientist, Institute of Forensic Medicine, Catholic University, School of Medicine, Rome, Italy. E-mail: [email protected]. Copyright * 2011 by Lippincott Williams & Wilkins ISSN: 0195-7910/11/3201-0001 DOI: 10.1097/PAF.0b013e3181c2dc96

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Cardiology has adopted the incidence ranges from 36 to 128 deaths per 100,000 people per year.4,5 More than 60% of these are the result of coronary heart disease. Among the general population of adolescents and adults younger than the age of 30 years, the overall risk of SCD is 1/100,000 and a wider spectrum of diseases can account for the final event.6 The major difficulties in interpreting epidemiological data on sudden death are the lack of standardization in death certificate coding and the variability in the definition of sudden death. Sudden death has been defined as Ba natural, unexpected fatal event occurring within 1 hour from the onset of symptoms in an apparently healthy subject or whose disease was not so severe as to predict an abrupt outcome.[7 This well describes many witnessed deaths in the community or in emergency departments. It is less satisfactory in forensic practice where autopsies may be requested on patients whose deaths were not witnessed, occurred during sleep or at an unknown time before their bodies were discovered. Under the latter circumstances, it is probably more satisfactory to assume that the death was sudden if the deceased was known to be in good health 24 hours before death occurred.8 Moreover, for practical purposes, a death can be classified as sudden if a patient is resuscitated after cardiac arrest, survives on life support for a limited period of time and then dies due to irreversible brain damage. Forensic pathologists are responsible for determining the precise cause of sudden death but there is considerable variation in the way in which they approach this increasingly complex task. A variety of book chapters, professional guidelines, and articles have described how pathologists should investigate sudden death,9Y14 but there is little consistency among centers, even in individual countries. Furthermore recent advances in the field of molecular genetics have expanded our understanding of the etiology of many lethal and heritable channelopathies leading to fatal arrhythmias, such as congenital long QT syndrome (LQTS), catecholaminergic polymorphic ventricular tachycardia (CPVT) and Brugada syndrome (BrS) which is an autosomal dominant form of cardiac arrhythmia with a typical electrocardiographic (ECG) pattern of ST segment elevation in leads V1 to V3, and incomplete or complete right bundle branch block15 linked to mutations in the SCN5A gene encoding for the alpha-subunit of the cardiac sodium channel16,17; thus actually forensic pathologists play a crucial role in such circumstances because an accurate postmortem diagnosis of the causes of SCD is of particular importance to establish pre-emptive strategies to avoid other tragedies among relatives.18 In this article, we summarize the state of art of forensic investigation and autopsy techniques for an adequate assessment of SCD in general population and we describe the main pathologic findings at postmortem analysis.

THE RANGE OF PATHOLOGY Many reports describe the pathologic findings in SCD (Table 1). These studies differ in many ways, especially in the age and type of patients investigated and the extent of histologic sampling. In adults, coronary artery disease is by far, the leading cause of death. The proportion of cases with evidence of acute www.amjforensicmedicine.com

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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TABLE 1. Sudden Cardiac Death in Adult Authors Davies et al

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Setting

Patients and Methods

London, England

168 patients (21 female) dying from cardiac disease within 6 h of onset of symptoms. Detailed histology

Leach et al29

Nottingham, England

Burke et al30

United States

Chugh et al19

United States

Bowker et al31

United Kingdom

Chase20

Southern England

Fabre and Sheppard32

United Kingdom

Di Gioia et al21

Italy

Selected Results

73% had intraluminal or occlusive coronary thrombosis. Presence of thrombus associated with single vessel disease, acute myocardial infarction and prodromal symptoms 206 out-of-hospital sudden Coronary artery thrombosis Tacute infarction deaths due to in 48.5% of cases. Presence of these changes coronary heart disease. decreased with age and a previous history Detailed histology of IHD 113 males who died of coronary heart 52% acute coronary thrombosis disease. Detailed histology (10 with acute infarcts) 48% coronary stenosis without thrombosis (2 with acute infarcts) 270 hearts referred to a cardiac 65% coronary artery disease pathology unit over 13-yr-period. 190 males and 80 females aged 920 yr 9% cardiomyopathy 11% myocarditis 14% CHD 5% structurally normal National study of SCD in white males 37% acute coronary thrombosis aged 16Y64 yr, no history of or acute infarction cardiac disease, seen alive within 12 h of death. Limited histology 20% coronary stenosis with healed infarction 18% coronary stenosis without infarction 8% cardiomyopathy or LVH 4% unexplained 321 SCDs in males and females 33% acute myocardial infarction or acute aged 916 yr, 2002Y2003. coronary thrombosis Limited histology 33% coronary stenosis with healed infarction 17% coronary stenosis without healed infarction 14% cardiomyopathy or LVH 2% unexplained 453 hearts referred to a cardiac 59% structurally normal pathology unit, 1994V2003 24% cardiac muscle disease 100 hearts referred to cardiac 30%, atherosclerotic pathology unit, 2001V2005 22% cardiomyopathies 28% various cardiac abnormalities 20% inherited cardiac disease

CHD indicates congenital heart disease; IHD, ischaemic heart disease; LVH, left ventricular hypertrophy; SCD, sudden cardiac death. Modified from Curr Diagn Pathol. 2007;13:366Y374.22

coronary thrombosis or recent myocardial infarction is higher in studies in which detailed histology was performed (Table 1). With detailed histology, acute thrombosis was identified in 72%, 52%, and 47% of cases.11,29,30 In contrast, recent studies where histology was limited showed acute thrombosis in 37% and 33% of cases.20,31 Whether this represents a genuine change in the incidence of acute thrombosis in SCD or a failure of pathologists to recognize thrombi without histologic confirmation is uncertain. Congenital heart disease, cardiomyopathy, and unexplained left ventricular hypertrophy are of particular importance in younger patients (Table 2), especially athletes. Studies with limited histology appear to report a lower incidence of myo-

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carditis. The wide range of uncommon pathology is especially apparent in reports from referral centers.32,33

METHODS OF INVESTIGATION Several book chapters, professional guidelines, and articles have described how pathologists should investigate sudden death.30,34,35 Despite these guidelines, there is little consistency between centers, even in individual countries. Forensic investigation of sudden death involves 4 steps36: 1. Circumstances of death and clinical information relevant to the autopsy; 2. Autopsy examination and histology; * 2011 Lippincott Williams & Wilkins



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Forensic Investigation of SCD

TABLE 2. Sudden Cardiac Death in Young Patients Authors

Setting

Wren et al

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North England

Corrado et al24

Maron25

Italy

United States

Fornes and Lecomte26

France

Patients and Methods 229 sudden deaths in patients aged 1Y20 yr, 1985Y1994

273 SCDs, 218 males, 82 females aged 1Y35 yr, 1979Y1998

387 sudden deaths in athletes aged 35 yr

31 sudden deaths during sport, 29 males, 2 females aged 7Y60 (mean 30) years

Selected Results Asthma, respiratory infection or epilepsy 111 (48.5%) SIDS 20 (8.7%) Previous diagnosis of cardiac disease, chiefly congenital heart disease 33 (14.5%) Cardiomyopathy 8 (3.5%) Myocarditis 5 (2.2%) Coronary atheroma 1 (0.4%) Unexplained 21 (9.2%) Cardiomyopathy 66 (24%) Myocarditis 27 (10%) Coronary atheroma 54 (20%) Unexplained 16 (6%) Cardiomyopathy 122 (32%) Myocarditis 20 (5%) Coronary atheroma 10 (3%) FUnexplained_ 2% Cardiomyopathy 10

Coronary atheroma 9 Henriques de Gouveia et al27 The Netherlands 11 sudden deaths from coronary heart Nine plaque erosions and 2 claque ruptures. disease in patients aged 24Y35 yr. Histology and immunohistochemistry suggested No history of heart disease that thrombus was fresh in only 3 cases Unexplained 31% Australia 193 SCDs in patients aged Coronary heart disease 24% Doolan et al28 G35 yr, 1994Y2002 Cardiomyopathy 18% Myocarditis 12% Congenital heart disease 7% SCD indicates sudden cardiac death; SIDS, sudden infant death syndrome. Modified from Curr Diagn Pathol. 2007;13:366Y374.22

3. Laboratory tests; 4. Formulation of a diagnosis: main findings at postmortem investigation; Finally, a forensic report including a clinicopathologic summary is written by the pathologist. At this stage it is critical to establish or consider: & Whether the death is attributable to a cardiac disease or to other causes of sudden death; & The nature of the cardiac disease, and whether the mechanism was arrhythmic or mechanical; & Whether the cardiac condition causing sudden death may be inherited, requiring screening and counseling of the next of kin; & The possibility of toxic or illicit drug abuse and other unnatural deaths.

CIRCUMSTANCES OF DEATH AND CLINICAL INFORMATIONS RELEVANT TO THE AUTOPSY Forensic and general pathologists approach sudden death autopsies with different degrees of suspicion. Forensic pathologists may visit the scene of death and carefully examine the clothing and effects of the deceased. Death scene investigation * 2011 Lippincott Williams & Wilkins

requires also a detailed interrogation of witnesses, if any, family members of the deceased, physicians of the rescue team who attempted resuscitation. On the other hand, general pathologists usually receive reports from the police or other investigators confirming that no suspicious circumstances have been discovered. Whatever the setting, pathologists should be provided with full details of the circumstances of the death of the patient, the medical history, and the prescribed medications. In practice, this is often not available. Although the majority of deaths occur at home, many are unwitnessed. Symptoms such as syncope, dizziness, and chest pain are of particular importance. A previous electrocardiogram is especially valuable, but a recent population study found that this was available in less than 40% of patients who died suddenly and had a previous history of heart disease.18 In practice the amount of information that is available before autopsy is extremely variable. Any potential source of information should be interrogated preferentially before autopsy is carried out. Ideally, in detail the following informations are required: Age, gender, occupation, lifestyle (especially alcohol or smoking), usual pattern of exercise, or athletic activity; Circumstances of death: date, time interval (instantaneous or G1 hours), place of death (eg, at home, at work, in hospital, at recreation), circumstances (at rest, during sleep, during exerciseVathletic or nonathletic, during emotional stress), www.amjforensicmedicine.com


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witnessed or un-witnessed, any suspicious circumstances (carbon monoxide, violence, traffic accident, etc); Medical history: general health status, previous significant illnesses (especially syncope, chest pain, and palpitations, particularly during exercise, myocardial infarction, hypertension, respiratory, and recent infectious disease, epilepsy, asthma, etc), previous surgical operations or interventions, previous ECG tracings and chest x-rays, results of cardiovascular examination, laboratory investigations (especially lipid profiles); Prescription and nonprescription medications; Family cardiac history: ischemic heart disease and premature sudden death, arrhythmias, inherited cardiac diseases; ECG tracing taken during resuscitation, serum enzyme and troponin measurements.

Cardiac Causes of Sudden Death

THE AUTOPSY PROCEDURE The care and attention to detail that pathologists give to sudden death autopsies varies considerably. Most are performed by general or forensic pathologists. Their major professional interests are likely to be in diagnostic surgical histopathology and the investigation of criminal death, rather than in cardiovascular pathology. Details of how to perform autopsies have been summarized by Cohle and Sampson33 and described and illustrated in detail in a recent textbook.34 The range of pathology in sudden death has been also summarized by Saukko and Knight.36 Moreover principles and rules relating to autopsy procedures are well delineated through the Recommendations on the Harmonization of Medico-Legal Autopsy Rules produced by the Committee of Ministers of the Council of Europe.10 In our opinion the procedures reported below are designed to make the diagnosis of SCD more straightforward and logical.

External Examination of the Body The external examination may find clinical signs of disease, such as alcohol disease, in which patients present a raised risk of sudden death. Trauma lesions such as contusions can also be found, particularly in case of fall after brutal loss of consciousness. Trauma due to resuscitation may be found as well. Moreover it is very important to perform the following procedures: & Establish body weight and height (to correlate with heart weight and wall thickness).37Y39 & Check for recent intravenous access, intubation, ECG pads, defibrillator and electrical burns, drain sites, and traumatic lesions; & Check for implantable cardioverter defibrillator/pacemaker; if in situ, see MDA Safety Notice 2002 for safe removal and interrogation.40

Full Autopsy With Sequential Approach to the Causes of Sudden Death Noncardiac Causes of Sudden Death Any natural sudden death can be considered cardiac in origin after the exclusion of noncardiac causes. Thus, a full autopsy with sequential approach should be always performed to exclude common and un-common extracardiac causes of sudden death, especially: Cerebral (eg, subarachnoid or intracerebral hemorrhage, etc) Respiratory (eg, asthma, anaphylaxis, etc) Acute hemorrhagic shock (eg, ruptured aortic aneurysm, peptic ulcer, etc) Septic shock (WaterhouseYFriderichsen syndrome)

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Many cardiovascular diseases can cause SCD, either through an arrhythmic mechanism (electrical SCD) or by compromising the mechanical function of the heart (mechanical SCD). These disorders may affect the coronary arteries, the myocardium, the cardiac valves, the conducting system, the intrapericardial aorta, or the pulmonary artery, the integrity of which is essential for a regular heart function (Table 3).

The Standard Gross Examination of the Heart 1. Check the pericardium, open it, and explore the pericardial cavity. 2. Check the anatomy of the great arteries before transecting them 3 cm on top of the aortic and pulmonary valves. 3. Check and transect the pulmonary veins. Transect the superior vena cava 2 cm above the point where the crest of the right atrial appendage meets the superior vena cava (to preserve sinus node). Transect the inferior vena cava close to the diaphragm. 4. Open the right atrium from the inferior vena cava to the apex of the appendage. Open the left atrium between the pulmonary veins and then to the atrial appendage. Inspect the atrial cavities, the interatrial septum, and determine whether the foramen ovale is patent. Examine the mitral and tricuspid valves (or valve prostheses) from above and check the integrity of the papillary muscles and chordae tendineae. 5. Inspect the aorta, the pulmonary artery, and the aortic and pulmonary valves (or valve prosthesis) from above. 6. Check coronary arteries: i. Examine the size, shape, position, number, and patency of the coronary ostia; ii. Assess the size, course, and Bdominance[ of the major epicardial arteries; iii. Make multiple transverse cuts at 3-mm intervals along the course of the main epicardial arteries and branches such as the diagonal and obtuse marginal, and check patency; iv. Heavily calcified coronary arteries can sometimes be opened adequately with sharp scissors. If this is not possible, they should be removed intact, decalcified, and opened transversely; v. Coronary artery segments containing a metallic stent should be referred intact to labs with facilities for resin embedding and subsequent processing and sectioning; vi. Coronary artery bypass grafts (saphenous veins, internal mammary arteries, radial arteries, etc) should be carefully examined with transverse cuts. The proximal and distal anastomoses should be examined with particular care. Side branch clips or sutures may facilitate their identification, particularly when dealing with internal mammary grafts. 7. Make a complete transverse (short-axis) cut of the heart at the midventricular level and then parallel slices of ventricles at 1-cm intervals towards the apex and assess these slices carefully for morphology of the walls and cavities. 8. Once emptied of blood, the following measurements are important: i. Total heart weight: assess weight of heart against tables of normal weights by age, gender, and body weight34Y36; ii. Wall thickness: inspect endocardium, measure thickness of mid cavity free wall of the left ventricle, right ventricle and of the septum (excluding trabeculae) against tables of normal thickness by age, gender, and body weight34Y36; iii. Heart dimensions: the transverse size is best calculated as the distance from the obtuse to the acute margin in the posterior atrioventricular sulcus. The longitudinal size is * 2011 Lippincott Williams & Wilkins



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TABLE 3. Sudden Cardiac Death at Postmortem Mechanical Intrapericardial hemorrhage and cardiac tamponade Ascending aorta rupture (hypertension, Marfan, bicuspid aortic valve, coarctation, others) Postmyocardial infarction free wall rupture Pulmonary embolism Acute mitral valve incompetence with pulmonary edema Postmyocardial infarction papillary muscle rupture Chordae tendineae rupture (floppy mitral valve) Intracavitary obstruction (eg thrombus/neoplasms) Abrupt prosthetic valve dysfunction (eg laceration, dehiscence, thrombotic block, poppet escape) Congenital partial absence of the pericardium with strangulation

Arrhythmic

Others

Coronary arteries (Tpostmyocardial infarction scar) Congenital anomalies

Fibromuscular dysplasia

Origin from the aorta

Coronary artery by-pass (saphenous vein, mammary and radial arteries, etc) Percutaneous balloon coronary angioplasty, stents

Intramural small vessel disease

Wrong sinus (RCA from the left sinus, LCA from the right sinus) LCx from the right sinus or from RCA

Myocardium

High take off from the tubular portion

Cardiomyopathy, hypertrophic

Ostia plication

Cardiomyopathy, arrhythmogenic right ventricular

Origin from the pulmonary trunk

Cardiomyopathy, dilated

Course: intra-myocardial course (Bmyocardial bridge[)

Cardiomyopathy, inflammatory (myocarditis)

Acquired

Secondary cardiomyopathies (storage, infiltrative, sarcoidosis, etc) Hypertensive heart disease Idiopathic left ventricular hypertrophy Unclassified cardiomyopathies (spongy myocardium, fibroelastosis) Valve Aortic valve stenosis Myxoid degeneration of the mitral valve with prolapse Conduction system Sinoatrial disease AV block (LevYLenegre disease, AV node cystic tumor) Ventricular pre-excitation (WolffYParkinsonYWhite syndrome, Lown Ganong Levine syndrome) Congenital heart disease (operated and un-operated) Eisenmenger syndrome Normal heart (Bsine materia[ or unexplained SCD or sudden arrhythmic death syndrome) Long and short QT syndromes Brugada syndrome Catecholaminergic polymorphic ventricular tachycardia Idiopathic ventricular fibrillation

Atherosclerosis Complicated (thrombus, haemorrhage) Uncomplicated Embolism Arteritis Dissection

AV indicates atrioventricular; LCA, left coronary artery; LCx, left circumflex branch; RCA, right coronary artery. Modified from Virchows Arch. 2008;452:11Y18.35

obtained from a measurement of the distance between the crux cordis and the apex of the heart on the posterior aspect. 9. Dissect the basal half of the heart in the flow of blood and complete examination of atrial and ventricular septa, atrioventricular valves, ventricular inflows and outflows, and semi-lunar valves. In case of ECG documented ventricular pre-excitation, the atrioventricular rings should be maintained intact. * 2011 Lippincott Williams & Wilkins

LABORATORY TESTS Progress in autopsy diagnosis of SCD depends also from the use of a rigorous protocol in order not to forget essential biologic samples for histology, toxicologic, or molecular studies that are maybe required at some stage in the investigation procedure. A suggestion of such protocol is shown in Table 4. To this end, appropriate storage of autopsy tissues/fluids is essential in SCD autopsies. If these laboratory tests are needed and no on-site facilities are available, the stored material needs to be sent to specialized labs. www.amjforensicmedicine.com


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TABLE 4. Range of Postmortem Laboratory Tests in SCD Systematic Procedures Histology Cytology Neuropathology Toxicology Biochemistry Microbiology Molecular biology

Samples

Complementary Techniques

All organs including thymus, thyroid, testes Pericardial, pleural and abdominal fluids, CSF Brain in formol during 3Y4 wks Blood, urine, hair, vitreous humor Pericardial fluid vitreous humor Blood, all recovered fluids, organs with septic lesions and CSF for cultures Blood, heart

Gram, Grocott, and PAS stains if needed Gram and PAS stains if needed Histology, immunohistochemistry Troponine electrolytes and glucose concentrations HIV, B and C hepatitis serology PCR for viral proteins detection Mutations screening according to pathology and family disease

Histology

Molecular Studies

The standard histologic examination of the heart myocardium is based on the collection of mapped and labeled blocks from a representative transverse slice of the ventricles to include the free wall of the left ventricle (anterior, lateral, and posterior), the ventricular septum (anterior and posterior), the free wall of the right ventricle (anterior, lateral, and posterior), and right ventricular outflow tract and 1 block from each atria. In addition, any area with significant macroscopic abnormalities should be sampled. Hematoxylin and eosin stain and a connective tissue stain (van Gieson, trichrome, or Sirius red) are standard. Other special stains and immunohistochemistry should be performed as required. Coronary arteries: in the setting of coronary artery disease, most severe focal lesions should be sampled for histology in labeled blocks and stained as before.

Molecular investigations of SCD include both detection of viral genomes in inflammatory cardiomyopathies and gene mutational analysis in both structural and nonstructural genetically determined heart diseases.9,42Y44 For these purposes, 10 mL of EDTA blood and 5 g of heart and spleen tissues are either frozen and stored at j80-C, or alternatively stored in RNA later at 4-C for up to 2 weeks. More in detail, considering the important role of ion channels and their function or malfunction in several heritable and acquired channelopathies, postmortem mRNA expression analysis on tissue from pathologic and nonpathologic hearts could be a very useful source to investigate the expression of Na+ and K+ channels. A recent article has confirmed the usefulness of this idea through the demonstration of an increase in mRNA levels for 3 previously undiscovered truncated transcripts in ventricular tissue from failing heart suggesting that the translation of the 3 truncated forms leads to a reduction of NaV1.5 protein levels in the tissue.45

Toxicology In investigating out-of-hospital deaths, the question is almost always raised of whether toxic substances are involved. Depending on the circumstances surrounding the death and toxicological data, the manner of death can be natural, accidental, or criminal. Even when the heart is found to be abnormal at gross and/or microscopic examination, and death occurred suddenly, the question still remains of whether a substance may have triggered the death, acting as additional factor to the anatomic substrate. Therefore toxicology is very important for 2 reasons: first, to exclude a toxic cause, second, to help for the determination of a drug-related cardiomyopathy such as cocaine or amphetamine-induced cardiomyopathy which can be responsible for sudden death. Hair testing is needed even if no or low levels of drug are detected in blood, to show a history of drug abuse. The results must be compared with cardiac pathologic findings suggestive of cocaine or amphetamine cardiac chronic toxicity, such as the association of microfocal fibrosis, contraction band necrosis, and cardiomyocyte hypertrophy. The cardiac toxicity of anabolic steroid abuse must also be taken into account. The proper selection, collection, and submission of specimens for toxicological analyses are mandatory if analytical results are to be accurate and scientifically useful. The types and minimum amounts of tissue specimens and fluids needed for toxicological evaluation are frequently dictated by the analytes that must be identified and quantitated. For the purpose of sudden death investigation, the following amounts are adapted from the Guidelines of the Society of Forensic Toxicologists and the American Academy of Forensic Sciences41: heart blood 25 mL, peripheral blood from femoral veins 10 mL, urine 30 to 50 mL, bile 20 to 30 mL (when urine is not available). All samples are stored at 4-C. A lock of hair (100Y200 mg) should be cut from the back head (or from the pubic hair when head hair is not available). Toxicological analyses are generally quantitative.

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Electron Microscopy Investigation In case of suspicion of rare cardiomyopathies (mitochondrial, storage, infiltrative, etc) a small sample of myocardium (1 mm) should be fixed in 2.5% glutaraldehyde for ultrastructural examination.

FORMULATION OF A DIAGNOSIS: MAIN FINDINGS AT POSTMORTEM INVESTIGATION Coronary Artery Disease Atherosclerotic coronary artery disease (CAD) remains the predominant substrate for SCD.46,47 From a pathologic point of view, CAD is defined by a heart showing at least one of the 3 coronary arteries narrowed to 75% or more by an atherosclerotic plaque and/or thrombosis. Approximately 80% of sudden cardiac deaths are caused by CAD. An analysis made in the Framingham population of 5209 men and women free of identified heart disease at baseline showed that 46% of men and 34% of women with SCD had CAD as the most likely etiology of their cardiac arrest.42 No specific pattern of coronary artery involvement has been correlated to the risk of SCD,48 and the extent of vessel disease involvement seems to have a greater predictive value than the location of specific lesions in the coronary arteries.49,50 Structural abnormalities of coronary arteries can be characterized as acute or chronic, and healed myocardial infarction (MI) has been reported in 40% to 70% of SCDrelated autopsies.42,51 But only 20% of those with SCD have shown any evidence of a recent MI.52 Acute coronary events with recent thrombi, plaque fissuring, and hemorrhage are believed to contribute significantly to SCD, although there has been a low incidence of acute MIs at autopsy in patients with * 2011 Lippincott Williams & Wilkins



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SCD. In the pathogenesis of ventricular arrhythmias, transient ischemia, and reperfusion, autonomic changes, and systematic derangements (eg, hypoxemia, acidosis, electrolyte imbalance) play a more significant role in healed myocardial tissue than in normal cardiac muscle.53 Nonatherosclerotic CAD leading to SCD is seen less commonly and can be a manifestation of anomalous origin of left coronary artery, (Fig. 1)54 embolism, arteritis, and coronary dissection.48,55

Cardiomyopathies Cardiomyopathies are a major cause of morbidity and mortality at all ages. They are defined by the World Health Organization56 as Bdiseases of the myocardium associated with cardiac dysfunction[ and are classified into 4 major groups: hypertrophic cardiomyopathy, dilated cardiomyopathy, restrictive cardiomyopathy, and arrhythmogenic right ventricular cardiomyopathy. An additional category referred to as Bspecific[ cardiomyopathies, which encompasses a wide variety of specific cardiac or systemic disorders, has also been included in the classification scheme.56 The cardiomyopathies may be either inherited or acquired. In the last 20 years, advances in molecular genetics have improved our understanding of the pathogenesis of cardiomyopathies by identifying underlying gene mutations that lead to myocardial disease. Although many cardiomyopathies result from a single gene defect and are therefore inherited in a predictable Mendelian fashion, the resultant disease phenotype may be clinically and pathologically diverse.57

Hypertrophic Cardiomyopathy Hypertrophic cardiomyopathy (HCM) is a well-recognized cause of SCD with sudden unexpected death occurring most frequently in young persons affecting 1:500 of the population.58,59 Decades ago, HCM was written about and known as idiopathic hypertrophic subaortic stenosis. It also was written about and known as asymmetric septal hypertrophy. These terms were replaced by the current term, HCM, because the segmental hypertrophy can occur in any segment of the ventricle, not just the septum.60 Furthermore, this entity can present without subaortic obstruction to flow, yet still carry the same ominous risk of arrhythmogenic sudden death and many of its clinical symptoms. Although this disease may occur at any age, most patients are in their 30s or 40s at the time of diagnosis and in 16% of cases the diagnosis is first made at autopsy (sudden death).61 On gross examination, the heart is typically enlarged to twice normal weight. The mean heart weight in a series of 40 autopsied cases was 634 grams.62 The hypertrophy is secondary to ventricular thickening and may occur almost anywhere in the ventricular mass, but is most often found in the interventricular septum

FIGURE 2. Hypertrophic cardiomyopathy. A, Long axis view of the ventricular septum (VS) and left ventricular free wall (LVFW) from a patient with hypertrophic cardiomyopathy. The ventricular septum shows asymmetric hypertrophy with scarring in the septum (arrow). Note the dilated left atrium (LA). The anterior mitral valve leaflet (AML), aorta (Ao), and right ventricle (RV) are shown for orientation. B, Histologically, there is myofiber disarray characterized by myocyte hypertrophy, and branching of myocytes (Masson trichrome). C, Microscopic section of a thickened intramural coronary artery in the ventricular septum (Hematoxylin and eosin). Adapted with permission from Dr. Renu Virmani, CVPath, International Registry of Pathology, Inc, Gaithersburg, MD. With kind permission of Springer Science + Business Media. Figure 2 can be viewed online in color at www.amjforensicmedicine.com.

(Fig. 2). Heart weight may occasionally be normal or only slightly increased, an observation that has been linked in some cases with troponin T mutations.63 Microscopically the most characteristic feature is myofiber disarray characterized by disorganized branching myocytes. Other features include myocyte hypertrophy, interstitial fibrosis, and intramural coronary artery thickening. Diagnostic confusion often exists in making the distinction between a true HCM and cardiac hypertrophy. Proper sectioning in a case of suspected HCM entails sectioning in the short axis plane or from endocardium to epicardium in the transverse plane. Histologic review of multiple cross-sections from the ventricular septum is required demonstrating myofiber disarray of at least 5% cross-sectional area.64 It has been shown that approximately 50% to 60% of HCM cases are familial with an autosomal dominant pattern of inheritance. Currently, 14 genes and more than 150 different mutations have been identified.65 The structural deformities of HCM result from mutations in genes that encode sarcomeric proteins, most commonly beta myosin heavy chains. High-risk mutations include the beta myosin heavy chain (MYH7) mutations (R403Q, R453C, G716R, and R719W).66 A diagnosis of HCM mandates genetic counseling with serious implications for family members and thus should be reserved only for cases fulfilling the diagnostic criteria.

Arrhythmogenic Right Ventricular Dysplasia

FIGURE 1. Coronary artery anomaly. (A: Macroscopic view) Left anterior descending and circumflex coronary arteries arousing from the left sinus of Valsalva with a separate origin. (B: Histology) Microscopic appearance of fibrosis: chronic ischemic damage of the left ventricular anterior wall. With kind permission of Springer Science + Business Media. Figure 1 can be viewed online in color at www.amjforensicmedicine.com. * 2011 Lippincott Williams & Wilkins

Arrhythmogenic right ventricular dysplasia (ARVD) is a genetic cardiomyopathy often presenting with SCD, particularly in adolescents and young adults.67 In Italy, ARVD is the most frequent cause of sudden death in young athletes. The mean age for patients dying suddenly is usually in the third decade.68Y70 Although the name implies a purely right-sided disease process, involvement of the left ventricle has been shown to occur in 975% of cases and rare cases are reported to affect the left ventricle exclusively.71 The heart is generally normal in size or www.amjforensicmedicine.com


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slightly enlarged. Grossly the right ventricle may show focal myocardial wall thinning to 2 mm or less, aneurysm formation, and cavitary dilatation. Additionally, the left ventricle may show subepicardial scars on gross examination.72 The histologic features of ARVD include transmural fatty infiltration of myocardium, fibrosis, and inflammation, principally lymphocytes (Fig. 3). Fat infiltration of the right ventricle is usually considered a mandatory finding for the diagnosis, but the diagnosis should not be based only on the presence of fat because normal hearts may show a certain degree of fatty infiltration in the right ventricle. It has been showed that it is not unusual to see fat infiltration occupying over 50% of myocardial area in the anterior wall of the right ventricle in trauma victims (autopsy control subjects73). Moreover 2 pathologic variants have been described in the literature including a predominantly Bfatty[ variant and a Bfibrofatty[ variant.67Y74 The fatty variant is characterized by transmural infiltration of adipose tissue with sparing of the septum and left ventricle and without wall thinning.67Y74 In contrast, the fibrofatty or Bcardiomyo-pathic[ variant is characterized by extensive replacement-type fibrosis. Islands or strands of surviving myocytes exhibit a combination of degenerative change with myocyte vacuolization and are frequently associated with focal mononuclear inflammatory cell infiltrates.67,74,75 The pathologic criteria for ARVD remain still controversial and there is not yet a universal agreement about the definitive diagnostic features. ARVD is a genetic cardiomyopathy that has been associated with mutations of plakoglobin, plakophilin, and desmoplakin genes.76 These genes encode desmosomal proteins which are involved with cell adhesion. Loss of normal desmosomal structure is considered a crucial event in the pathogenesis of


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FIGURE 4. Left ventricular noncompaction. Isolated left ventricular noncompaction in an autopsy specimen, shown in short-axis view. Note the compacted epicardial layer and noncompacted endocardial layer with marked hypertrabeculation and deep recesses. With kind permission of Springer Science + Business Media. Figure 4 can be viewed online in color at www.amjforensicmedicine.com.

ARVD, but the precise mechanisms underlying the development of disease are as yet unknown.

Left Ventricular Noncompaction Ventricular noncompaction (Fig. 4), also known as left ventricular noncompaction (LVNC), is a rare form of cardiomyopathy believed to result from an unexplained arrest in cardiac development. This disease was first described over a decade ago and is now gaining increased recognition as an important cause of heart failure and its complications.56 LVNC has been also reported as a cause of sudden death in both children and adults.77,78 Since the diagnosis is often made initially at autopsy, forensic pathologists should be aware of the diagnostic features. Grossly the left ventricular wall demonstrates deep recesses extending to the inner half of the ventricle occurring most prominently in the midventricle to apex. The recesses show variable patterns including anastomosing broad trabeculae, coarse trabeculae resembling multiple papillary muscles, and fine interlacing bundles that may only be appreciated microscopically. The histologic features of LVNC are distinct, characterized by anastomosing muscle bundles forming irregular, large branching staghorn recesses in the endocardium. Another pattern shows spongy parenchyma with compressed invaginations that are not grossly apparent. Marked endocardial fibroelastosis with prominent elastin deposition is present as well.

Inflammatory Myocardial Diseases FIGURE 3. Arrhythmogenic right ventricular dysplasia (ARVD). A, Right ventricle from a patient with ARVD. Note the fatty infiltration of the right ventricular wall and absence of myocardial tissue with mild focal fibrosis (arrow). B, Longitudinal section of a heart showing biventricular involvement of ARVD. Note the subepicardial scarring in the left ventricle (arrow) and aneurysmal dilatation with fibrofatty infiltration of the right ventricle (double arrows) with marked thinning. C, Fibrofatty replacement of the right ventricle with interspersed myocytes (red). D, Subepicardial scarring of the left ventricle corresponding to single arrow in Figure B. Adapted with permission from Dr. Renu Virmani, CVPath, International Registry of Pathology, Inc, Gaithersburg, MD. With kind permission of Springer Science + Business Media. Figure 3 can be viewed online in color at www.amjforensicmedicine.com.

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Myocarditis is defined as inflammation of the myocardium and may be attributed to a number of causes including infectious, toxic, and idiopathic.79,80 Examples of inflammatory myopathies include lymphocytic myocarditis (viral), hypersensitivity myocarditis, giant cell myocarditis, toxic myocarditis, infectious myocarditis, and sarcoidosis together with others myocardial infiltrative diseases responsible of SCD such as amyloid and tuberculous myocarditis.81,82

Lymphocytic Myocarditis Viral, or lymphocytic myocarditis (Fig. 5), is seen more commonly in cases of neonatal and childhood SCD, and may follow a recent viral syndrome.80 Gross examination of the heart is typically unrevealing. Histologically the inflammation is usually diffuse and consists primarily of lymphocytes macrophages, * 2011 Lippincott Williams & Wilkins



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disease manifests as dilated cardiomyopathy. This progression is characterized by inflammation and myocytolysis, gradually resulting in death of myocytes and replacement by fibrous tissue.86 Etiologic agents in this category include catecholamines, arsenicals, venoms, paracetamol, and chemotherapeutic agents.

Giant Cell Myocarditis

FIGURE 5. Lymphocytic myocarditis. AYD, complex low and high power views of diffuse lymphocytic infiltrate. Adapted with permission from Professor Arnaldo Capelli, Institute of Pathology, Catholic University, Rome, Italy. With kind permission of Springer Science + Business Media. Figure 5 can be viewed online in color at www.amjforensicmedicine.com.

and occasional neutrophils with associated evidence of myocyte damage. In cases of SCD, it is presumed that the lesion(s) acts as an inflammatory substrate for an arrhythmia, usually ventricular tachyarrhythmias. In North America, enteroviruses, in particular Coxsackie viruses are common agents producing myocarditis, although adenovirus, cytomegalovirus, and herpes simplex have also been associated with lymphocytic myocarditis. Up to the present time, the most useful and rapid technique for detecting virus in cases of suspected viral myocarditis is polymerase chain reaction. In one study, polymerase chain reaction. analysis detected a viral genome in 68% of endomyocardial biopsies showing lymphocytic myocarditis from a pediatric population.83 Besides viruses, a large number of other pathogens have been associated with infectious myocarditis including bacteria, fungi, and parasites. The gross and histologic features of infectious myocarditis vary depending on the etiologic agent and the stage of the disease.

Giant cell myocarditis (Fig. 6) is a rare disease of unknown etiology most commonly seen in adults 20 to 50 years old.87 Clinically, it usually presents as sudden onset of congestive heart failure and is rapidly fatal in most cases. The histopathologic features include widespread, often serpiginous, myocardial necrosis with chronic inflammation including multinucleated giant cells.88 The giant cells are usually seen at the margins of necrosis and have been shown to be derived from the histiocyte.

Sarcoidosis Most patients with cardiac sarcoidosis have clinically apparent systemic involvement, but in some patients the heart may be the primary site. The clinical manifestations are determined by the extent and location of involvement and may include conduction defects, ventricular arrhythmias, congestive heart failure, mitral regurgitation, and sudden death. Cardiac sarcoidosis is a focal disease involving the myocardium in decreasing order of frequency; left ventricular free wall, base of the ventricular septum, right ventricular free wall, and atrial walls.62 Grossly the heart may display scarring in a distribution not typical for ischemic disease, also involving the epicardial surface.89 The histologic features (Fig. 7) of cardiac sarcoid are similar to those of extracardiac sarcoid consisting of noncaseating granulomas, histiocytes, giant cells, lymphocytes, and

Hypersensitivity Myocarditis Hypersensitivity myocarditis is a rare cause of SCD. More than 20 drugs have been incriminated as possible etiologic agents84 in hypersensitivity myocarditis with penicillin, sulfonamides, and methyldopa being the most common. Although often asymptomatic, hypersensitivity myocarditis may cause congestive heart failure, arrhythmias, and rarely sudden death. Most cases of hypersensitivity myocarditis are diagnosed at autopsy,85 therefore, the true prevalence of nonlethal cases is unknown. The histopathologic features of hypersensitivity myocarditis include interstitial and perivascular chronic inflammatory infiltrates consisting of lymphocytes, plasma cells, and macrophages, with a prominence of eosinophils. There is little associated necrosis and no scarring.

Toxic Myocarditis In addition to eliciting a hypersensitivity myocarditis, some drugs may be directly toxic to the myocardium and produce what is referred to as toxic myocarditis, characterized histologically by edema, neutrophil infiltration, and necrosis, sometimes with contraction band necrosis. Endothelial swelling and vasculitis may be present as well. By a clinical point of view toxic myocarditis is characterized by either acute or insidious onset and usually runs a protracted course. Frequently, irreversible end-stage * 2011 Lippincott Williams & Wilkins

FIGURE 6. Giant cell myocarditis. A, B, Pronounced lymphoeosinophilic infiltrate is associated with numerous multinucleated giant cells. Adapted with permission from Professor Arnaldo Capelli, Institute of Pathology, Catholic University, Rome, Italy. With kind permission of Springer Science + Business Media. Figure 6 can be viewed online in color at www.amjforensicmedicine.com. www.amjforensicmedicine.com


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plasma cells. Special stains should be performed to rule out the presence of fungi and acid-fast bacilli.

SCD in the Absence of Autopsy Findings

FIGURE 7. Sarcoidosis. A, Sarcoid granulomas located in the myocardium, (hematoxylin and eosin). B, Subepicardial deposition of amyloid (Congo red stain). With kind permission of Springer Science + Business Media. Figure 7 can be viewed online in color at www.amjforensicmedicine.com.

Although cardiac abnormalities evident at autopsy explain the majority of sudden deaths in young people, several population-based studies (Fig. 8) show that a significant number of sudden deaths remain unexplained following a comprehensive postmortem investigation including full autopsy. In fact in some cases, the underlying defect responsible for a SCD is not found on gross, microscopic, or even ultrastructural examination of the heart. In detail for nearly half of young victims from 1 to 35 years of age, there are no apparent warning signs and sudden death often occurs as the sentinel event, thus placing extreme importance upon the forensic investigation and autopsy to determine the cause and manner of death.93 With recent advances in molecular biology, it has become apparent that a proportion of these deaths are due to mutations in cardiac ion channels that may lead to ventricular arrhythmias and sudden death. Classifications of electric heart diseases have proved to be exceedingly complex and in many respect contradictory. A new contemporary and rigorous classification of arrhythmogenic cardiomyopathies have been proposed recently in consensus with a recent American Heart Association Scientific Statement.94 This consensus report has provided an important framework and overview to this increasingly heterogeneous group of primary cardiac membrane channel diseases. Of particular note, the present classification scheme (Fig. 9) incorporates ion channelopathies as a primary cardiomyopathy. Basically, the underlying gene defects alter the electrical activity in the heart predisposing the patient to fatal cardiac arrhythmias, without any morphologic changes seen in the myocardium. Such disorders of ion channels are sometimes referred

FIGURE 8. Structurally normal heart versus pathologic at postmortem analysis: Comparison of data from 4 cohorts: A. Maron et al90 (N = 134; mean age: 17 years; frequency of cardiomyopathy subtypes: HCM, 36%; dilated cardiomyopathy [DCM], 3%, arrhythmogenic right ventricular dysplasia [ARVD], 3%; and unexplained increase in cardiac mass [HCM], 10%); B. Puranik et al91 (N = 241, mean age: 27 years; frequency of cardiomyopathy subtypes: HCM, 6%; DCM, 5%; ARVD, 2%; and idiopathic left ventricular hypertrophy, 3%); C. Corrado et al24 (N = 273; mean age: 24 years; frequency of cardiomyopathy subtypes: HCM, 7%; DCM,4%; and ARVD, 13%; a significant fraction of those included in ‘Other structural causes’ (24/38) had histologic evidence of conduction system abnormalities); D. Eckart et al92 (N = 108, mean age: 19 years; frequency of cardiomyopathy subtypes: HCM, 8%; DCM, 1%; ARVD, 1%). ‘‘Structurally normal’’ includes the diagnosis of arrhythmia disorders, such as long QT syndrome, as well as all sudden unexplained deaths. In some instances, minimal structural abnormalities were noted at autopsy, but these were felt to be insufficient to cause sudden death. Adapted with permission from Curr Opin Cardiol.44 With kind permission of Springer Science + Business Media. Figure 8 can be viewed online in color at www.amjforensicmedicine.com.

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FIGURE 9. A, Long QT and related arrhythmia syndromes genes contributing to the same membrane currents and/or distinct phenotypes: j indicates gain of function; ,, loss of function. B, Brugada and related arrhythmia syndromes genes: , indicates loss of function; ?, unknown. C, Short-QT syndromes genes: j indicates gain of function; ?, unknown. D, Dilated cardiomyopathy genes: j indicates gain of function; ?, unknown.

to as Bcardiac channelopathies[Vexamples of these include LQTS and Brugada Sindrome (BrS) (Fig. 10). Actually in forensic field there is unlimited potential for the use of molecular testing to identifying natural causes of death, so that a new investigatory tool so-called Bgene autopsy[ for inherited arrhythmia syndromes and also for genetic predisposition to acquired arrhythmia has increasingly emerged.95Y97 For instance, a recent study has completed one of the largest molecular autopsy series of sudden unexplained death (SUD) to date.98 In this study comprehensive mutational analysis of all 60 translated exons in the LQTS-associated genesVKCNQ1, KCNH2, SCN5A, KCNE1, and

KCNE2Valong with targeted analysis of the CPVT1-associated, RyR2-encoded cardiac ryanodine receptor was conducted in a series of 49 medical examiner-referred cases of SUD. Herein, over one-third of SUD cases hosted a presumably pathogenic cardiac channel mutation, with mutations in RyR2 alone accounting for nearly 15% of the cases. In this series, sudden death was the sentinel event in all but 4 mutation-positive SUD cases. According to these results, postmortem genetic testing has provided an answer 35% of the time, meaning that this new tool in forensics could possibly save another family member_s life.63,44Y89,93Y98 Considering that autopsy-negative SUD accounts for a significant

FIGURE 10. Schematic representation of the primary structure of the cardiac sodium channel >- and A-subunit with location of SCN5A mutations associated with sodium channel overlap syndromes. IFM indicates the cluster of 3 hydrophobic amino acids (isoleucine, phenylalanine, and methionine) which forms part of the inactivation gate. BrS indicates Brugada syndrome; LQT3, long-QT syndrome type 3; SSS, sick sinus syndrome; CCD, cardiac conduction defect; AS, atrial standstill; AF, atrial fibrillation; DCM, dilated cardiomyopathy. Figure 10 can be viewed online in color at www.amjforensicmedicine.com. * 2011 Lippincott Williams & Wilkins



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number of sudden deaths in young people and that epidemiological, clinical, and now postmortem genetic analyses all suggest that approximately one-third of SUD after the first year of life may stem from a lethal cardiac channelopathy, the cardiac channel molecular autopsy in these cases should be viewed as the standard of care for the postmortem evaluation of SUD.44 A suggestion of postautopsy care pathways to the relatives of the deceased in case of young or adult SUD or SCD where an inherited heart disease is suspected is shown in Figure 11. Unfortunately, it is profoundly difficult for the forensic pathologist to provide this level of care, for several reasons. One of these is essentially that genetic testing is still time consuming and costly, so that accordingly to these limitations it should be restricted to selected cases. Regardless of these critical aspects, the role of the forensic pathologist is vital, as current Bstandard operating procedures[ for the conduct an accurate diagnosis, derived from either a clinical assessment of surviving relatives or a molecular autopsy, enables informed genetic counseling for families and guides the appropriate commencement of preemptive strategies targeted towards the prevention of another tragedy among those left behind.

other such searches, that many false positive and negative findings will be encountered on the way. Developments to date suggest improvements in SCD analysis can be achieved in the not too distant future and one might even envision development of forensic applicable dedicated gene chip technologies, like those recently commercialized to assess cytochrome P450 gene variants affecting drug metabolism. It is also worth noting that high throughput approaches have been developed to screen for previously identified channel mutations in patients suspected of harboring susceptibility to one of the rare SCD syndromes such as LQTs or BrS, as well as so-called Bacquired LQTs,[ which may occur in response to drugs that interact with myocardial K channels. Such analyses are now commercially available and can be critical in assessing risk in individual suspected of inheriting channel mutations. Application of genomic technologies in such cases may thus be helpful in understanding causative factors, which determine expressivity and penetrance in specific patients. Thus, while speculative, the Bgenomic[ tea leaves are promising, and it is encouraging that prospects of success are sufficiently exciting that literally dozens of pharmaceutical and biotechnology concerns are investing tens of millions of dollars, pounds, yen, and euros in exploring this very possibility.

Future Applications Back to the question: How will genomic approaches translate into forensic applications? Obviously, answers and identification of relevant arrhythmogenic pathways are not yet available, but it is clear that new diagnostic applications are well within our grasp. Whether constellations of risk-conferring alleles can be identified in common arrhythmia-prone syndromes is a problem only beginning to be studied and it is likely, as with


FORENSIC REPORT AND CLINICO-PATHOLOGICAL SUMMARY It is well known that forensic report represents the final official document where the pathologist describes accurately the pathologic findings related also to the clinical history, the circumstances of the death and any investigation performed close

FIGURE 11. Postautopsy care pathways service in cases of young or adult SUD or SCD where an inherited heart disease is suspected: *Add suitable statement to postmortem report: SUD: ‘‘Unexplained death may be caused by inherited cardiac disease. The deceased individual’s relatives may therefore be at risk. Please refer the deceased individual’s next of kin to Cardiac Genetics Service.’’ or SCD: ‘‘Death has been caused by a cardiac disease which may have a genetic basis. The deceased individual_s relatives may therefore also be at risk. Please refer the deceased individual’s next of kin to Cardiac Genetics Service.’’ **Ongoing surveillance seems inadvisable; there is a need for written information telling the individual that he/she will need to be reassessed if he/she develops key symptoms, or if the family history changes. With kind permission of Springer Science + Business Media.

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TABLE 5. Certainity of Diagnosis in SCD Autopsies Certain

Highly Probable

Massive pulmonary embolism

Stable atherosclerotic plaque with luminal stenosis 975% with or without healed myocardial infarction

Haemopericardium due to aortic or cardiac rupture Mitral valve papillary muscle or chordae tendineae rupture with acute mitral valve incompetence and pulmonary edema Acute coronary occlusion due to thrombosis, dissection or embolism

Anomalous origin of the LCA from the right sinus and interarterial course Cardiomyopathies (hypertrophic, arrhythmogenic right ventricular, dilated, others)

Anomalous origin of the coronary artery from the pulmonary trunk Neoplasm/thrombus obstructing the valve orifice Thrombotic block of the valve prosthesis Laceration/dehiscence/poppet escape of the valve prosthesis with acute valve incompetence Massive acute myocarditis

Myxoid degeneration of the mitral valve with prolapse, with atrial dilatation, or left ventricular hypertrophy and intact chordae Aortic stenosis with left ventricular hypertrophy ECG documented ventricular pre-excitation (WolffYParkinsonYWhite syndrome, Lown Ganong Levine syndrome) ECG documented sinoatrial or AV block Congenital heart diseases, operated

Uncertain Minor anomalies of the coronary arteries from the aorta (RCA from the left sinus, LCA from the right without interarterial course, high take-off from the tubular portion, LCx originating from the right sinus or RCA, coronary ostia plication, fibromuscular dysplasia, intramural small vessel disease) Intramyocardial course of a coronary artery (myocardial bridge) Focal myocarditis, hypertensive heart disease, idiopathic left ventricular hypertrophy

Myxoid degeneration of the mitral valve with prolapse, without atrial dilatation or left ventricular hypertrophy and intact chordae Dystrophic calcification of the membranous septum (Tmitral annulus/aortic valve) Atrial septum lipoma

AV node cystic tumor without ECG evidence of AV block, conducting system disease without ECG documentation Congenital heart diseases, unoperated with or without Eisenmenger syndrome

AV indicates atrioventricular; ECG, electrocardiogram; LCA, left coronary artery; LCx, left circumflex branch; RCA, right coronary artery. Modified from Virchows Arch. 2008;452:11Y18.35

to the time of the death. In the majority of SCDs, a clear pathologic cause can be identified, although with varying degrees of confidence. Wherever possible, the most likely underlying cause should be stated and the need for familial clinical screening and genetic analysis clearly indicated.99 Different degrees of certainty exist in defining the causeYeffect relationship between the cardiovascular substrate and the sudden death event. Table 5 lists the commonest substrates of SCD, classifying each as certain, highly probable or uncertain. In the probable, and especially the uncertain categories, each case should be considered on its individual merits. The clinical history and the circumstances of death may influence the decision making process. Finally, there are myocardial diseases in which the border between physiological and pathologic changes is poorly defined. Some diagnostic gray zones are generally present in a variable percentage of SCD autopsies. In cases as such, if there is real doubt as to whether the changes are physiological or pathologic, an expert opinion to specialized heart centers should be sought. Deaths that remain unexplained after careful macroscopic, microscopic and laboratory investigation is generally classified as sudden arrhythmic death syndrome.

CONCLUSIONS Sudden and unexpected cardiac death frequently represent one of the most challenging task faced by the forensic pathologist especially for the difficulties encountered in determining the precise cause of death. The progress in autopsy diagnosis of SCD depends, respectively, on death scene investigation, quality of autopsies, which is strictly linked to the use of a rigorous pro* 2011 Lippincott Williams & Wilkins

tocol in collecting essential biologic samples or in dissection procedures, and on the use of complementary techniques, especially histology, toxicology, and molecular biology. In detail, SCD scene investigation requires a careful interrogation of witnesses, family members, and physicians of the rescue team who eventually attempted the resuscitation. Recent symptoms before death and medical history must be sought. Prodromal symptoms are unfortunately often nonspecific, and even those taken to indicate ischemia (chest pain), a tachyarrhythmia (palpitations), or congestive heart failure symptoms (dyspnea) can only be considered suggestive. Although most of these deaths may be ascribed to coronary atherosclerosis, there are many other potential causes of a SCD such as cardiomyopathies, which are more frequently encountered in people aged less than 35 years. In the majority of cases only a detailed pathologic examination of the heart in conjunction with meaningful clinicopathologic correlation allows the pathologist to determine the underlying disease process leading to death. When no anatomic abnormality is present at autopsy, it may be of benefit to archive DNA for genetic studies if an ion channel disorder is suspected. In fact recent advances in the field of molecular genetics have expanded our understanding of the etiology and classification of many of the aforementioned cardiac diseases. These new techniques not only augment our diagnostic capabilities, but also highlight the importance of molecular diagnostics in identifying new disease-causing mutations. Thereafter the major challenge is faced by cardiologists who are directly involved in managing postautopsy care pathways to the relatives of the deceased, especially in identifying asymptomatic subjects at high risk of sudden death. To develop preventive strategies such www.amjforensicmedicine.com


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as the use of antiarrhythmic agents or implantable cardioverterdefibrillator, the incidence, causes and circumstances surrounding SCD must be better known and are mainly provided by forensic pathology.

19. Chugh SS, Kelley KL, Titus JL. Sudden cardiac death with apparently normal heart. Circulation. 2000;102:649Y654.

ACKNOWLEDGMENTS The authors thank Prof Arnaldo Capelli and Dr Vincenzo Arena from the Institute of Pathology, Catholic University, Rome, Italy. REFERENCES


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32. Fabre A, Sheppard MN. Sudden adult death syndrome an other non-ischaemic causes of sudden cardiac death. Heart. 2006;92: 316Y320. 33. Cohle SD, Sampson BA. The negative autopsy. Sudden cardiac death or other. Cardiovasc Pathol. 2001;10:271Y274. 34. Finkbeiner WE, Ursell PC, Davis RL. Basic Post-Mortem Examination in Autopsy Pathology. A Manual and Atlas. Philadelphia, PA: Churchill Livingstone; 2004;41Y65. 35. Basso C, Burke M, Fornes P, et al. Guidelines for autopsy investigation of sudden cardiac death. Virchows Arch. 2008;452:11Y18. 36. Saukko P, Knight B. The pathology of sudden death. In: Knight_s Forensic Pathology. 3rd ed. London: Edward Arnold; 2004:492Y526. 37. Kitzman DW, Scholz DG, Hagen PT, et al. Age-related changes in normal human hearts during the first 10 decades of life. Part II (maturity): a quantitative anatomic study of 765 specimens from subjects 20 to 99 years old. Mayo Clin Proc. 1988;63:137Y146. 38. Scholz DG, Kitzman DW, Hagen PT, et al. Age-related changes in normal human hearts during the first 10 decades of life. Part I (growth): a quantitative anatomic study of 200 specimens from subjects from birth to 19 years old. Mayo Clin Proc. 1988;63:126Y136. 39. Schulz DM, Giordano DA. Hearts of infants and children: weights and measurements. Arch Pathol. 1962;73:464Y471. 40. Medical Devices Agency Safety Notice 2002(35). Removal of implantable cardioverter defibrillators (ICDs); 2002:1Y3. Available at: http://www. mhra.gov.uk/home/idcplg?IdcService=SS_GET_PAGE&useSecondary= true&ssDocName=CON008731&ssTargetNodeId=420. 41. SOFT and AAFS (2002) Forensic toxicology laboratory guidelines; 2002:1Y23. Available at: www.soft-tox.org/docs/Guidelines. 2002.final.pdf.




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42. Carturan E, Tester DJ, Brost BB, et al. Postmortem genetic testing for conventional autopsy negative sudden unexplained death: an evaluation of different DNA extraction protocols and the feasibility of mutational analysis from archival paraffin embedded heart tissue. Am J Clin Pathol. In press. 43. Chugh SS, Senashova O, Watts A, et al. Postmortem molecular screening in unexplained sudden death. J Am Coll Cardiol. 2004;43:1625Y1629. 44. Tester DJ, Ackerman MJ. The role of molecular autopsy in unexplained sudden cardiac death. Curr Opin Cardiol. 2006;21:166Y172. 45. Shang LL, Pfahnl AE, Sanyal S, et al. Human heart failure is associated with abnormal C-terminal splicing variants in the cardiac sodium channel. Circ Res. 2007;101:1146Y1154. 46. Kannel WB, Cupples LA, D_Agostino RB. Sudden death risk in overt coronary heart disease: the Framingham Study. Am Heart J. 1987;113:799Y804. 47. Zipes DP, Wellens HJ. Sudden cardiac death. Circulation. 1998;98: 2334Y2351. 48. Weaver WD, Lorch GS, Alvarez HA, et al. Angiographic findings and prognostic indicators in patients resuscitated from sudden cardiac death. Circulation. 1976;54:895Y900. 49. Perper JA, Kuller LH, Cooper M. Arteriosclerosis of coronary arteries in sudden unexpected deaths. Circulation. 1975;52(suppl 6): III27YIII33. 50. Theroux P, Fuster V. Acute coronary syndromes: unstable angina and non-Q-wave myocardial infarction. Circulation. 1998;97:1195Y1206. 51. Huikuri HV, Castellanos A, Myerburg RJ. Sudden death due to cardiac arrhythmias. N Engl J Med. 2001;345:1473Y1482. 52. Basso C, Corrado D, Thiene G. Congenital coronary artery anomalies as an important cause of sudden death in the young. Cardiol Rev. 2001;9:312Y317. 53. Schwartz PJ, La Rovere MT, Vanoli E. Autonomic nervous system and sudden cardiac death: experimental basis and clinical observations for post-myocardial infarction risk stratification. Circulation. 1992; 85(suppl 1):I77YI91. 54. Cittadini F, Oliva A, Arena V, et al. Sudden cardiac death associated with a coronary artery anomaly considered benign. Int J Cardiol. In press. 55. Corrado D, Thiene G, Cocco P, et al. Non-atherosclerotic coronary artery disease and sudden death in the young. Br Heart J. 1992;68: 601Y607. 56. Richardson P, McKenna W, Bristow M, et al. Report of the 1995 World Health Organization/International Society and Federation of Cardiology Task Force on the definition and classification of cardiomyopathies. Circulation. 1996;93:841Y842. 57. Hughes SE, McKenna WJ. New insights into the pathology of inherited cardiomyopathy [review]. Heart. 2005;91:257Y264. 58. Maron BJ. Hypertrophic cardiomyopathy: a systematic review. JAMA. 2002;287:1308Y1320. 59. Rosenbaum DS, Jackson LE, Smith JM, et al. American College of Cardiology/European Society of Cardiology clinical expert consensus document on hypertrophic cardiomyopathy: a report of the American College of Cardiology Foundation Task Force on clinical expert consensus documents and the European Society of cardiology committee for practice guidelines. J Am Coll Cardiol. 2003;42: 1687Y1713. 60. Braunwald E, Wynne J. The cardiomyopathies and myocarditides. In: Heart Disease: A Textbook of Cardiovascular Medicine. 5th ed. Philadelphia, PA: WB Saunders; 1997:1414Y1426. 61. Codd MB, Sugrue DD, Gersh BJ, et al. Epidemiology of idiopathic dilated and hypertrophic cardiomyopathy. A population-based study in Olmsted County, Minnesota, 1975Y1984. Circulation. 1989;80: 564Y572.



62. Roberts WC, McAllister HA Jr, Ferrans VJ. Sarcoidosis o the heart. A clinicopathologic study of 35 necropsy patients (group 1) and review of 78 previously described necropsy patients (group 11). Am J Med. 1977;63:86Y108. 63. Moolman JC, Corfield VA, Posen B, et al. Sudden death due to troponin T mutations. J Am Coll Cardiol. 1997;29:549Y555. 64. Maron BJ, Anan TJ, Roberts WC. Quantitative analysis of the distribution of cardiac muscle cell disorganization in the left ventricular wall of patients with hypertrophic cardiomyopathy. Circulation. 1981;63:882Y894. 65. Scheffold T, Binner P, Erdmann J, et al. Hypertrophic cardiomyopathy. Herz. 2005;30:550Y557. 66. Ackerman MJ, VanDriest SL, Ommen SR, et al. Prevalence and age-dependence of malignant mutations in the beta-myosin heavy chain and troponin T genes in hypertrophic cardiomyopathy: a comprehensive outpatient perspective. J Am Coll Cardiol. 2002;39: 2042Y2048. 67. Basso C, Thiene G, Corrado D, et al. Arrhythmogenic right ventricular cardiomyopathy. Dysplasia, dystrophy or myocarditis? Circulation. 1996;94:983Y991. 68. Nava A, Thiene G, Canciani B, et al. Familial occurrence of right ventricular dysplasia: a study involving nine families. J Am Coll Cardiol. 1988;12:1222Y1228. 69. Corrado D, Basso C, Thiene G, et al. Spectrum of clinicopathologic manifestations of arrhythmogenic right ventricular cardiomyopathy/dysplasia: a multicenter study. J Am Coll Cardiol. 1997;30:1512Y1520. 70. Corrado D, Fontaine G, Marcus FI, et al. Arrhythmogenic right ventricular dysplasia/cardiomyopathy; need for an international registry. Study group on arrhythmogenic right ventricular dysplasia/cardiomyopathy of the working groups of myocardial and pericardial disease and arrhythmias of the European Society of Cardiology and of the scientific council of cardio-myopathies of the World Heart Federation. Circulation. 2000;101:E101YE106. 71. De Pasquale CG, Heddle WF. Left sided arrhythmogenic ventricular dysplasia in siblings. Heart. 2001;86:128Y130. 72. Gallo P, d_Amati G, Pelliccia F. Pathologic evidence of extensive left ventricular involvement in arrhythmogenic right ventricular cardiomyopathy. Hum Pathol. 1992;23:948Y952. 73. Burke A, Mont E, Kutys R, et al. Left ventricular noncompaction: a pathological study of 14 cases. Hum Pathol. 2005;36:403Y411. 74. D_Amati G, Leone O, Di Gioa CR, et al. Arrhythmogenic right ventricular cardiomyopathy: clinicopathologic correlation based on a revised definition of pathologic patterns. Hum Pathol. 2001;32:1078Y1086. 75. Burke AP, Farb A, Tashko G, et al. Arrhythmogenic right ventricular cardiomyopathy and fatty replacement of the right ventricular myocardium: are they different diseases? Circulation. 1998;97: 1571Y1580. 76. Norman M, Simpson M, Mogensen J, et al. Novel mutation in desmoplakin causes arrhythmogenic left ventricular cardiomyopathy. Circulation. 2005;112:636Y642. 77. Oechslin EN, Attenhofer Jost CH, Rojas JR, et al. Long-term follow-up of 34 adults with isolated left ventricular noncompaction: a distinct cardiomyopathy with poor prognosis. J Am Coll Cardiol. 2000;36:493Y500. 78. Ladich E, Virmani R, Burke A. Sudden cardiac death not related to coronary atherosclerosis. Toxicol Pathol. 2006;34:52Y57. 79. Braunwald E, ed. Myocarditis. In: Heart Disease. 6th ed. 2001: 1783Y1793. 80. Feldman AM, McNamara D. Myocarditis. N Engl J Med. 2000;343: 1388Y1398.



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81. Chan AC, Dickens P. Tuberculous myocarditis presenting as sudden cardiac death. Forensic Sci Int. 1992;57:45Y49.

92. Eckart RE, Scoville SL, Campbell CL, et al. Sudden death in young adults: a 25-year review of autopsies in military recruits. Ann Intern Med. 2004;141:829Y834.

82. Dada MA, Lazarus NG, Kharsany ABM, et al. Sudden death caused by myocardial tuberculosis. Case report and review of the literature. Am J Forensic Med Pathol. 2000;21:385Y388. 83. Martin AB, Webber S, Fricker FJ, et al. Acute myocarditis. Rapid diagnosis by PCR in children. Circulation. 1994;90:330Y339. 84. Fenoglio JJ Jr, McAllister HA Jr, Mullick FG. Drug related myocarditis. I: Hypersensitivity myocarditis. Hum Pathol. 1981;12:900Y907. 85. Burke AP, Saenger J, Mullick F, et al. Hypersensitivity myocarditis. Arch Pathol Lab Med 1991;115:764Y769. 86. Kawai C. From myocarditis to cardiomyopathy: mechanisms of inflammation and cell death: learning from the past for the future. Circulation. 1999;99:1091Y1100. 87. Kodama M, Matsumoto Y, Fujiwara M, et al. Characteristics of giant cells and factors related to the formation of giant cells in myocarditis. Circulation Res. 1991;69:1042Y1050. 88. Litovsky SH, Burke AP, Virmani R. Giant cell myocarditis: an entity distinct from sarcoidosis characterized by multiphasic myocyte destruction by cytotoxic T cells and histiocytic giant cells. Mod Pathol. 1996;9:1126Y1134. 89. Silverman KJ, Hutchins GM, Bulkley BH. Cardiac sarcoid: a clinicopathologic study of 84 unselected patients with systemic sarcoidosis. Circulation. 1978;58:1204Y1211. 90. Maron BJ, Shirani J, Poliac LC, et al. Sudden death in young competitive athletes: clinical, demographic, and pathological profiles. JAMA. 1996;276:199Y204. 91. Puranik R, Chow CK, Duflou JA, et al. Sudden death in the young. Heart Rhythm 35. 2005;2:1277Y1282.

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93. Liberthson RR. Sudden death from cardiac causes in children and young adults. N Engl J Med. 1996;334:1039Y1044. 94. Lehnart SE, Ackerman MJ, Benson DW Jr, et al. Inherited arrhythmias: a National Heart, Lung, and Blood Institute and Office of Rare Diseases workshop consensus report about the diagnosis, phenotyping, molecular mechanisms, and therapeutic approaches for primary cardiomyopathies of gene mutations affecting ion channel function [Erratum in: Circulation. 2008;118:e132]. Circulation. 2007;116:2325Y2345. 95. Oliva A, Pascali VL, Hong K, et al. Molecular autopsy of sudden cardiac death (SCD): the challenge of forensic pathologist to the complexity of genomics. Am J Forensic Med Pathol. 2005;26: 369Y370. 96. Oliva A, D_Aloja E, Pascali VL. Focussing on hard science in forensic medicine: genetics of sudden cardiac death (SCD). Forensic Sci Int. 2007;172:e2Ye3. 97. Michaud K, Lesta Mdel M, Fellmann F, et al. Molecular autopsy of sudden cardiac death: from postmortem to clinical approach. Rev Med Suisse. 2008;4:1590Y1593. 98. Tester DJ, Spoon DB, Valdivia HH, et al. Targeted mutational analysis of the RyR2 encoded cardiac ryanodine receptor in sudden unexplained death: a molecular autopsy of 49 medical examiner/coroner_s cases. Mayo Clin Proc. 2004;79:1380Y1384. 99. Oliva A, Bjerregaard P, Hong K, et al. Clinical heterogeneity in sodium channelopathies. What is the meaning of carrying a genetic mutation? Cardiology. 2008;110:116Y122.



CASE REPORT

Accidental Through and Through Penetrating Injury to the Neck Steven A. Koehler, PhD, MPH, Abdulrezak Shakir, MD, and Karl E. Williams, MD, MPH

Abstract: We present the case of a 24-year-old driver who died when a metal pole entered the front windshield, traveled through the victim_s neck, and then exited via the back windshield. This case illustrated an unusually penetration injury and the importance of a through and complete death scene investigation. Key Words: accident, neck injury, penetration injury (Am J Forensic Med Pathol 2011;32: 17Y19)

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n general the majority of penetrating wounds are homicidal in nature, a few are suicides, but rarely are they accidental. The neck region is very vulnerable to penetrate type injuries because of the high concentration of arteries, veins, and the airway. Penetrating injuries caused by a nonfirearm typically penetrate the body from a few millimeters to several centimeters. Knives or other sharps typically enter the body then are withdrawn. Rarely, in either scenarios does the object causes a through and through injury. Penetrating injuries to the region of the neck can take 3 forms. They can be the result of an intentional action of others in the form of an assault with a knife or a firearm (homicide). They can be self-inflected (suicide). They could also be accidentalVcaused by falling onto sharp objects or by flying objects capable of piercing the skin. Although rare, successful suicides caused by penetrating injuries have been reported. A 2003 report cited a suicide of a 46-year-old man by means of a nail gun.1 Accidental penetration injuries typically involve individuals falling from heights then landing onto objects protruding from the ground (sticks, iron fences), from flying objects originating from machinery or from broken safety glass during a motor vehicles accidents. A 2003 case report cited a young boy who fell into a bush, resulting in a penetrating wound to the neck.2 Recently, in the United Kingdom, a 55-year-old man sustained an injury to the neck from a piece of flying metal weighing 43 g and measuring 3 2.5 2 cm.3 The major site of stabbing is the chest region, whereas wounds to the neck region are infrequent. Wounds to the neck typically results in rapid death from exsanguinations, air embolism, or asphyxia due to massive soft tissue hemorrhage with compression of the trachea and vessels in the neck.4 Approximately 5% to 10% of trauma cases involves penetrating neck trauma and mortality has been reported as high as 11% within this group.5 Studies have reported that among wounds to the neck the majority (40%Y54%) are the result are stab wounds followed by gunshot wounds (46%Y47%), and 12% from other

Manuscript received June 1, 2007; accepted September 14, 2007. From the Allegheny County Medical Examiner_s Office, Pittsburgh, PA. Reprints: Karl Williams, MD, MPH, 1520 Penn. Ave. Pittsburg, PA 15222. E-mail: [email protected]. Copyright * 2011 by Lippincott Williams & Wilkins ISSN: 0195-7910/11/3201Y0017 DOI: 10.1097/PAF.0b013e3181875aed


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causes.6,7 We present the first cited case of an accidental through and through penetrating wound to the neck while operating a vehicle.

CASE REPORT During the late afternoon hours of August in 2001, a 24-year-old white male driver was witnessed driving in the wrong lane. After drifting back into the correct lane, he hit a stopped bus, a newspaper machine, a metal sign pole, and then came to rest in a drive way after hitting a pile of dirt (Fig. 1). The driver was pronounced dead at the scene. At the time of the accident where were no adverse weather conditions. The vehicle was observed resting on a hillside with massive front-end damage. The front (Fig. 2) and back windshields were shattered. The unrestrained driver was located in the driver_s seat and the driver_s and passenger_s airbags had deployed (Fig. 3). A search of the interior of the vehicle located 2 spoons, 3 yellow baggies, a plastic bag, 7 pills, a bag containing an unknown green substance, and a syringe. The body was transported to the Allegheny County Coroner_s Office for a complete forensic examination. According to the Next of Kin the victim was a heroin abuser. The vehicle was towed to a garage and the breaking system was tested and found to be in working condition.

POSTMORTEM EXAMINATION A medicalYlegal autopsy was performed on a 24-yearold well-developed man weighing 144 pound and measuring 66 inches. The eyes displayed pale conjunctivae and there was no petechial or hemorrhages. The neck exhibited the following trauma. There was a 13 cm 6 cm laceration in the right side of the neck, exposing the larynx (Fig. 4). This laceration involved the thyro-hyoid region of the anterior larynx exposing the cavity of the larynx. A second laceration, 8 cm 4.5 cm was located in the left side of the neck (Fig. 5) exposing the muscle and soft tissues of the neck. There were also several red abrasions on the left and middle forehead. Internally, there were traumatic injuries to the thyroid, larynx, and the hyoid bone. There were fractures of the thyroid cartilage and hyoid bone in the left neck region. The epiglottis showed lacerations and hemorrhage. The vocal cords were unremarkable. Examination of the arms revealed multiple needle track marks surrounded by yellow/purple contusion on the right ventral forearm. There was also a possible intravenous needle scar line on the right upper arm. The only internal findings were unremarkable except for moderate congestion to the lungs. Toxicological analysis of the items located in the vehicle tested positive for cocaine and marijuana. Toxicological analysis revealed 1.644 Kg/mL of morphine in the heart blood. During the postmortem examination the injuries observed were not typical of injuries encountered in a single motor vehicle accident. The forensic pathologist conducting the examination asked death investigator to return to the scene. At the scene, an approximately 6-feet long, severely twisted sign pole was closely examined (Figs. 6 and 7). The pole, a green metal sign pole that www.amjforensicmedicine.com


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FIGURE 1. Final position of vehicle after hitting several objects.

FIGURE 3. Position of unrestrained driver within the vehicle.

was angular at one end. A close-up examination of the straight end showed a moderate amount of blood (Fig. 7). Base on this new information the events of this accident were as follows. The driver lost control of his car hitting the mailbox a then a sign post. The bumper of the vehicle sheered the pole causing it to become airborne, which then penetrated the front windshield, then entered the right side of the neck region, exiting the posterior of the neck, and then exited through the back windshield. The pole then came to rest on the sidewalk behind the vehicle. The immediate cause of death was blunt force trauma of the neck and the manner of death was ruled accidental.

The investigation involving individuals that have been impaled on a fixed object should focus on whether they were pushed from a height or jumped, as in a case of a suicide. Death from flying objects are most likely encountered in industrial scenarios filled with high speed tools capable of launching objects as projectiles. The investigator should visit the incidence site and determine the location of the victim at the time of the incident and his proximity to equipment. When it comes to an MVA, the most common type of penetrating injuries is received by the shards from the front or side windows. These injuries are typically superficial cuts or dicing injuries.4 The investigation focuses primarily on the environmental factors (weather condition, lighting), the vehicle (speed of the vehicle and vehicle worthiness), and the state of the driver. Rarely, is their search for nonbullet projectiles that might have penetrated the interior of the vehicle. In this case, although very unusual, the exact mechanism of the death would have remained unknown if the forensic

DISCUSSION The forensic investigation of a death caused by a fatal penetrating injury regardless of the site of injury should include an attempt to locate the cause and the instrument responsible for the inflected the injury. The cause is any object that is capable of penetrating the skin and lacerating the blood vessels, organs, or nerves. The most frequent objects include knifes, bullets, or sharp objects, either stationary or airborne, that penetrate the skin. If a knife was used, the body should be observed to determine if the knife is still imbedded. If no weapon is located, the scene should be searched. In the case of firearm, the path of each bullet that penetrated the vehicle is determined and a search is conducted to locate shell cartilages and the weapon.

FIGURE 2. Close-up of shattered front windshield.

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FIGURE 4. Injuries to right anterior side of the driver_s neck region. * 2011 Lippincott Williams & Wilkins



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Penetrating Injury to Neck

FIGURE 7. Close-up of one end of the pole.

FIGURE 5. Injuries to left posterior side of the neck region.

investigators had not gone back to the scene and discovered the twisted sign post near the scene. The reason that forensic investigators were sent back to the scene was that the injuries seen by the pathologist where not typical of an MVA and he could not explain the mechanism of the seen trauma. The next step is to confirm that the pole was the projectile. The force required for an object to penetrate the skin depends on the configuration and sharpness of the tip object. The shaper the tip, the earlier it will perforate the skin, and once the tip has perforated the skin the rest of that object will slide into the body with ease. If the object does not come in contact with the bone, the object can pass through the internal organs with little force. The size and shape of the wound in the skin depends on the configuration and movement of the object, the direction of the thrust, and the movement of the individual. The sharpness of the object will determine the appearances of the margins of the woundYYsharp and regular, abraded and bruised, or jagged and contused.4

In this case, the vehicle was traveling at a high rate of speed when it impacted the pole. The energy of the impact caused the pole to be dislodged from it housing and become airborne, entered the front windshield through the neck and out of the back window. Anatomically, the neck can be divided into 3 major zones. In brief zone I is the area between the clavicle and the cricoid cartilage, zone II lies above the cricoid cartilage extending to the inferior border of the mandible, and zone III is located above the inferior border of the mandible to the base of the skull.7 The pole passed through zone II of the neck without hitting the bone, thus allowing it to pass through the neck. Injuries to anatomic zone II are the most fatal because of the proximity of the carotid arteries, jugular veins, larynx, esophagus, trachea, thyroid, and nerves.3 The shape of the injuries to the neck matches the shape of the pole. ACKNOWLEDGMENTS The authors thank Marty Coyne and ACCO chief photographers for their assistance in preparing the photographs in this manuscript. REFERENCES 1. Shakir A, Koehler SA, Wecht CH. A review of nail gun suicides and an atypical case report. J Forensic Sci. 2003;48:409Y413. 2. Imokawa H, Tazawa T, Sugiur N, et al. Penetrating neck injuries involving wooden foreign bodies: the role of MRI and the misinterpretation of CT images. Auris Nasus Larynx. 2003;30:S145YS147. 3. Hammawa HJ, Marshall SG, Ghareeb E, et al. Unusual penetrating metal fragment injury to the neck. Available at: www.edu.rcsed.ac.uk/ Case%20Presentation/CP18.htm. Accessed March 16, 2007. 4. DiMaio DJ, DiMaio VJM. Forensic Pathology. New York, NY: Elsevier; 1989. 5. Quinn FB. Penetrating neck trauma. Available at: www.utmb.edu/otoref/ grnds/Pen-neck-trauma-9901/Pen-neck-trauma-9901.html. Accessed March 16, 2007. 6. Ayuyao AM, Kaledzi YL, Parsa MH, et al. Penetrating neck wounds. Ann Surg. 1985;202:563Y567.

FIGURE 6. A twisted sign pole. * 2011 Lippincott Williams & Wilkins

7. Demetriades D, Theodorou D, Cornwell E, et al. Evaluation of penetrating injuries of the neck: prospective study of 223 patients. World J Surg. 1997;21:41Y48.



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CASE REPORT

Unsuspected Hereditary Hemochromatosis at Forensic Autopsy Its Presentation, Confirmation, and Implications Michael Panella, MD, JD, Steven A. Koehler, MPH, PhD, Abdulrezzak Shakir, MD, and Karl Williams, MD, MPH Abstract: Hereditary hemochromatosis (HH) is one of the most common genetic disorders and may present clinically in a variety of ways. The most common presentation is micronodular cirrhosis with possible associated diabetes. However, HH may also present with cardiac dysfunction and sudden death. The confirmation of unsuspected HH at autopsy is complicated by the growing number of genetic abnormalities, which are not detected by current commercial genetic testing for C282Y and H63D mutations. Consequently, quantitative liver iron studies on fresh or paraffin embedded liver is recommended in confirming HH. The importance of detection and confirmation of HH cannot be overemphasized given the need to screen surviving family members in preventing organ damage of asymptomatic individuals. We present a case of a 38-year-old white woman with micronodular cirrhosis secondary to unsuspected HH that was confirmed by a quantitative liver iron study. The possible presentation of cardiac sudden death from HH, confirmation issues and implications of a HH diagnosis for surviving family members are also discussed. Key Words: hereditary hemochromatosis, sudden death, forensic autopsy, postmortem diagnosis

common HFE mutation is C282Y with a homozygote frequency of 1 in 220 people and a heterozygote frequency of 1 in 9 people. Although the risk of clinical HH via the HFE mutation is reduced by only a 20% level of penetrance, HH is nevertheless one of the most common human genetic diseases, which stresses the importance of premortem and postmortem diagnosis for family members.1 Consequently, forensic pathologists can perform an invaluable service by detecting unsuspected cases of HH and ensuring the testing of potentially affected family members of the deceased. This article will present a case report of an individual presenting for forensic autopsy at the Allegheny County Medical Examiner_s Office with unsuspected HH. A review of the forensic literature is also performed for the possible presentation of unsuspected HH at autopsy with a discussion of HH confirmation and its implications for family members of the deceased.

CASE REPORT

Manuscript received July 9, 2007; accepted November 15, 2007. From the Allegheny County Medical Examiner_s Office, Pittsburgh, PA. Reprints: Karl Williams, MD, MPH, 1520 Penn. Ave. Pittsburg, PA 15222. E-mail: [email protected]. Copyright * 2011 by Lippincott Williams & Wilkins ISSN: 0195-7910/11/3201-0020 DOI: 10.1097/PAF.0b013e318187decb

The deceased was a 38-year-old white woman with a past medical history of deep venous thrombosis, right ankle fracture reduced by pinning, and chronic seizure disorder treated by previous right temporal lobectomy. The deceased had recent onset of diabetes, infertility, and increased bruising. A week before death, she had complained of nonspecific flu-like symptoms with nausea and vomiting. On the day of death, her husband had difficulty awaking the deceased. On arrival of paramedics, hypotension, tachycardia, and cyanosis were noted. The deceased was transferred to the hospital with an admitting diagnosis of massive cardiovascular and pulmonary collapse of undetermined etiology. Her admission laboratory studies demonstrated elevated liver transaminases (SGOT 759 U/L and SGPT 516 U/L), thrombocytopenia (78 K/UL), increased PT/PTT coagulation studies, elevated serum creatinine (2.6 mg/dL), massive lactic acidosis, and increased serum glucose (226 mg/dL). Despite aggressive medical treatment, she coded and was eventually pronounced dead within 24 hours of her hospital admission. At autopsy, a well nourished white woman was noted with no significant external findings other than hospital therapeutic devices, a right frontotemporal craniotomy scar, a left medial malleolus ankle scar from the previous pinning, and ecchymosis around iatrogenic puncture sites. The internal examination was significant for fibrosing pancreatitis and golden-brown micronodular cirrhosis (Fig. 1) with splenomegaly (450 g), ascites, and bilateral pleural effusions. There was also a mild nonspecific subacute pericarditis consisting of a slightly thickened pericardium with a 50 mL serosangiuneous effusion. On microscopic evaluation, end-stage cirrhosis was identified with separate scarring atrophic chronic pancreatitis. Furthermore, intracytoplasmic fine brown granules were seen on H and E stain light microscopic examination of the hepatic lobules, bile ductules, adrenal cortex, pancreatic acini, and myocardium (Figs. 2Y5). These granules stained brightly on Prussian Blue iron stain that confirmed iron deposition (Figs. 6Y9).

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(Am J Forensic Med Pathol 2011;32: 20Y24)

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ereditary hemochromatosis (HH) is a genetic condition associated with excessive iron deposition in a variety of organs. The organs most affected by HH include the liver and pancreas, with subsequent development of micronodular cirrhosis and pancreatic fibrosis with diabetes. In addition to liver and pancreas damage, other organs adversely impacted by the iron deposition include myocardium, synovium, skin, pituitary, gonads, and adrenal glands. Given the various organs at risk, individuals with HH may present with a diverse array of symptoms and signs, such as cardiac failure, arthritis, bronze skin hyperpigmentation, and infertility. This diverse clinical presentation may delay diagnosis leading to irreversible organ damage or worse yet death. Such delay is particularly tragic given the prevention of organ damage by routine serial phlebotomy in reducing excess body iron levels. The importance of diagnosis is further heightened by the genetic nature of HH that places blood relatives at risk. The more common genetic variant of HH centers on the short arm of chromosome 6 with mutation of the HFE gene that regulates the intestinal absorption of iron. Other less common non-HFE genetic types of HH also exist and are discussed later. The most


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FIGURE 1. Autopsy photograph of grossly appearing cirrhotic liver.

FIGURE 4. H and E stain of pancreatic acini (16).

FIGURE 2. H and E stain of liver (16).

FIGURE 5. H and E stain of myocardium (16).

FIGURE 3. H and E stain of adrenal cortex (16).

FIGURE 6. Prussian Blue Iron stain of liver (16).




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FIGURE 7. Prussian Blue Iron stain of adrenal cortex (16).

FIGURE 9. Prussian Blue Iron stain of myocardium (16).

At this point, the possibility of HH was raised. After further discussion with the family, secondary sources for the hematochromatosis were excluded. In addition, there was no known familial history of HH. To confirm HH, a quantitative liver iron study was performed on paraffin embedded liver tissue. This study revealed marked elevation of liver iron at 22,525 Kg/g (normal levels 400Y1600 Kg/g). The hepatic iron index was also markedly elevated at 10.4 Kmol/g/year (normal less than 1.0 Kmol/g/yr). Given the absence of prior transfusions for the deceased and a hepatic iron index of greater than 1.9 Kmol/g/year represents either HH or transfusion-related iron overload, the diagnosis of HH was confirmed.2 Based on these findings, the cause of death was listed as micronodular cirrhosis arising from HH with the manner classified as natural.

Although limited in size and based on a hospital population with a high referral for liver anomalies, one could nevertheless extrapolate from these results a possible maximal 0.57% incidence of unsuspected HH at forensic autopsy. This figure is significant with possibly 5 cases of unsuspected HH per 1000 autopsies performed at a medical examiner_s office. Consequently, the forensic pathologist must consider HH in cases where the autopsy findings are suggestive of the disease. The typical finding, which raises the possibility of HH is micronodular cirrhosis with accompanying liver failure and diabetes, as noted in our case. Yet, HH may present in another manner within the forensic setting. A recent forensic case report notes that a high percentage of HH individuals develop congestive heart failure with malignant arrhythmias. This case report documented a sudden cardiac death in a 35-year-old man with HH.4 A separate clinical study also supports an association between cardiovascular deaths and HH. In that study, HH heterozygote postmenopausal women who smoked and were hypertensive were found to have a significantly greater risk of cardiovascular death than nonheterozygotes who were also smokers and hypertensive.5 In view of this risk, the forensic pathologist must consider HH not only in cirrhotic individuals but also in cases of sudden unexpected cardiac deaths. Detection and confirmation of unsuspected HH is important in view of the genetic nature of the disease and its implications for surviving family members. A review of the forensic literature offers little guidance in confirming HH at autopsy. Some forensic pathologists may rely on genetic testing for confirmation. As noted earlier, there exists genetic testing for HFE mutations. This testing typically looks for the C282Y and H63D mutations, which are detected in approximately 87% of people with HH.6 Therefore, testing for C282Y and H63D mutations may miss a significant number of HH cases arising from other genetic mutations. In fact, several other nonclassic types of HH have been described with separate non-HFE genetic abnormalities. These nonclassic types include type IIa juvenile HH with mutation of Hemojuvelin on chromosome 1, type IIb juvenile HH with mutation of Hepcidin on chromosome 19, type III HH with mutation of transferrin receptor 2 on chromosome 7, and type IV with mutation of ferroportin.7 This growing number of genetic abnormalities only complicates genetic testing of forensic autopsy cases by producing potential negative results for HH individuals with non-C282Y and H63D mutations. This problem is highlighted by the earlier described case report of the

DISCUSSION This autopsy represents an unsuspected HH case discovered at forensic autopsy. The actual incidence of HH at forensic autopsy is unclear with no firm figures within the forensic literature. One would expect a small but significant incidence of unsuspected HH at forensic autopsy given the relative common nature of this genetic disease. A hospital-based retrospective study found 1 case of unsuspected HH in 176 autopsies.3

FIGURE 8. Prussian Blue Iron stain of pancreatic acini (16).

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FIGURE 10. Algorithm to confirm unsuspected HH at autopsy.

35-year-old man with HH and cardiac sudden death. In that case, the deceased had genetic testing performed at autopsy with a reported negative result. Given this problem of negative genetic tests for HH and the absence of firm guidance from the literature, our recommendation is to do quantitative iron analysis on readily available liver tissue obtained at autopsy on suspected HH cases with correlation of familial and past medical history, as performed in our case. Not only will quantitative iron analysis avoid negative genetic results in HH individuals, but also this approach is cost-effective because the C282Y and H63D genetic test can be 2 to 3 times more expensive than quantitative iron analysis.8 See Figure 10 for an algorithm in confirming unsuspected HH at autopsy. With the added time and expense, one might question the need for such confirmation of unsuspected HH at forensic autopsy. The importance of confirmation centers on the need for familial member follow-up of this common genetic abnormality. Both the National Institutes of Health and the Centers for Disease Control recommend screening of individuals with a family history of the disease.6 This screening is vital for implementing serial phlebotomy in preventing organ damage. The screening is relatively easy with an initial fasting morning transferrin saturation level. If the transferrin level is abnormal, further testing is required and may include ferritin, liver enzymes, C282Y/H63D genetic test, and possible liver biopsy for quantitative iron analysis.9

CONCLUSION HH is a treatable and relatively common genetic abnormality, which may first be diagnosed at autopsy. The forensic * 2011 Lippincott Williams & Wilkins

pathologist must consider this diagnosis not only in the background of micronodular cirrhosis, but also in cardiac sudden death. Careful review of microscopic sections with iron stain will provide support for an initial diagnosis of HH. Confirmation of unsuspected HH is possible by genetic testing or quantitative liver iron analysis. Given the potential negative results in nonC282Y and H63D HH individuals and the costs of current commercial genetic testing, we recommend quantitative liver iron analysis with correlation of familial and past medical history. The importance of forensic diagnosis of HH at autopsy cannot be overemphasized based on the need for screening of family members in treating and preventing organ damage of asymptomatic individuals. ACKNOWLEDGMENTS The authors thank Marty Coyne and ACCO chief photographers for their assistance in preparing the photographs in this manuscript. REFERENCES 1. Kumar V, Abbas A, Fausto N. Robbins and Cotran Pathologic Basis of Disease. 7th ed. Philadelphia, PA: Elsevier Saunders Publishing; 2005;908Y910. 2. Mayo Medical Laboratories 2007 Test Catalog. Iron Liver Tissue Test. Rochester, MN: Mayo Clinic; 2007:337. 3. Nichols L, Aronica P, Babe C. Are autopsies obsolete? Am J Clin Pathol. 1998;110:210Y218.



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4. Klintschar M, Stiller D. Sudden cardiac death in hereditary hemochromatosis: an underestimated cause of death? Int J Legal Med. 2004;118:174Y177. 5. Roest M, van der Schouw Y, de Valk B, et al. Heterozygosity for a hereditary hemochromatosis gene is associated with cardiovascular death in women. Circulation. 1999;100:1268Y1273. 6. Toland A. Hereditary hemochromatosis: is genetic testing available? Available at: http://www.genetichealth.com/HCROM_Genetic_Testing_ for_Hemochromatosis.html. Accessed April 4, 2007. 7. Iron Disorders Institute. Hemochromatosis. Available at: http://www.

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irondisorders.org/Disorders/Hemochromatosis.asp. Accessed April 4, 2007. 8. At the Mayo Clinic Laboratories, the cost of HFE genetic test for C282Y, H63D and S65C mutations as of 2007 is $411.20 compared to a quantitative liver iron analysis cost of $192.20. Mayo Medical Laboratories 2007 Test Catalog. Hemochromatosis HFE Gene Analysis and Iron Liver Tissue. Rochester, MN: Mayo Clinic; 2007:281, 337. 9. Mayo Medical Laboratories2007 Test Catalog. Hereditary HemochromatosisVScreening Algorithm. Rochester, MN: Mayo Clinic; 2007:628.



CASE REPORT

Death From Bilateral Pulmonary Congenital Cystic Adenomatoid Malformation A Rare Case Report Luo Zhuo, PhD,* Liang Ren, PhD,* Qian Liu, PhD,* Lan Zhou, PhD,* Fan Yang, PhD,* Man Liang, PhD,* and Liang Liu, PhDÞ

Abstract: Congenital cystic adenomatoid malformation is one of rare pulmonary hypoplastic diseases. It has been subdivided into 3 types (IYIII). Respiratory distress and hydrops are usually diagnosed preor postnatally by ultrasonography or radiography. The pathogenesis of CCAM has not been clarified yet. Here, we present an unusual case of bilateral CCAM (type III) of a 2-month-old infant who died suddenly. Concomitant lung malformation and fatty degeneration in hepatic cells make this case unique since such malformation is seldom found in type III CCAM. Key Words: congenital cystic adenomatoid malformation, lung hypoplasia, forensic pathology (Am J Forensic Med Pathol 2011;32: 25Y27)

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ongenital cystic adenomatoid malformation (CCAM) is a distinct type of pulmonary hypoplasia. It was first reported as a clinical entity by Ch_In and Tang in 1949.1 CCAM results from aberrations in lung and airway embryogenesis, which may or may not present with symptoms after birth.2 Most researches found that CCAM can cause hydrops and severe respiratory distress with pulmonary hypoplasia,3 especially in the wide or bilateral cystic lesion of the lung.4 Also, CCAM is considered a benign hamartomatous or dysplastic lung tumor. By taking full advantage of the prenatal ultrasonography and computed tomography(CT) the cystic lesion can be diagnosed and removed from the chest antenatally or in the neonatal phase.5 Here, we present a special bilateral type III CCAM in combination with abnormal development of lung which was responsible for sudden death of the infant. This type of uncommon case involving type III CCAM has been rarely reported in the past.

CASE REPORT A premature newborn male (gestational weeks = 30) was the first pregnancy of his mother, collapsed and died 2 months after birth. Apgar score was 7 to 8 at birth, then he had persistent dyspnea, which could not be improved by using mechanical ventilation and finally died of respiratory failure.

Manuscript received June 9, 2009; accepted July 28, 2009. From the *Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People_s Republic of China; †Key Laboratory of Evidence Science (China University of Political Science and Law), Ministry of Education, China. Reprints: Liang Liu, PhD, Key Laboratory of Evidence Science (China University of Political Science and Law), Ministry of Education, Beijing, People_s Republic of China. E-mail: liangl)cupl.edu.cn. Copyright * 2011 by Lippincott Williams & Wilkins ISSN: 0195-7910/11/3201Y0025 DOI: 10.1097/PAF.0b013e3181c21c51


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Autopsy Findings The body weight was 3770 g, the crown-to-heel length was 50 cm, and the crown-to-sacrum length was 36 cm. The head, chest, and abdominal circumferences were 37 cm, 37 cm and 34.5 cm, respectively. Livor mortis was reddish purple and distributed in dependent areas of the body. The body displayed no external injuries or other abnormalities. Internally, the organs were in situs solitus and no fluid was found in the pleural or abdominal cavities. Bilateral lungs weighed 99 g. The left lung and the right lung had 4 lobes and 5 lobes, respectively. On gross examination, both lungs appeared grayish and small white nodules were visible on bilateral inferior lobes. The cut surface was solid, and a large collection of numerous cysts (less than 0.5 cm in diameter) could hardly be seen (Fig. 1). Microscopic examination revealed a diffuse lesion in every lobe and cysts of various sizes could be observed as the irregular bronchiole-like structures interspersed inbetween normal areas of lung tissue lined by cuboidal to columnar epithelium. Smooth muscles, not striated muscles, were found in several walls of the cysts. The alveolar septa were wider than normal and the small vessels were congested. Subpleural emphysematous dilatations of alveoli were also noted. Focal intra-alveolar hemorrhage was occasionally seen. However, there was no obvious inflammation. In addition, several areas of fatty degeneration in the liver tissue, which was suspected to be nonalcoholic fatty liver disease, were found. Other organs were unremarkable on both gross and microscopic examination (Figs. 2Y4).

DISCUSSION The 3 types of CCAM were proposed by Stocker in 1977, depending on the gross and microscopic criteria.6 Type I, which accounts for over 50% of cases, is composed of single or multiple cysts (more than 2 cm in diameter) from gross appearance and which are lined by ciliated pseudostratified columnar epithelium. Type II contains multiple small cysts (diameter less than 1cm) lined by ciliated cuboidal to columnar epithelium, and striated muscles can be found occasionally. Type III is rare, and the lesion consists of tiny cysts that can hardly be seen. Also, the cut-surface of the cysts is sponge-like in appearance. Cysts are lined by nonciliated cuboidal or columnar epithelium. According to the above criteria, this case seemed to fit the type III CCAM, but it had some peculiarities, such as the irregular shape of the both lungs and the focal fatty degeneration in the hepatic cells, which we mentioned before. There are still different arguments about the cause of CCAM. It was recognized as a benign hamartomatous or dysplastic lung tumor associated with single or multiple tissues anomaly by embryonic and pathologic findings.5 Researches indicate that some unknown factors prevent normal maturation of fetal lungs, thus leading to pulmonary hypoplasia,7 eg, a www.amjforensicmedicine.com


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FIGURE 1. A, Showing left lung was divided into 4 lobes. B, Showing right lung was divided into 5 lobes. C, The cut surface was solid, and was full of numerous tiny cysts of which the diameter is less than 0.5 cm in gross.

proliferation of dilated bronchiolar-like air spaces.5,8 Nevertheless, Moerman9 described 4 cases and the findings of serial microscopic examination indicated segmental bronchial congenital absence. He presumed the primary defect leading to CCAM was bronchial malformation. In addition, through investigation by chromosome analysis,10,11 the genetic abnormalities were reported as well, including trisomy 13 or 18. The incidence rate of fetal CCAM is between 1:25000 and 1:35000.10 Davenport et al12 reviewed the cases of CCAM from 1995 to 2001 and found that bilateral CCAM were much less than unilateral ones. Moreover, the incidence of left lung was

higher than the right lung, approaching 55%. Respiratory distress is a common clinical manifestation of CCAM in both fetuses and infants.13 Severe signs, such as hydrops, are present in 7% of cases. Still, some cases appear asymptomatic pre-or postnatally.3 Later on in life, CCAM only presents as recurrent pneumonias with cough, dyspnea, and thoracic pain.13Y15 In this case, the newborn could be observed the obvious persistent dyspnea, respiratory distress as well, that could be directly caused by the malformation of the lungs. And the Apgar score, which was less than the normal, indicated the possibility of the asphyxia neonatorum. Generally speaking, cases of death during the clinical therapy are of forensic interest, especially the ones due to clinically rare diseases. The type III CCAM is infrequent, leads to

FIGURE 2. Low magnification (4) of the cysts lesion, and the cysts were lined by columnar epithelium without the smooth muscle or striated muscle in the walls of the cysts.

FIGURE 3. Showing the irregular bronchiole-like structures interspersed between the normal areas of the lung (10). The cysts were lined by nonciliated cuboidal or columnar epithelium.

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3. Fiala M, Baumert M, Walencka Z, et al. ECongenital cystic adenomatoid lung malformation-diagnosis and treatmentVbased on literature and own experiences^. Med Wieku Rozwoj. 2008;12:795Y798. 4. Fitzgerald DA. Congenital cyst adenomatoid malformations: resect some and observe all? Paediatr Respir Rev. 2007;8:67Y76. 5. Argeitis J, Botsis D, Kairi-Vassilatou E, et al. Congenital cystic adenomatoid lung malformation: report of two cases and literature review. Clin Exp Obstet Gynecol. 2008;35:76Y80. 6. Stocker JT, Madewell JE, Drake RM. Congenital cystic adenomatoid malformation of the lung. Classification and morphologic spectrum. Hum Pathol. 1977;8:155Y171. 7. Berrocal T, Madrid C, Novo S, et al. Congenital anomalies of the tracheobronchial tree, lung, and mediastinum: embryology, radiology, and pathology. Radiographics. 2004;24:e17. 8. Cakan A, Samancilar O, Cagirici U, et al. ECongenital cystic adenomatoid malformation of the lung resembling bronchiectasis in an adult^. Tuberk Toraks. 2008;56:201Y203.

FIGURE 4. High power magnification (20) of the CCAM, and the cysts were lined by stratified columnar epithelium.

respiratory distress and has a high mortality rate associated with pulmonary hypoplasia and hydrops.10 In our case, autopsy and microscopic examinations indicated a rare bilateral type III CCAM. This kind of case is so rare that, so far, only 8 have been reported with bilateral pulmonary lesions.16Y22 Banerjea et al16 reported a similar case of a short-term-survival infant with only mild manifestations. Afterward, it died of persistent pulmonary hypertension and severe tachypnea. Moreover, heteromorphosis of both left and right lungs are identified as another part of the malformation but the genesis is a matter of discussion.3 Fatty degeneration in hepatic cells also attracted our attentions. We have not come across any similar report. Some researches point out that oxidative stress may causes this disorder of metabolism, but the pathogenesis is still not clear yet.23 Was it induced by the respiratory distress of the pulmonary malformation in this case? Or did they have the interacted genetic defect? In summary, through detailed forensic pathologic examination, the clinical symptoms and the pertinent literature review, the case of bilateral type III CCAM was reported as the primary cause of death. Cardiac and respiratory failures were induced by respiratory distress and hydrops. Nowadays, for a patient_s sudden death is unusual, but it should be borne in mind that over 50% affected infants have respiratory distress during the early postnatal period. This report focuses on the unknown factors causing sudden death, especially among infants and newborns. For forensic interest rests not only in the uncommon disease but also in finding out or excluding whether medical malpractice is involved. For another aspect, as forensic pathologic examiners, we should keep in learning about the uncommon clinical disease, and comprehensive examinations must be taken carefully. ACKNOWLEDGMENTS The authors thank Dr Hongmei Dong and Mr Sunnassee Ananda for their technical and writing assistance. REFERENCES 1. Ch_In KY, Tang MY. Congenital adenomatoid malformation of one lobe of a lung with general anasarca. Arch Pathol (Chic). 1949;48: 221Y229. 2. Azizkhan RG, Crombleholme TM. Congenital cystic lung disease: contemporary antenatal and postnatal management. Pediatr Surg Int. 2008;24:643Y657.


9. Moerman P, Fryns JP, Vandenberghe K, et al. Pathogenesis of congenital cystic adenomatoid malformation of the lung. Histopathology. 1992;21:315Y321. 10. Laberge JM, Flageole H, Pugash D, et al. Outcome of the prenatally diagnosed congenital cystic adenomatoid lung malformation: a Canadian experience. Fetal Diagn Ther. 2001;16:178Y186. 11. Heling KS, Tennstedt C, Chaoui R. Unusual case of a fetus with congenital cystic adenomatoid malformation of the lung associated with trisomy 13. Prenat Diagn. 2003;23:315Y318. 12. Davenport M, Warne SA, Cacciaguerra S, et al. Current outcome of antenally diagnosed cystic lung disease. J Pediatr Surg. 2004;39: 549Y556. 13. Hashemzadeh S, Aslanabadi S, Jafari Rouhi AH, et al. Congenital malformations of the lung. Indian J Pediatr. 2007;74:192Y194. 14. McLean SE, Pfeifer JD, Siegel MJ, et al. Congenital cystic adenomatoid malformation connected to an extralobar pulmonary sequestration in the contralateral chest: common origin? J Pediatr Surg. 2004;39:e13Ye17. 15. Herrero Y, Pinilla I, Torres I, et al. Cystic adenomatoid malformation of the lung presenting in adulthood. Ann Thorac Surg. 2005;79: 326Y329. 16. Banerjea MC, Wirbelauer J, Adam P, et al. Bilateral cystic adenomatoid lung malformation type IIIYYa rare differential diagnosis of pulmonary hypertension in neonates. J Perinat Med. 2002;30: 429Y436. 17. Atalabi OM, Ogunseyinde AO, Obajimi MO, et al. Bilateral congenital cystic adenomatoid malformation of the lungs: a case report. Afr J Med Med Sci. 2006;35:183Y185. 18. Quintero R, Hale-Burnett E, Bornick PW, et al. Fetal laryngoscopy and lung biopsy in a case of bilateral lethal congenital cystic adenomatoid malformation of the lung. Fetal Pediatr Pathol. 2007;26:229Y234. 19. Suarez-Penaranda JM, Rodriguez-Calvo MS, Munoz JI, et al. Sudden neonatal death from congenital cystic adenomatoid malformation. Int J Legal Med. 2001;115:76Y78. 20. Wigglesworth JS. Pathology of the lung in the fetus and neonate, with particular reference to problems of growth and maturation. Histopathology. 1987;11:671Y689. 21. Cloutier MM, Schaeffer DA, Hight D. Congenital cystic adenomatoid malformation. Chest. 1993;103:761Y764. 22. Tristan JU, Gracia Urgelles X, Wiehoff Neumann A, et al. EBilateral multilobular cystic adenomatoid malformation^. Cir Pediatr. 1995;8: 167Y169. 23. Lerret SM, Skelton JA. Pediatric nonalcoholic fatty liver disease. Gastroenterol Nurs. 2008;31:115Y119.



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CASE REPORT

An Unusual Cause of Death in Poisoning A Case Report Sharija Jayaprakash, MD

Abstract: Arterioesophageal fistula is a rare cause of upper gastrointestinal tract bleeding. Arterioesophageal fistula and haematemesis are rare in poisoning, especially in noncorrosive poisoning. An arterioesophageal fistula can occur in patients with retroesophageal subclavian artery. This is usually associated with prolonged presence of nasogastric tube. Key Words: retroesophageal subclavian artery, arterioesophageal fistula, dysphagia lusoria (Am J Forensic Med Pathol 2011;32: 28Y30)

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n arterioesophageal fistula if it occurs culminates fatally. It may happen in the course of esophageal or thoracic disease or in impaction of a foreign body and involves the thoracic aorta or the subclavian artery.1 In Medical College, Thiruvananthapuram, one-fourth of all autopsies are done for cases with poisoning. One such case with history of haematemesis during hospital stay is reported. This patient was treated with Ryle_s tube feeding and other supportive measures following poisoning with a carbamate compound.

CASE REPORT History Mr. X, a 17-year-old adolescent male was brought to the casualty with history of consumption of FuradanVa carbamate poison. He was brought within an hour of ingestion of poison and was treated with gastric lavage in the casualty. He was admitted and treated with Ryle_s tube aspiration, injections of Atropine Sulfate, Antibiotics, and other supportive measures. The investigations like blood routine examination, urine routine examination, renal function tests, and serum electrolytes were within normal limits. Subsequently, he developed atropine psychosis and was on continuous Ryle_s tube feeding. He seemed to have recovered apparently after 11 days treatment except for slight disorientation caused by atropine. The patient expired on 12th day of hospitalization following massive haematemesis. The body was brought for postmortem examination as it was a case of death by unnatural causes.

Relevant Autopsy Findings Externally, there were pale conjunctivae and finger nails. Bedsores in varying stages of healing were seen on the back of elbows and small of back.

Internally, stomach contained 800 g of blood clot and 200 mL of fluid blood. Duodenum and proximal part of small intestine contained blood stained mucous. Stomach and duodenum were thoroughly examined for the source of blood. There were no ulceration or injury, and the mucosa was pale. Esophagus showed multiple areas of erosion with sloughing of mucosa (Fig. 1). One of these erosions was deep and was found to have a fistulous connection with right subclavian artery (Fig. 2). Aorta had 4 branches instead of normal 3 branches, right and left common carotid and left and right subclavian arteries. Right subclavian artery was originating from the arch of aorta as a fourth branch, distal to the origin of left subclavian artery (Fig. 3). It was passing close to esophagus. All other internal organs showed features of severe blood loss. Cause of death was stated as Bdeath due to bleeding from arterioesophageal fistula.[

DISCUSSION An aberrant right subclavian artery is the common anatomic variant of the origin of subclavian artery.2 It occurs in 0.5% to 1.8% of the population.3

Normal Development Arch of aorta and its branches develop from the primitive aortae and the 6 pharyngeal arch arteries. Arch of aorta develops from (1) the ventral part of aortic sac, (2) its left horn, and (3) left fourth arch artery. (4) The innominate artery develops from the right horn of aortic sac. (5) Common carotid arteries develop from third arch arteries. The left dorsal aorta becomes the descending aorta and right dorsal aorta distal to the attachment of fourth arch artery disappears. (6) Right subclavian artery develops from right fourth arch and seventh cervical intersegmental artery, and left subclavian artery develops from seventh cervical intersegmental artery (Fig. 4).4

Development of Aberrant Artery The anomalous origin of right subclavian artery is because of persistence of right dorsal aorta along with involution of right fourth arch, and the right dorsal aorta with the seventh intersegmental artery forms an aberrant right subclavian artery.4,5 This aberrant artery often follows a retroesophageal course in its way to right upper extremity and called retroesophageal subclavian artery (Fig. 5).4,5 Along with arch of aorta it forms a vascular ring around the mediastinal structures.2

Clinical Significance of an Aberrant Artery

Manuscript received December 18, 2008; accepted July 5, 2009. From the Department of Forensic Medicine, Government Medical College, Thiruvananthapuram, Kerala, India. Correspondence: Sharija Jayaprakash, MD, Department of Forensic Medicine, Government Medical College, Thiruvananthapuram, Kerala, S. India Pin: 695 011. E-mail: sharijajp)yahoo.co.in. Copyright * 2011 by Lippincott Williams & Wilkins ISSN: 0195-7910/11/3201-0028 DOI: 10.1097/PAF.0b013e3181ed7868

In majority of cases this anomaly is asymptomatic. Symptoms may appear when it causes external compression of the esophagus causing dysphagia or may demonstrate symptomatic atherosclerotic or aneurysmal degeneration.1 This phenomenon was first described in 1794 by a London Physician David Bayford and was originally described as Bdysphagia[ by freak of nature.6 Now it is commonly called as Bdysphagia lusoria.[7 It was

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An Unusual Cause of Death in Poisoning

FIGURE 3. Opened arch of aorta with 4 branches. FIGURE 1. Areas of erosion in esophagus.

diagnosed in 1 of 920 patients undergoing diagnostic endoscopy (223 for dysphagia).8 In 1936, Kommerell described that the aberrant subclavian artery frequently arises from a dilated segment of the proximal descending aorta, called Diverticulum of Kommerell.2,6 Arterioesophageal fistula has been reported in patients with retroesophageal subclavian artery. However, spontaneous fistulization of esophagus has not been reported. It can occur with prolonged presence of nasogastric tube.1

rant artery. This prolonged irritation might have caused erosion, ulceration, and later fistulous connection of artery and esophagus.

Medicolegal Significance of an Aberrant Artery 1. The part of esophagus compressed by aberrant artery may be a site of impaction of foreign body,9 or it may be a site of erosion in esophageal prosthesis.1 2. Nonrecognition of an aberrant artery may cause fatal consequences during cardiovascular surgery.10

CONCLUSIONS In the present case, the patient had a retroesophageal subclavian artery. He was bedridden as suggested by bedsores. The prolonged presence of nasogastric tube might have irritated the narrow part of esophagus which was compressed by the aber-

FIGURE 2. Fistulous connection between right subclavian artery and esophagus. * 2011 Lippincott Williams & Wilkins

FIGURE 4. Diagrammatic representation showing normal development of branches of arch of aorta. www.amjforensicmedicine.com


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Sreedevi, MD, K. S. Meena, MD, N. A. Balaram, MD, K. Valsala, S. R. Saritha, T. Karikalan, M. M. Seena, Smitha S., and Salini R. REFERENCES 1. Eynden FV, Jacques D, Laureys M, et al. Erosion of a retroesophageal subclavian artery by an esophageal prosthesis. J Thorac Cardiovasc Surg. 2006;131:1183Y1184. 2. Available at: http://en.wikipedia.org/wiki/Aberrant_subclavian_artery. 3. Stewart JR, Kincaid OW, Edwards JE. An atlas of vascular rings and related malformations of the aortic arch system. Springfield, IL: Charles C. Thomas; 1964:53. 4. Singh IB. Human Embryology. 5th ed. India: Macmillan; 1991:250Y255. 5. Soubhagya RN, Mangala MP, Latha VP, et al. Anatomical organization of aortic arch variations in the India: embryological basis and review. J Vasc Bras. 2006;5:95Y100. Porto Alegre June. 6. Carrizo GJ, Marjani MA. Dysphagia lusoria caused by an aberrant right subclavian artery. Tex Heart Inst J. 2004;31:168Y171.

FIGURE 5. Diagrammatic representation showing anomalous course of retro esophageal subclavian artery.

3. The sudden death in a patient seeming to recover well after treatment for some other illness may raise the allegation of negligence on the part of treating doctor. ACKNOWLEDGMENTS Dr Prakasham wishes to acknowledge K. Sreekumari, MD, S. Sivasuthan, MD, K. Sasikala, MD, O. Geetha, MD, C. S.

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7. Standring S, ed. Gray_s Anatomy: The Anatomical Basis of Clinical Practice. 39th ed. Edinburgh, United Kingdom: Elsevier Churchill; 2006:1050. 8. Kelly, Michael D. Endoscopy and the aberrant right subclavian artery. Am Surg. 2007;73:1259Y1261. 9. Currarino G, Nikaidoh H. Esophageal foreign bodies in children with vascular ring or aberrant right subclavian artery: coincidence or causation? Paediatr Radiol. 1991;21:406Y408. 10. Satyapal KS, Singaram S, Partab P, et al. Aortic arch branch variationsVcase report and arteriographic analysis. S Afr J Surg. 2003;41:48Y50.



CASE REPORT

An Unusual Accidental Death From Positional Asphyxia Fawzi Abdussalam Benomran, MBChB, MSc, DCH, MD and A.I. Hassan, MBChB, MSc, MD

Abstract: Death from postural or positional asphyxia takes place in circumstances when the victim’s body assumes an abnormal position compromising the process of respiration. The diagnosis is usually based on circumstantial evidence in conjunction with excluding other significant underlying causes of death. This case report is about a 37-year-old man who had been drinking the previous night and was found dead in the morning in a knee-chest position. The forensic medical examiner had the opportunity to examine and photograph the scene of death while the body was still in its original position. Apart from a blood alcohol level of 290 mg/100 mL, marked congestion of the face, and petechial hemorrhages on the conjunctivae, autopsy findings were unremarkable. There were no injuries or pathological findings to account for his death. Death was certified as due to postural asphyxia secondary to intoxication by alcohol. Key Words: accidental deaths, asphyxial deaths, postural asphyxia, positional asphyxia, alcohol intoxication, death scene investigation (Am J Forensic Med Pathol 2011;32: 31Y34)

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eath from positional or postural asphyxia occurs when the victim’s position interferes with adequate breathing by causing partial or complete airway obstruction. Being in an inverted or head-down position for an extended period of time suppresses normal respiration and circulation. Mechanical and gravitational forces exert pressure on the diaphragm by the weight of the viscera.1 In addition, the normal venous return to the heart is impaired, causing brain hypoxia consequent on severe congestion of the brain.2,3 It is not necessary that the whole body is inverted to cause death from positional asphyxia, as partial inversion of the torso and hyperflexion of the neck or face down position during inebriation can also be fatal.4 Fatal positional asphyxia is usually accidental and associated with drunkenness or other intoxicants or disabilities. It may also be a factor in a proportion of the rare cases of sudden deaths occurring during restraint by police, prison officers, and health care staff.5 Even in the presence of the abnormal posture, the diagnosis of positional asphyxia is conditional on excluding other possible significant underlying causes of death. The importance of this case report is attributed to the availability of scene photographs of the undisturbed decedent that are extremely helpful in illustrating the cause and the manner of death to the reader. The forensic pathologist was called to the scene where he directed the forensic photographer to take appropriate pictures and examined the body before it was moved. This would not have been possible if not for the call system followed Manuscript received March 30, 2008; accepted July 19, 2008. From the Forensic Medicine Department, General Department of Forensic Science, Dubai Police General Headquarters, Dubai, United Arab Emirates. Reprints: Fawzi Abdussalam Benomran, MBChB, MSc, DCH, MD, Dubai Medical College, Dubai, United Arab Emirates; and Forensic Medicine Department, General Department of Forensic Science, Dubai Police General Headquarters, PO Box 39844, Dubai, United Arab Emirates. E-mail: [email protected]. Copyright * 2011 by Lippincott Williams & Wilkins ISSN: 0195-7910/11/3201Y0031 DOI: 10.1097/PAF.0b013e3181f70d41


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in our department, whereby the forensic medical examiner is summoned to the scenes of all suspicious deaths.

CASE REPORT The deceased, a 37-year-old man was known to have a habit of spending solitary time at night on the roof of his residence consuming alcoholic beverages. The forensic medical examiner was summoned by the police and arrived promptly at the scene. On the roof of an apartment building, the body of the deceased, which had not been moved, was in a knee-chest position in front of a bed (Fig. 1). The weight of the body was supported by the upper chest and shoulders at one end (Fig. 2) and by the flexed knees on the other (Fig. 3). The neck was severely hyperextended and laterally rotated, so that the right side of the head, the face, and the neck pressed firmly against the floor (Fig. 4). The torso was lying at right angle to 2 parallel water pipes running across the roof’s floor. The right front lateral aspect of the root of the neck was pressing hard against 1 of the 2 pipes. Blood had been oozing, partly from the mouth and partly from ant bites around the right eye, and formed a small collection on the floor around the congested head (Fig. 5). The body revealed localized fixed hypostasis to the face (Fig. 6), the neck, and the upper chest and ventral areas of the rest of the body. It was also completely rigid by rigor mortis, so when it was turned on the side it maintained the same position (Fig. 7). It revealed contact points with the supporting floor as areas of dust soiling on the right side of the face and the ear, right temporal and parietal areas, dorsum of the right hand, the left elbow, the 2 knees, and dorsal surfaces of the toes of the right foot. The dust mark on the left hand, partially on its palm and partially on dorsal surfaces of its flexed fingers, indicates the exact position recorded by photography.

External Examination The body was that of an Indian man in his fourth decade, of 177 cm in height and weighing 66 kg. He was wearing a T-shirt and shorts. He had a wristwatch on his left hand and a bracelet on his right. Fixed postmortem hypostasis involved the head, the neck, and the upper chest, which is believed to have formed on top of extensive congestion (Fig. 8). The ventral aspects of the lower thighs, the medial aspects of the arms, the anterior aspects of the legs, and the dorsal aspects of the feet were heavily stained with hypostasis. A layer of dust from the floor was covering the right side of the face, and when washed off, a pale area of contact flattening was exposed. There was also a pressure mark amidst hypostasis on the right front lateral aspect of the root of the neck, due to compression caused by pressure of the neck against the water pipe (Fig. 8). Bilateral subconjunctival hemorrhages were also noted, which were thought to be partly of asphyxial nature, that is, petechial hemorrhages, and partly of positional nature. Multiple minute abrasions consistent with ants’ bites were present on skin of the lids of the right eye. An oval pressure abrasion was present on skin of the right cheek bone (Fig. 8), and abrasions of the same nature were present on the right elbow (Fig. 9) and both knees (Fig. 10). There were no other external injuries on the body that was fully rigid. www.amjforensicmedicine.com


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FIGURE 1. General view of the death scene showing the body in its original position in front of the bed on the roof of the building in which the deceased had been living.

FIGURE 4. Left lateral view showing the collection of blood about the face, which was turned to the left.

FIGURE 2. Front view illustrating the lateral rotation of the head and how the torso was supported on the floor.

FIGURE 5. Close-up picture of the markedly congested face showing that the blood had partly originated from around the right eye due to the effect of ant bites.

FIGURE 3. Posterior view showing how the body was supported on the knees with the left arm touching the floor with its lateral aspect.

FIGURE 6. Close-up of the upturned face showing the sand and dust mark on the area of contact with the floor and the still liquid blood trickling from the right eye area to the brow.

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FIGURE 7. Scene picture demonstrating postmortem rigidity, hypostasis, and the dust marks at points of contact, all indicating the original position of the body.

Internal Examination There were multiple hemorrhagic patches on the undersurface of the scalp, particularly on the frontal and parietal areas. The neck structures were intact including the cervical vertebrae. The vessels of the brain were markedly congested, and the brain was edematous. The lungs were edematous and congested with frothy fluid in the trachea, bronchi, and bronchioles. The overall lung weight was 950 g. The heart was normal from all respects, including its coronaries, valves, and great blood vessels. The abdominal viscera were generally congested. The stomach contained a small amount of semidigested food. The liver was enlarged, weighing 1750 g, and showed fatty change. The urinary bladder was full. A sample of blood was sent to the toxicology laboratory for analysis and found to contain ethanol in a concentration of 290 mg/100 mL.

DISCUSSION The diagnosis of accidental postural or positional asphyxia depends largely on circumstantial evidence. It is essentially based on the following criteria: the body must be in such position

FIGURE 8. Mortuary picture after cleaning the body, showing a pressure abrasion at the right templar region surrounded by ant bite abrasions. It also shows the pale mark amidst hypostatic staining on the front aspect of the lower neck, due to displacement by slight pressure from the water pipe. * 2011 Lippincott Williams & Wilkins

Unusual Accidental Death From Positional Asphyxia

FIGURE 9. Mortuary picture showing an abrasion on the posterior aspect of the upper forearm as well as postmortem hypostasis of the front of the torso.

that normal respiratory movements were impaired, accidental nature must be ascertained by scene investigation or historical evidence, it must be impossible to move to another position, and other significant underlying causes of death, natural or violent nature, must be excluded.4,6 Death from positional asphyxia was reported in a variety of circumstances such as reverse suspension,7,8 hyperflexed head or head down position,3,4 and a jackknife position.1 In most of the reported cases, the victim was intoxicated or incapacitated to a degree that it was impossible to move out of that abnormal position. Fatalities occurred while victims were restrained in prone position in rear compartments of police patrol cars.5 The impairment of respiration from pressure of the abdominal viscera on the diaphragm is complicated further by the central depressant effect of alcohol on the respiratory center.7 It has also been suggested that the reduced venous return to the heart is an important mechanism in the pathophysiological understanding of postural asphyxia.9,10 In this case, the high blood level of ethanol would have affected the consciousness and impaired normal reflexes of the

FIGURE 10. Mortuary picture of the knees showing bilateral pressure abrasions on the points of contact with the floor. www.amjforensicmedicine.com


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victim. It is suggested that he has been sleeping on the nearby bed after he had consumed too much alcohol. He probably woke up and crawled out of bed seeking to return to his residence downstairs when he got himself in such position. Extreme hyperextension and lateral rotation of the neck were incompatible with adequate respiration. The impaired state of consciousness and depressed reflexes from alcohol intoxication made it impossible for him to move from that position, resulting in his demise. Locus examination by the forensic medical examiner ruled out any question as to the original position at death. The characteristic distribution of postmortem hypostasis, the localized marks caused by dust on points of support, and the stiffening of the body in that position were additional confirmatory evidence to that fact. It must be pointed out that the slight pressure on the right aspect of the root of the neck by the water pipe was just enough to displace hypostasis without any constricting effect to the neck.

The role of intoxication by alcohol or other inebriants is important in affecting the normal reflexes so that the deceased would be unable to correct his abnormal position. REFERENCES 1. Saukko P, Knight B. Suffocation and asphyxia. In: Knight B, ed. Forensic Pathology. London: Arnold; 2004. p. 352Y367. 2. Falk J, Riepert T, Iffland R, et al. Death due to unusual position of the bodyVan explanation for the consequences of reduced venous reflux to the heart. Arch kriminol. 2004;213:102Y107. 3. Madea B. Death in a head-down position. Forensic Sci Int. 1993;61: 119Y132. 4. Bell MD, Rao VJ, Wetli CV, et al. Positional Asphyxiation in adults. A series of 30 cases from the Dade and Broward county Florida medical examiner offices from 1982 to 1990. Am J forensic Med Pathol. 1992;13:101Y107. 5. Reay DT, Fligner CL, Stilwell AD, et al. Positional asphyxia during law enforcement transport. Am J Forensic Med Pathol. 1992;13:90Y97.

CONCLUSIONS Without proper scene-of-death investigation, the cause of death in positional asphyxia is more a matter of speculation. It may be taken into account, however, in cases where the position of the body was such that it hinders the process of respiration, where there was a reason for the impossibility of changing that position, and where other possible significant underlying causes of death, natural or violent, had been excluded. Pressure on the right aspect of the root of the neck was just enough to displace hypostasis but not enough to affect a constricting force to the neck.

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6. Belviso M, De Donno A, Vitale L, et al. Positional asphyxia: reflection on two cases. Am J Forensic Med Pathol. 2003;24:292Y297. 7. Purdue B. An unusual accidental death from reverse suspension. Am J Forensic Med Pathol. 1992;13:108Y111. 8. Iannaccone S, Grocova Z, Bobrov N, et al. Death in an unusual body position. Soud Lek 2001;46:58Y61. 9. Lawler W. Death by reverse suspension. Am J Forensic Med Pathol. 1992;13:87Y88. 10. Madea B, Henssge C, Esser W. Death in inverted head position. Arch Kriminol. 1990;186:65Y74.



CASE REPORT

Medicolegal Aspects of 3 Cases of Bizarre Self-Mutilation Abdel Wahab A. Dawood, MD

Abstract: Three cases of bizarre self-mutilation are reported because of the unusual methods used and the unexpected good sequel in one of them. Key Words: self-mutilation, suicide, self-aggression, self-inflicted injuries (Am J Forensic Med Pathol 2011;32: 35Y38)

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elf-inflicted injuries can be classified into 2 main classes: those where some abnormality of mind leads the victim to mutilate his body and those in which deliberate injuries are inflicted for motives of gain.1 They stated that those caused by mental aberration are usually bizarre in either their multiplicity or their site. Wood et al2 stated that self-mutilation is a frequent occurrence in patients with schizophrenia, and the mortality rate is higher among the schizophrenic group than that in the general population. This article reports 3 different cases of self-mutilation in whom the social or psychological troubles in addition to the circumstances plays the main role in their diagnosis.

CASE 1 A 41-year-old man was working as a translator. Because of some social problems, he was depressed, refusing to eat or to talk for 7 days, so he was transferred to a hospital. Two days after admission, the treating physician noticed some blood streaks on the patient’s head and a big nail was inserted into the right side of his head. The patient was conscious, was alert, and asked water to drink. The hospital informed the authorities, and medicolegal and psychiatric opinions were obtained. The patient was well dressed, preserved self-hygiene, and was cooperative. On examination, the right parietal eminence showed the head of a big nail (Fig. 1), which traversed the skull from the right to the left and from above downward to reach near the base of the left side of the skull as shown in the radiographs (Figs. 2 and 3). The patient gave his personal history as mentioned. He stated that he inserted the nail by himself using at first a stone then hitting his head against the wall. The nail was extracted in the operating room with precautions; it was approximately 15 cm long. The patient was put under observation for 12 days and revealed normal function of the central and peripheral nervous systems without any apparent deficits. He was referred to a psy-

Manuscript received September 26, 2007; accepted November 15, 2007. From the Forensic Medicine & Clinical Toxicology, Faculty of Medicine, Assiut University, Assiut, Egypt. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.amjforensicmedicine.com). Reprints: Abdel Wahab A. Dawood, MD, Forensic Medicine & Clinical Toxicology, Faculty of Medicine, Assiut University, Assiut, Egypt. E-mail: [email protected]. Copyright * 2011 by Lippincott Williams & Wilkins ISSN: 0195-7910/11/3201Y0035 DOI: 10.1097/PAF.0b013e3181ff61ff


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chiatric hospital to deal with his original problem, and he was apparently normal for 6 months before his departure.

CASE 2 A cadaver of a 42-year-old man was found on his right side, dressed, on the stair of his home surrounded with a pool of clotted blood. A sharp, long, one-bladed knife (the handle was 12.5 cm in length, whereas the blade was 20 cm in length) was found near his hands that were stained with clotted blood (Fig. 4). Beside the knife and hands, 2 parts of the intestines and mesentery were found on the ground (1 part approximately 2 m and the other 2.5 m) with irregularly torn edges. The clothes were free from suspicious tears or signs of struggle, and a suicidal note was found in the pocket of the chemise. The cadaver showed: 1. Cut throat on the right side of the neck beginning 5 cm below the right mastoid, deep, gapped directed downward, and to the left side for approximately 11 cm to end in the middle line of the neck. The mentioned cut throat was accompanied in its beginning by 2 longitudinal abrasions each approximately 3-cm-long Btentative marks[ (Fig. 5). 2. Transverse sharp cut wound 6 cm long in the abdominal wall 5 cm to the left of the umbilicus through which the

FIGURE 1. Head of the nail in the right parietal region. Figure 1 can be viewed online in color at www.amjforensicmedicine.com. www.amjforensicmedicine.com


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FIGURE 4. Pool of clotted blood, long knife, and parts of intestine nearby the cadaver. Figure 4 can be viewed online in color at www.amjforensicmedicine.com.

FIGURE 2. Radiograph of the skull showing the traversing nail from the right to the left and from above downward (anteroposterior view). Figure 2 can be viewed online in color at www.amjforensicmedicine.com.

FIGURE 5. Cut throat with tentative marks on the right side of the neck. Figure 5 can be viewed online in color at www.amjforensicmedicine.com.

FIGURE 3. Radiograph of the skull showing the traversing nail from the right to the left and from above downward (lateral view). Figure 3 can be viewed online in color at www.amjforensicmedicine.com.

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FIGURE 6. Stab wound in the abdominal wall with protruded intestinal part. Figure 6 can be viewed online in color at www.amjforensicmedicine.com. * 2011 Lippincott Williams & Wilkins



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FIGURE 7. Nonpenetrating cut wound in the right side of the abdomen. Figure 7 can be viewed online in color at www.amjforensicmedicine.com.

intestines were protruding (Fig. 6). This wound was accompanied by some abrasions. 3. Nearly transverse nonpenetrating sharp cut wound 8 cm long in the right side of the abdominal wall 5 cm to the right of the middle line approximately 3 cm below the level of the umbilicus (Fig. 7). History revealed that this man was under psychiatric treatment of some psychological and psychosomatic troubles (anxiety, insomnia, headache, indigestion, throat, stomach, and colonic pains).

CASE 3 A cadaver of a 48-year-old man was discovered in his bed showing signs of putrefaction, on a blood-stained bed in a room that served a refuge for this semivagrant. The circumstantial evidences revealed past history of: & Traffic accident leading to head trauma followed by unbalanced mental and psychiatric conditions (posttraumatic psychiatric syndrome). & Alcohol abuse.

FIGURE 8. Round perforation in the pyloroduodenal region. Figure 8 can be viewed online in color at www.amjforensicmedicine.com. * 2011 Lippincott Williams & Wilkins

Medicolegal Aspects of Bizarre Self-Mutilation

FIGURE 9. Mixture of foreign bodies found in the stomach. Figure 9 can be viewed online in color at www.amjforensicmedicine.com.

Autopsy was performed and revealed: 1. Depression of approximately 3 cm diameter in the left frontotemporal region of the skull. 2. The frontal sinuses showed dirty purulent lining. 3. The peritoneal cavity showed signs of septic peritonitis. 4. Round perforation in the pyloroduodenal region approximately 2 cm in diameter (Fig. 8). 5. The liver was yellowish and granular. 6. A mixture of foreign bodies weighing approximately 1 kg was found in the stomach. It includes a wide variety of metallic and wooden objects such as coins, screws, nails, rings, earrings, keys, safety pins, glass dolls eyes, a razor blade, clock springs, pieces of glass, wood, stones, and a carefully folded piece of paper (Fig. 9).

DISCUSSION Although homicidal injuries are usually different from suicidal or accidental injuries, in some suicidal cases, one should hesitate in considering them as self-inflicted. The multiplicity of the injuries, their nature, sites, and the used instruments may be pointing to homicide. In such cases, the circumstantial evidence as well as the psychological conditions and the mental health of the victim are very important to diagnose the condition. Saukko and Knight1 reported a case of self-mutilation thought by the police to be a bizarre homicide. The genitals have been amputated, the throat cut through 360 degrees, the eyeballs punctured, and the scalp stabbed many times, all with scissors. The dead man had paranoid delusions of a religious nature. These cases were interesting because of the following reasons: Case 1: 1. The sudden attempt of self-mutilation or suicidal attempt was unexpected and occurred within few days from the beginning of the social problems. 2. The tool applied to perform the self-mutilation was by introduction of long nail into the head. 3. The path taken by the nail through the brain tissue of the victim while keeping conscious and alert opens discussion about the ability of similar head-injured victims to speak and move. 4. Psychiatric consultation is important to diagnose such selfinflicted injuries. www.amjforensicmedicine.com


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Case 2: 1. Unless the clothes were free from signs of struggle or suspicious tears coincide with the abdominal injuries, in addition to the presence of suicidal note in the chemise and the history of psychological and psychosomatic troubles, one should hesitate in considering the case as self-mutilation. 2. The multiplicity of injuries Bstabs and cut throat,[ extraction of the intestine, and tearing not only points to the unsound mind but also to the amount of abdominal pain from which the victim was suffering. Case 3: 1. The depression that was found in the frontotemporal region may result from the old traffic accident which was followed by mental and psychological troubles.

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2. The multiplicity and weight of the foreign bodies indicated gradual and continuous administration of these foreign bodies during a long period. 3. Alcohol abuse and lack of financial support acted as motives for swallowing of foreign bodies of different nature as part of shows to gain money.

REFERENCES 1. Saukko P, Knight B. Self-inflicted injuries other than suicide. Knight’s Forensic Pathology. 3rd ed. London, UK: Arnold; 2004:240Y241. 2. Wood JB, Evenson RC, Cho DW. Mortality variations among public mental health patients. Acta Psychiatr Scand. 1985;72:218.



CASE REPORT

Deer Stand Fatalities in Kentucky Two Cases of Reverse Suspension and Blunt Force Trauma Lisa B. E. Shields, MD and Donna Stewart, MD

Abstract: Hunting many types of wild game is an avidly pursued outdoor activity that attracts all ages and both genders at various times of the year. Deer hunting is a popular sport in many regions of North America. A variety of weapons are used in the hunting, trapping, and killing of game. As a variety of different modalities are used, myriad types of injuries unique to the type of hunting can occur. Most deer hunting-related fatalities identified at the Office of the Chief Medical Examiner in Kentucky are accidental firearm injuries. Less commonly encountered are fatalities resulting from elevation of the hunter in a tree stand, often associated with poor design or construction of the perch. We present 2 tree stand-related deaths. One victim died of positional asphyxia due to reverse suspension from a hunting tree stand. The second victim died of multiple blunt force injuries sustained in a 20-foot fall from a tree stand. We summarize the features of morbidity and mortality related to deer hunting based on investigations by the Office of the Chief Medical Examiner. Key Words: deer stand, hunting, death, accident, forensic pathology, forensic science (Am J Forensic Med Pathol 2011;32: 39Y43)

CASE REPORTS Case 1 Case History A 65-year-old white man was found by his son-in-law hanging upside down in a deer tree stand at 8:00 PM in the first week of October. He was last seen preparing for deer hunting dressed in Army fatigues. His legs were discovered suspended by a nylon-webbed rope around his waist extending from a rudimentary-made wooden stand wedged between 2 thin hardwood trees (Fig. 1). He was not wearing a safety harness. The victim had a history of cardiac disease, diabetes mellitus, hypertension, hyperlipidemia, chronic obstructive pulmonary disease, obesity, and smoking cigarettes. He experienced congestive heart failure and underwent a 3-vessel coronary bypass graft 9 years earlier. The decedent_s wife reported that her husband had complained of chest pain 6 days prior to his demise and had been evaluated by his family physician 3 days before his death. He was treated with a host of medications, specifically, K-Dur, Isosorbide, Neurontin, Lanoxin, Glyburide, Prinivil, Bumetanide, Manuscript received October 13, 2009; accepted November 22, 2009. From the Office of the Chief Medical Examiner; and Department of Pathology and Laboratory Medicine, University of Louisville School of Medicine, Louisville, KY. Reprints: Donna Stewart, MD, Office of the Chief Medical Examiner, Urban Government Center, 810 Barret Ave, Louisville, KY 40204. E-mail: [email protected]. Presented at the 37th Annual NAME Meeting, September 19Y24, 2003, San Jose, CA. Copyright * 2011 by Lippincott Williams & Wilkins ISSN: 0195-7910/11/3201Y0039 DOI: 10.1097/PAF.0b013e3181eafe05


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Chlorothiazide, Verapamil, Combivent, and Aspirin. A NitroTab bottle was noted with his body.

Autopsy Findings The decedent was an obese male measuring 75.5 inches and weighing 300 pounds (Body Mass Index = 37.1). Autopsy examination confirmed evidence of asphyxiation, including extensive dark red-purple suffusion of the face (Fig. 2); dark purple livor mortis with petechial hemorrhages of the neck, shoulders, and arms; marked scleral edema and injection; and bilateral inferior palpebral conjunctival petechial hemorrhages. Minor external blunt force injuries were evident, specifically, a right upper quadrant abdominal purple contusion measuring 0.5 0.4 inches, 2 oval cutaneous avulsion lacerations up to 0.5 inches on the dorsal aspect of the right hand, and 2 abrasion up to 1.0 inch of the dorsal aspect of the left leg. A 12 inch, vertical, linear midline well-healed scar was noted over the sternum. There was evidence of cardiomegaly (900 g) with left ventricular hypertrophy and dilatation. The 3-vessel coronary artery bypass graft was confirmed in association with severe coronary atherosclerosis; each of the grafts was patent. Microscopic examination demonstrated myocardial fibrosis, bullous and centrilobular emphysema, diabetic nephropathy, and severe hepatic steatosis. The blood and urine toxicological examination revealed negative findings for alcohol and drugs of abuse. The vitreous fluid analysis was negative for alcohol and showed a normal postmortem electrolyte profile. The cause of death was attributed to positional asphyxia due to reverse suspension from a hunting tree stand. Ischemic heart disease was a significant factor contributing to his death. The manner of death was accident.

Case 2 Case History A 65-year-old white retired coalminer was found under a tree by fellow Bhunting buddies[ in the early morning of the first week of November. The individuals who found his body stated that he had fallen approximately 20 feet to the ground from a homemade deer hunting tree stand. He lacked a safety harness. The victim was transported to a neighboring county_s Emergency Room and was pronounced dead upon arrival.

Autopsy Findings The decedent was a well-developed male with a height of 70.5 inches and a weight of 198 pounds. The autopsy findings were predominantly limited to blunt force trauma. External injuries consisted of abrasions ranging from 0.25 to 0.5 inches of the left shoulder, hip, and buttock; abrasion measuring 0.25 inches of the anterior mid right thigh; multiple contusions up to 1.0 inches of the anterior surfaces of the lower extremities; and a contusion of the penis. Multiple rib fractures were present, specifically of the second to seventh left anterolaterally, fifth and sixth left posteriorly, and third to eighth right anteriorly. He had also sustained a left superior ramus pelvic fracture. Both hemopneumothorax of the www.amjforensicmedicine.com


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FIGURE 1. Position of victim hanging in reverse suspension from a deer tree stand (Case 1).

left smooth pleural space (1 L of bloody fluid) and hemoperitoneum primarily within the left pericolic gutter (500 mL of bloody fluid) were evident. In addition, multifocal grade I coronary atherosclerosis was noted within the left circumflex coronary artery. The blood toxicological examination revealed negative findings for alcohol and drugs of abuse. The cause of death was attributed to truncal blunt force injuries sustained in a fall from a 20-foot height. The manner of death was accident.

DISCUSSION Tree stands are routinely used for large game hunting and provide the hunter with a wide visibility of the forest while at the same time decrease the hunter_s scent on the ground.1,2 Additionally, the stand allows the hunter to be positioned above the animal_s normal field of vision and permits the hunter to be more visible to other hunters to decrease of the likelihood of being hit by a stray bullet.1 On the other hand, tree stands increase the risk of injury by falling, may be difficult to carry, offer minimal room for movement, and do not protect against poor weather.1 Falls from tree stands represent the leading cause of hunting-related accidents.2,3 Various methods have been introduced to increase the safety of using a tree stand, including using a commercial model instead of a homemade device as well as wearing safety gear. Three popular commercial elevated portable tree stands include the following: nonclimbing stands, self-climbing stands, and ladder stands.4 The nonclimbing style provides approximately 4 square feet of space and is secured to the tree with belts or chains (Fig. 3A). The self-climbing style is used in trees with straight trunks, and the hunter Bwalks[ up the tree with the stand by moving 1 section of the stand with the hands and the other section with the feet (Fig. 3B). The ladder style provides a platform 10 to 20 feet above the ground and requires 3 to 5 individuals to build and disassemble it (Fig. 3C). It may be used on a wider variety of trees. Hunter-constructed stands usually consist of an elevated wooden platform which is nailed to a tree, and the hunter gains access by a self-constructed wooden ladder

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or wooden steps nailed to the trunk of the tree.5 In addition, the hunter may use an elevated free-standing stand such as a tripod style (Fig. 3D). This type of stand does not require a tree, may be placed in any location, and has a firm base. Hunters also have the option of wearing a safety strap or harness which is designed to support the hunter if he or she should fall. Several comprehensive studies in the literature have featured the prevalence of deer stand-related injuries (Table 1). Metz et al reported 51 tree stand-related injuries between 1996 and 2001 referred to regional trauma centers or Medical Examiner_s offices in New York and Maryland.2 Two West Virginia studies were conducted using hospital and trauma registries: Rose et al reported 24 patients (1988Y1992), and Gates et al identified 90 individuals (1994Y1999).3,6 Lawrence et al performed a study of spinal cord injuries reported to the Louisiana Spinal Cord Injuries Registry (1985Y1994), which ensued after a fall from a deer stand.7 Urquhart et al reviewed 19 cases of individuals admitted to the Medical College of Georgia Hospital and Clinics who sustained falls from a deer stand.5 Between 1979 and 1989, the Georgia Department of Human Resources and Georgia Department of Natural Resources conducted a thorough investigation of 594 deer huntingrelated injuries, of which 214 (36%) were tree stand-related.8 This latter study included both falls from tree stands as well as unintentional discharges of firearms while hunters were carrying their firearms up to or down from a tree stand or upon impact after a fall. These previous studies and the present report demonstrate numerous similarities. The mean ages of those injured were in the fourth and early in the fifth decades, with a range of 8 to 72 years. Both of the decedents in our study were aged 65. The extent and bodily locations of injuries varied among the previous studies; however, a common thread permeated, specifically, the lack of fatalities following a fall from a deer stand. Both Rose et al_s and Lawrence et al_s investigations reported no deaths, while Metz et al reported 3 (5.9%), Gates et al noted 7 (8%), and Urquhart et al encountered 1 (5.2%).2,6,7 Nonfatal injuries ranged from fractures of the vertebrae, ribs, pelvis, and extremities to solid organ injury, pneumothorax, and head injuries.2,3,6 Several studies in the literature involving falls from deer stands reported that the majority of injuries were due to fractures of the long bones and spine.3,5 Two primary features play a role in the mechanical force associating with injuries from

FIGURE 2. Congestion ecchymosis secondary to positional asphyxia (Case 1). * 2011 Lippincott Williams & Wilkins



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Deer Stand Fatalities in KY

FIGURE 3. A, Type of elevated portable tree stand: nonclimbing style (Copyright Obtained from Kalkomey Enterprises Inc.). B, Type of elevated portable tree stand: self-climbing style (Copyright Obtained from Kalkomey Enterprises Inc). C, Type of elevated portable tree stand: ladder style (Copyright Obtained from Kalkomey Enterprises Inc). D, Type of elevated free-standing stand: tripod style (Copyright Obtained from Kalkomey Enterprises Inc.).

falls, specifically, the duration of deceleration and body orientation.9 Injuries sustained in a vertical fall involve compressiondecompression deceleration forces.3 Flexion forces result in spinal fractures, whereas long bone fractures are caused by rotational forces. Although the majority of studies involving deer stand-related injuries do not demonstrate a high incidence of victims who had been consuming alcohol, the risk of falling from a tree stand is increased if the hunter was drinking alcohol (Table 1).2,3,6Y8 Both of the individuals in the present study had a negative blood toxicology for alcohol and other drugs of abuse.

Spinal cord injury represents one of the most devastating sequelae ensuing after a fall from a deer stand, with the degree of injury varying from incomplete paraparesis to complete quadriplegia.10 Three comprehensive studies in various states (Louisiana, Oklahoma, Pennsylvania) were conducted to determine the incidence of spinal injuries after falls from tree stands.7,10,11 In each of these studies, none of the victims wore safety devices at the time of the injury. Of note, Lawrence et al reported their findings of spinal cord injuries between 1985 and 1994 in Louisiana.7 In 1992, a public information campaign

TABLE 1. Characteristics Associated With Falls From Deer Stands Studies

Years of Study

Present study Kentucky N=2 Metz et al2 New York, Maryland N = 51 Rose et al6 West Virginia N = 24 Gates et al3 West Virginia N = 90 Lawrence et al7 Los Angeles N = 28 Urquhart et al5 Georgia N = 19 CDC*8 Georgia N = 214

2007

Age of Victims (yr) 65 (n = 2)

Fatalities (No. Cases)

Ethanol Present (No. Cases)

2 (100%)

0

1996Y2001

22Y69 (mean = 42.6)

3 (5.9%)

1988Y1992

17Y59 (mean = 31.1)

0

1994Y1999

16Y66 (mean = 38.6)

1985Y1994

17Y61 (median = 38)

1982Y1989

20Y68 (mean = 40)

1979Y1989

8Y72 (median = 38)

7 (8%)

0

1 (5.2%)

17 (8%)

5 (10%)

3 (12.5%)

6 (7%) [Level 9100 mg/dL]

12/18 (66%)

4 (21%)

N/A

*The CDC (centers for disease control and prevention) study includes all cases of deer stand-related injuries, including falls from a tree stand and unintentional discharge of firearms.




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took place in Louisiana to raise awareness of the risks of using deer stands without safety belts.7 After this campaign, a spinal cord injury due to a deer stand fall was not reported for the next 3 years. Metz et al reported that the primary cause of fall from a tree stand was structural failure of the tree stand, including either of the tree stand itself or of the tree to which the stand was attached.2 The second cause of fall from a tree stand was loss of balance with entering or exiting the tree stand. Of the 51 individuals who sustained an injury in their study, only 2 hunters (4%) were wearing a safety strap or harness. Rose et al demonstrated that the highest percentage (13 of 20 cases, 65%) of falls from a deer stand occurred when the hunter was ascending or descending the tree without a safety belt.6 These falls were attributed to poor judgment or careless behavior. Urquhart et al_s review also demonstrated that hunters were unlikely to use safety devices as none of the 17 individuals contacted in their study were wearing safety restraints at the time of the fall.5 Of the 31 tree stand falls in Mississippi between 1999 and 2001, only 10% of the hunters wore a safety harness.12 Neither of the 2 victims in the present study were wearing safety harnesses. The extensive study of tree stand-related injuries conducted by the Georgia Department of Human Resources and Georgia Department of Natural Resources between 1979 and 1989 demonstrated that 17 (8%) of the 214 cases of tree stand-related injuries were fatal.8 None of the 214 individuals were wearing a safety harness or seat-belt device at the time of the injury, and 43 (66%) hunters had not taken a hunter-safety course. Tree stand-related injuries represented 36% of all reported hunting injuries and 20% of hunting-related fatalities. A total of 73% of the hunters who were involved in a tree stand injury sustained fractures, including those of the cervical or lumbar vertebrae. Although tree stands are widely available commercially, hunters are not always inclined to use them. Urquhart et al reported that 83% (15 of 18 cases) of deer stand falls in their study were attributed to hunter-constructed stands. Both of the victims in the present study did not use a commercial tree stand as they preferred using a homemade stand. The first victim had designed a rudimentary-made wooden stand which he had wedged between 2 thin hardwood trees. Deer stands are usually positioned between 15 and 25 feet above the ground. Individuals who fall from this height may attain a final velocity of 30 mph and as a result, kinetic energy is transmitted throughout the axial skeleton and soft tissues.3 Several factors influence the extent and severity of injuries, including impact surface, tissue elasticity and viscosity, impact velocity, area and orientation of bodily impact, and duration of impact.9,13 The duration of impact force is the primary indicator of the severity of injury in that an impact force extended over the shortest period of time is the most likely scenario resulting in an injury.3,14 Impact surfaces such as rock, steel, and concrete allow minimal deformation and impact duration, thus, have the highest risk of injury. On the contrary, surfaces such as water, snow, and soil provide greater deformation, resulting in a lesser risk for injury.12,15 The second case in this study demonstrated the classic findings of blunt force injuries associated with a fall from a height of 20 feet. He had sustained numerous cutaneous abrasions and contusions of various locations of his body. Furthermore, he experienced multiple rib fractures as well as a pelvic fracture. Both hemopneumothorax and hemoperitoneum were noted at the time of autopsy. The first case in this study represents the unique phenomenon of reverse suspension. Rarely reported in the literature, reverse suspension has been postulated to be due to postural as-

phyxia which, in many cases, is associated with alcohol intoxication.16,17 Purdue reported the case of an individual_s accidental death who was found suspended by the right foot from a security fence.17 The victim had evidence of marked congestion of the lungs and brain as well as a blood alcohol level of 129 mg% and a vitreous alcohol level of 158 mg%. Purdue speculated that the stretching effect of the suspension would tense the abdominal muscles fixing the chest in expiration while the weight of the arms and upper body would induce fixation in inspiration.17 Another case of a victim_s body suspended by a right foot entrapped beneath a broken boarding led the author state that the cause of death may have been the additional factors of pooling of blood, impairment of venous return, and physiological reflexes.18 An experimental study of reverse suspension suggested that the cause of death in the head-down position is postural asphyxia as a result of hindered respiratory movements and that an individual may survive for half a day in this position.19 Several factors are associated with death attributed to accidental positional asphyxia, as follows: (1) Person discovered in a compromised breathing position; (2) Scene and historical circumstances indicate decedent placed himself in a position inadvertently and without deliberate action of another person; (3) Individual could not extricate self from fatal position due to central nervous system debilitation or alcohol or drug intoxication; (4) No evidence of internal airway obstruction; (5) No findings of asphyxiating gases on toxicologic examination; and (6) No evidence of obvious natural causes of death, such as acute intraluminal coronary atherosclerosis or hemorrhagic stroke.16 The mechanism of death associated with crucifixion, specifically, hanging upright from a cross or patibulum, is multifactorial.17,20 The literature has reported that St. Peter suffered such asphyxiation via crucifixion by his own desire.17 It is a form of exhaustion asphyxia, involving stretching of the chest and abdominal muscles. The resulting compromise of expiration leads to hypercarbia, hypovolemic shock, dehydration, stress-induced cardiac dysrhythmias, as well as ensuing congestive heart failure with rapid accumulation of pericardial and pleural effusions. We encountered 2 cases in the literature of deer standrelated deaths involving asphyxial fatalities, however, neither of them were due to reverse suspension. In 1 case, a 14-year-old hunter wore a safety harness which was improperly fitted, and it compressed too tightly around his waist causing asphyxiation.12 In another case, an individual fell from a tree stand while wearing a Bbelt-type[ safety harness and died due to asphyxia when the harness slid up around his neck.2 We present the first reported case of a hunter who died as a result of reverse suspension after falling out of a deer stand. He was found hanging upside down with his legs suspended by a nylon-webbed rope around his waist extending from a rudimentary-made wooden stand wedged between 2 thin hardwood trees. He had confirmed evidence of asphyxiation at the time of autopsy, and his cause of death was positional asphyxia by reverse suspension.

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CONCLUSION While the risks associated with firearms during hunting are well-recognized,5,21,22 including the passage of the BHunter Orange[ law in North Carolina in 1987 to 1988 aimed at reducing hunters_ deaths by making them wear orange clothing,23 less attention has been focused on the dangers related to tree stands. Injuries associated with tree stands are avoidable with forethought and consideration of Bcommon sense[ safety rules. Although safety devices are likely to prevent injuries from falls, hunters should be educated about their proper usage and be astute to wearing the harness throughout the entire duration from climbing the tree to descending it following the hunting * 2011 Lippincott Williams & Wilkins



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experience. Hunters should avoid complete isolation and organize hunting groups of at least 2 individuals with planned meeting times and places. They should also perform an annual inspection of the construction of the tree stands and safety equipment as wooden stands are predisposed to decay which may alter their stability. In addition, hunters should avoid all alcohol and drugs, and tree stands should not be used by those with significant medical conditions that increase the risk of falling. As illustrated in our first case, the hunter had a host of severe medical conditions including complaints of chest pain before 6 days of death and an evaluation by his family physician 3 days before death. Rose et al_s study included interviews with injured hunters who offered numerous recommendations for improved safety with deer stands, including using a safety harness at all times, thoroughly inspecting the equipment before use, avoiding alcohol and drugs while hunting, discontinuing hunting when fatigued, and purchasing high-quality tree stands.6 In addition, hunter safety courses and safety literature are available.8 The forensic pathologist may encounter fatalities as a result of a deer stand fall and is encouraged to bring awareness to the preventable risk factors associated with this common method used in hunting. ACKNOWLEDGMENTS The authors thank the Medical Examiners at the Office of the Chief Medical Examiner in Louisville, KY. We also thank Kalkomey Enterprises Inc for the graphic art used in this manuscript. REFERENCES 1. Today_s Hunter in Indiana. Hunting from Elevated Stands. Available at: http://www.hunter-ed.com/in/course/ ch6_hunting_from_elevated_stands.htm. Accessed October 13, 2009. 2. Metz M, Kross M, Bakey P, et al. Tree stand falls: a persistent cause of sport injury. South Med J. 2004;97:715Y719. 3. Gates RL, Helmkamp JC, Wilson SL, et al. Deer stand-related trauma in West Virginia: 1994 through 1999. J Trauma. 2002;53:705Y708. 4. Today_s Hunter in Indiana. Types of Elevated Stands. Available at: http://www.hunter-ed.com/in/course/ch6_types_of_elevated_stands.htm. Accessed October 13, 2009. 5. Urquhart CK, Hawkins ML, Howdieshell TR, et al. Deer stands: a significant cause of injury and mortality. South Med J. 1991;84:686Y688.


Deer Stand Fatalities in KY

6. Rose WD, Laird SL, Williams J, et al. Tree-stand-related injuries: a wilderness emergency. J Wilderness Med. 1994;5:382Y388. 7. Lawrence DW, Gibbs LI, Kohn MA. Spinal cord injuries in Louisiana due to falls from deer stands, 1985Y1994. J La State Med Soc. 1996; 148:77Y79. 8. Centers for Disease Control and Prevention. Tree stand-related injuries among deer hunters: Georgia, 1979Y1989. MMWR Morb Mortal Wkly Rep. 1989;38:697Y700. 9. Li L, Smialek JE. The investigation of fatal falls and jumps from heights in Maryland (1987Y1992). Am J Forensic Med Pathol. 1994;15:295Y299. 10. Price C, Mallonee S. Hunting-related spinal cord injuries among Oklahoma residents. J Okla State Med Assoc. 1994;87:270Y273. 11. Fayssoux RS, Tally W, Sanfilippo JA, et al. Spinal injuries after falls from hunting tree stands. Spine J. 2008;8:522Y528. 12. Forks TP. Hunting injuries in Mississippi. J Miss State Med Assoc. 2002;43:339Y343. 13. Lowenstein SR, Yaron M, Carrero R, et al. Vertical trauma: injuries to patients who fall and land on their feet. Ann Emerg Med. 1989;18: 161Y165. 14. Snyder RG, Snow CS. Fatal injuries resulting from extreme water impact. Aerosp Med. 1967;38:779Y783. 15. Gupta SM, Chandra J, Dogra TD. Blunt force lesions related to the height of a fall. Am J Forensic Med Pathol. 1982;3:35Y43. 16. Bell MD, Rao VJ, Wetli CV, et al. Positional asphyxiation in adults: a series of 30 cases from the Dade and Broward County Medical Examiner Offices from 1982 to 1990. Am J Forensic Med Pathol. 1992;13:101Y107. 17. Purdue B. An unusual accidental death from reverse suspension. Am J Forensic Med Pathol. 1992;13:108Y111. 18. Lawler W. Death by reverse suspension [letters to the editor]. Am J Forensic Med Pathol. 1993;14:87Y88. 19. Uchigasaki S, Takahashi H, Suzuki T. An experimental study of death in a reverse suspension. Am J Forensic Med Pathol. 1999;20:116Y119. 20. Edwards WD, Gabel WJ, Hosmer FE. On the physical death of Jesus Christ. JAMA. 1986;255:1455Y1463. 21. Cole TB, Patetta MJ. Hunting firearm injuries, North Carolina. Am J Public Health. 1988;78:1585Y1586. 22. Smith JL, Wood GC, Lengerich EJ. Hunting-related shooting incidents in Pennsylvania, 1987Y1999. J Trauma. 2005;58:582Y590. 23. Cina SJ, Lariscy CD, McGown ST, et al. Firearm-related fatalities in North Carolina: impact of the BHunter Orange[ law. South Med J. 1996;89:395Y396.



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CASE REPORT

A Novel Macabre Ritual of the Italian Mafia (‘Ndrangheta) Covering Hands With Gloves and Burying the Corpse With Burnt Lime After Execution Stefano D_Errico, MD, Emanuela Turillazzi, MD, PhD, Cristoforo Pomara, MD, Carmela Fiore, MD, Floriana Monciotti, MD, and Vittorio Fineschi, MD, PhD

Abstract: ‘Ndrangheta is one of the famous B4 mafias,[ which typically insists in Southern Italy. A particular case of ‘Ndrangheta-related homicide double execution by means of multiple gunshots is presented. To the best of our knowledge, this is the first report of ‘Ndrangheta_s homicidal modality (covering hands with gloves and burying) as a macabre ritual. In homicides committed by criminal organization, the method used as well as the positioning of the body follow a macabre ritual laden with significance and intending to be an admonition to other persons. Key Words: Italian mafia, BNdrangheta,[ execution (Am J Forensic Med Pathol 2011;32: 44Y46)

he existence of the B4 Italian mafias[ is known all over the world and referred to as BCosa Nostra[ in Sicily, the BCamorra[ in Campania, the BSacra Corona Unita[ in Puglia, and the B‘Ndrangheta[ in Calabria.1 The latter is estimated to be Italy_s most powerful organized crime association, surpassing the Sicilian Mafia. The ‘Ndrangheta is a specific confederation of mafia Bfamilies[ that is located mostly in southern Calabria and has been documented since the late 19th century.2Y4 Their ascendancy in the city of Reggio Calabria was the revelation in 1888 of the existence of a Bsect that fears nothing.[5 The ‘Ndrangheta itself suggests as much. It means a Bsociety of honorable men,[ deriving from the Greek word andragathes, indicating a noble, courageous man, worthy of respect as the result of his capacities. A code of honor is the pillar of a collective identity in the sect, forming a brotherhood of solidarity among its affiliates and a common purpose. Their moneymaking schemes include racketeering, extortion, loan sharking, illegal immigration, money laundering, cigarette smuggling, and arms and narcotic trafficking.6 As the other criminal groups, the features of the ‘Ndrangheta include durability over time, diversified interests, hierarchical structure, capital accumulation, reinvestment, access to political protection, and use of intimidation and violence to protect and promote their interests. A way in which the ‘Ndrangheta succeeds is apparently in its ability to remain less noticed, and therefore, more difficult to penetrate and defeat. As one official noted, the ‘Ndrangheta Bis invisible like the dark side of the moon.[

T

We present a particular case of ‘Ndrangheta-related homicide double execution, to discuss the scene and the homicidal modality used by the mafia.

CASE REPORT In the early morning of a spring day, a farmer noted the presence of bloodstains near the road leading to his own property, in the woods of the Tuscan countryside. The course of bloodstains ended in a wooded area where a pit covered with foliage and dry sprigs was detected. The presence of white dust was also observed and identified as burnt lime for its particular piercing smell. The farmer immediately alerted the authorities. A strange arrangement of the leaves next to the road limit addressed researches. Cautious foliage removing into the pit revealed a part of a blood-soaked jerkin, a few centimeters under soil. Under the jerkin, a lifeless body of a man (Bcadaver A[), laying down on the left hip and completely covered with burnt lime was found (Fig. 1A). The man_s face was partially corroded by the burnt lime, and he was dressed only in underpants and had worn a pair of constructor gloves (Fig. 1, B and C). The body was cautiously removed, but during this maneuver, the right leg of another man (Bcadaver B[) was found in the burnt lime (Fig. 1D). He was laying down on the right hip, beside the first cadaver and completely covered with burnt lime. This man was dressed only in a blood-soaked T-shirt, underpants, and socks. On the t-shirt, in correspondence of the dorsal region, a round laceration of 0.1 cm in diameter was revealed. He had also worn a pair of gloves in latex. Other working clothes belonging to the deceased exactly close to the cadavers and soiled of burnt lime were detected: its examination revealed 3 round lacerations. Two lacerations were noted on a blue sports jacket: 1 of 0.3 cm in diameter, in correspondence of the right dorsal region and the other of 0.8 cm in diameter, on the left end of the collar. The third laceration, of 0.1 cm in diameter, was revealed in correspondence of the right lumbar region of a brown jerkin. Two shell cases, one identified as BGF6 7.65,[ one as BGFL 6.35,[ were found near the pit. The cadavers were completely covered with the burnt lime. Caustic effects of burnt lime represented by full thickness burns on the face and wide and reddish areas affected the trunk were observed in both bodies (Fig. 2A). After strip off the gloves, the fleshy parts of the fingertip were undamaged (Fig. 2, BYD).

External Examination Manuscript received February 10, 2008; accepted May 7, 2008. From the Department of Forensic Pathology, Policlinico BLe Scotte,[ Siena, Italy. Reprints: Vittorio Fineschi, MD, PhD, Department of Forensic Pathology, University of Foggia, Ospedale Colonnello D_Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy. E-mail: [email protected]. Copyright * 2011 by Lippincott Williams & Wilkins ISSN: 0195-7910/11/3201-0044 DOI: 10.1097/PAF.0b013e3181efbbf2

Cadaver A

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In the left occipital region a star-shaped wound, with triangular skin flaps at the margin, dimensions of 1.5 1 cm, surrounded by a wide zone of raw, abraded skin was detected (Fig. 3A); a second and a third round-like wound were observed in correspondence of the right mandibular angle, 0.3 cm in diameter and right lumbar region, 0.6 cm in diameter, respectively.

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A Novel Macabre Ritual of the Italian Mafia (‘Ndrangheta)

FIGURE 1. Photographic sequence of cadaver_s detection. Cadaver A lays down on the left hip and was completely covered with burnt lime (AYC). The hands were covered by gloves (red arrow in B). During cadaver A removing, the right leg of cadaver B was appearing in the burnt lime (red arrow in D).

Cadaver B

Radiologic Study

In the left occipital region an irregular circular wound, with irregular margins, 1.5 cm of diameter, surrounded by abraded skin was detected (Fig. 3B); a second round-like wound, of 0.3-cm diameter, was observed on the right suprascapular region.

A complete multislice TC study was performed before autopsy, recording the presence of 3 (right orbital region, right lateral-cervical region, left hip region) and 2 (right temporal region, right zygomatic region) metallic foreign bodies, respectively (cadavers A and B).

FIGURE 2. Caustic effects of burnt lime represented by wide and reddish areas were observed on the face and the trunk (cadaver A) (A). After strip off the gloves (red arrow in B), the fleshy part of the fingertip were undamaged (C, D). * 2011 Lippincott Williams & Wilkins



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D_Errico et al

FIGURE 3. In the left occipital region a star-shaped wound, with triangular skin flaps at the margin, dimensions of 1.5 1 cm, surrounded by a wide zone of raw abraded skin was detected (cadaver A) (red arrow in A). In the left occipital region an irregular circular wound, with irregular margins, 1.5 cm of diameter, surrounded by abraded skin was detected (cadaver B) (red arrow in B).

Autopsy Cadaver A 1. A gunshot hit the left occipital region, passed through the left occipital lobe, caused comminuted fractures (secondary) on the left middle and anterior fossa and stopped in the right orbital region, fracturing the floor of the anterior fossa. 2. A gunshot hit the right mandibular angle, passed through the muscles of the right anterior cavity of the neck, and stopped in the right lateral-cervical region, level to C3. 3. A gunshot hit the right lumbar region, level to L4, passed through the lumbar muscles and stopped in the left hip region.

Cadaver B


make us believe that both victims after having been shot were intentionally undressed, thrown into the excavated pit, and covered with burnt lime. Bodies covered with burnt lime were probably adopted to hide the smell of the blood and the decomposition of the bodies, delaying the discovery of the bodies (about 48 hours after the killing) and altering their appearance by means of caustic injuries on the face and trunk. This substance, commonly known also as quicklime (CaO), is a white, caustic, and alkaline crystalline solid, traditionally used in the burial of bodies in open graves, to hide the smell of decomposition. Prolonged exposure of the skin to this substance cause several types of skin reactions from mild irritation to full thickness burns.10 Hands, covered with gloves, appeared undamaged in both victims and few days after our examination, the victims were identifiedVwhich was because of the fingerprints taken from the bodies. They were 2 brothers belonging to the criminal association ‘Ndrangheta, in probation in the Tuscan countryside. Postmortem examination give establish gunshots pathways and indicate brain lesions caused by the gunshot fired at each one in the left occipital region, as the cause of death in both case. The macroscopic characteristics of these wounds let us to establish a firing distance less of 40 cm. To the best of our knowledge, it is the first report of ‘Ndrangheta_s homicidal modality (covering hands with gloves and burying) as a macabre ritual. Burying cadavers have to be correctly interpreted: to make the face unrecognizable is a typical macabre ritual of the Italian Mafia, intending to be an admonition to other persons. Covering hands with gloves still represents a question mark: does the killer needed to allow the identification of the men through the digital prints as an advertisement for all ‘Ndrangheta_s affiliates? We agree with this hypothesis. REFERENCES 1. European Committee on Crime Problems (CDPC) and Committee of Experts on Criminal Law and Criminological Aspects of Organised Crime (PC-CO). Report on the Organised Crime Situation in Council of Europe Member StatesV1997. Strasbourg, France: Council of Europe; 1999:70Y77. 2. Varese F. How Mafias Migrate: the case of the ‘Ndrangheta in Northern Italy. Law Soc Rev. 2006;40:411Y444.

1. A gunshot hit the left occipital region, passed through the left and right cerebellar lobe, and stopped in the right temporal lobe. 2. A gunshot hit the right suprascapular region and with a surface and oblique path directed from low to high, from behind to forward, passing through the muscles of the neck and malar region on the right side, stopped in correspondence to the zygomatic bone, fracturing it.

DISCUSSION In homicides committed by criminal organization, the method used as well as the positioning of the body follow a macabre ritual laden with significance and intending to be an admonition to other persons.7Y9 The rarity of the modality of executions used, makes these homicides peculiar. The findings of lacerations on the clothes

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3. Ciconte E. ‘Ndrangheta Dall_Unita` a Oggi. Bari, Italy: Laterza; 1992:5Y6. 4. Paoli L. Mafia Brotherhood: Organized Crime, Italian Style. Oxford, United Kingdom: Oxford University Press; 2003:37Y39. 5. La Sorte M. The ‘Ndrangheta looms large. Feature Articles 286. 2004. http://www.americanmafia.com/Feature_Articles_286.html. 6. La Sorte M. Organized crime in Italy. Feature Articles 281. 2004. http://www.americanmafia.com/Feature_Articles_281.html. 7. De Leo G, Strano M, Pezzato G, et al. Evoluzione Mafiosa e Tecnologie Criminali. Milano, Italy: Giuffre`; 1995:30Y33. 8. Jones AM. An unusual atypical gunshot wound: a coin as an intermediate target. Am J Forensic Med Pathol. 1987;8:338Y341. 9. Fineschi V, Dell_Erba AS, Di Paolo M, et al. Typical homicide ritual of the Italian Mafia (incaprettamento). Am J Forensic Med Pathol. 1998;19:87Y92. 10. Sherman SC, Larkin K. Cement burns. J Emerg Med. 2005;29:97Y99.



CASE REPORT

Sudden Death Following Delayed Traumatic Diaphragmatic Herniation Adam M. Yates,* James W. Fulcher, MD,Þþ§ and Michael E. Ward, MDÞþ§ Abstract: Blunt force trauma to the chest can often result in diaphragmatic tears. These tears can go months without being discovered, until a secondary injury or circumstance causes an organ to herniate through the diaphragm. Special care should be taken at autopsy to determine the mechanism of injury of any tears in the diaphragm as this may influence the cause and manner of death. We present a case of a 28-year-old man who suffered multiple injuries in a motor vehicle collision. Six months later he presented with a left diaphragmatic tear and gastric fundal herniation, and died eventually. Key Words: delayed death, ruptured diaphragm, herniation, blunt force trauma (Am J Forensic Med Pathol 2011;32: 47Y49)

HISTORY A diaphragmatic tear may occur in those who sustain blunt force or piercing trauma to the chest.1 A lateral tear of the muscular fibers of the diaphragm leads to a reduction in the structural integrity of the muscle. Because of the lack of direct repair and the continual use of the muscle, unrecognized diaphragmatic tears tend to heal very slowly, if at all. Any increased pressure in the chest (via exercising, another accident, sneezing, or coitus) can cause organs housed below the diaphragm to herniate through the tear, causing painful complications that may lead to death.1Y3 Diaphragmatic tears associated with blunt force trauma can be extremely difficult to diagnose without surgery. Understanding the signs and symptoms of a diaphragmatic tear, as well as the mechanisms of injury may lead to earlier clinical diagnosis. Recognizing the injury at autopsy can be instrumental in finding a proper cause of death in autopsy. Diaphragmatic tears resulting from blunt force trauma may be associated with secondary injuries that include long bone or pelvic fractures, pleural effusions, a pneumothorax localized around one side of the diaphragm, and trauma sustained on the left side of the body.1

with multiple fractures including pelvis, left clavicle and left ribs, as well as a 900 mL left hemothorax requiring chest tube placement (Fig. 1). His fractures were treated conservatively, and his hemothorax resolved. He was discharged on the 10th hospital day (Fig. 2). On April 25, 2009, approximately 6 months after the accident he was seen in the emergency room complaining of left shoulder and arm pain. This pain developed following a workout in a local gym, which included weightlifting. He was diagnosed with shoulder strain and prescribed narcotic analgesics for pain control. No radiographic examination of the chest was performed. On the same day, he began complaining of nausea with vomiting which worsened with eating. He was found dead in his bed 3 days later. At autopsy, there were 2300 mL of brown turbid fluid present in the left pleural cavity. A 5-cm defect was present in the medial left hemidiaphragm with associated herniation of the partial left lobe of liver and the fundal portion of the stomach (Fig. 3, A and B). There was perforation of the gastric wall with associated focal mucosal hemorrhage (Fig. 3C). Microscopic examination of the gastric wall from the region of perforation demonstrated ischemic change of gastric mucosa, acute hemorrhage within submucosal tissues, and acute inflammation (Fig. 3D). Toxicological analysis of femoral blood demonstrated therapeutic levels of prescription medications including Cyclobenzaprine, Paroxetine, diphenhydramine, and Hydrocodone. Delta-9 THC was also present. The cause of death was determined to be complications of blunt force trauma of chest

CASE STUDY We report the case of a 28-year-old man who on October 30, 2008 while reportedly driving through a red light, was struck on the left side of the car at the driver_s door. He was hospitalized

Manuscript received January 22, 2010; accepted June 7, 2010. From the *Clemson University Forensic Anthropology Intern at the Greenville County Medical Examiners Office; †Office of the Medical Examiner, Greenville County; ‡Pathology Associates of Greenville; and §The Greenville Hospital System University Medical Center, Greenville, SC. Images were optimized by Angie Yates, Graphic Communications student at Clemson University. Reprints: Adam M. Yates, Greenville Medical Examiner Office, Greenville Memorial Hospital Suit 110 890 Feris Road, Greenville, SC 29605. E-mail: [email protected]. Copyright * 2011 by Lippincott Williams & Wilkins ISSN: 0195-7910/11/3201Y0047 DOI: 10.1097/PAF.0b013e3181ed7a13


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FIGURE 1. Admission CT demonstrating fracture of left iliac wing and flattening of left hemidiaphragm with residual hemothorax. No diaphragmatic injury is demonstrated. www.amjforensicmedicine.com


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FIGURE 2. Discharge anterior-posterior x-ray with mild elevation of left hemidiaphragm and lower lobe atelectasis.

Noninvasive diagnosis of diaphragmatic rupture is usually made radiographically and successful diagnosis depends on the severity of the injury. Diaphragmatic ruptures associated with visceral herniation, especially those of a hollow viscus, are easily radiographically demonstrated with the presence of an air interface with the pleural cavity. Nonherniated diaphragmatic rupture may have minimal radiographic findings on both plain films and computerized tomography of the chest. Without herniation, there is minimal separation of diaphragmatic muscular fibers which may not be apparent radiographically.1Y3 A high clinical level of suspicion is often needed to make the diagnosis of a nonherniated diaphragmatic rupture. Knowledge of the mechanism of injury is important, as diaphragmatic trauma is often associated with blunt force trauma resulting from motor vehicle collisions. Impacts to the side of the vehicle, especially the left side of the vehicle, increase the risk for diaphragmatic injury as the left diaphragm is described as being structurally weaker than the right.3,4 Blunt trauma with coexisting injuries, especially pelvic fracture, is highly associated with diaphragmatic rupture.1 Numerous cases of traumatic diaphragmatic rupture with delayed herniation are presented in the literature. Generally the presentation occurs weeks to months following injury, is associated with physical activity, and presents with chest pain often associated with eating. In one case a woman was involved in a motor vehicle collision with impact to the driver_s side. No diaphragmatic injuries were diagnosed during the initial hospitalization. She apparently recovered from her initial injuries, however, suffered abdominal visceral herniation during coitus. She was radiologically diagnosed with diaphragmatic herniation and surgical repair was accomplished.1 We present the case of a 28-year-old man who was the driver of a vehicle in collision with another vehicle. The point of impact was the driver_s left side. Diagnosed injuries included left-sided rib, clavicle, and pelvic fractures, as well as a left hemothorax. He apparently recovered from his injuries and was discharged from the hospital on the 10th hospital day. There were no apparent complications for approximately 6 months following initial injury. In the weeks prior to death, our subject began an episode of increased physical activity which included weight lifting. Three days prior to death and following a period of weightlifting, he developed left-sided pain which was clinically diagnosed as Bshoulder strain.[ According to family members, he also was felt to be suffering from a flu-like illness with nausea, vomiting, and decreased food intake. He was found dead in his bed 3 days following onset of left chest pain. Autopsy findings were similar to clinical findings of other cases presented in the literature with herniation of left lobe of liver and the fundal region of the stomach. Unlike other cases, this herniation of gastric fundus resulted in ischemia of gastric

with left diaphragmatic tear and herniation of visceral organs, with gastric ischemia and perforation.

DISCUSSION The presentation of diaphragmatic injuries is fairly rare, occurring in cases involving blunt force trauma somewhere between 0.8% and 8% of the time.2 While some diaphragmatic ruptures are relatively easy to diagnose in the clinical setting, these are usually associated with abdominal visceral herniation. Those without herniation are most often discovered during surgical exploration of the chest or abdomen, or while surgically repairing other chest injuries. Associated injuries are reported to occur in over 50% of cases of diaphragmatic rupture and include fractures of pelvis, ribs, or long bones.2 This is not surprising as these are also common injuries for blunt force trauma to the chest; however, it is significant as they point to a severity of trauma that would indicate the possibility of diaphragmatic injury as well. Likewise, Cameron et al reports that up to 62% of cases resulting in a herniation through the diaphragm are delayed.1 The herniation of the visceral organs is often caused by an increase in abdominal cavity pressure, most often by a new or infrequent activity such as weightlifting, as in the case of our victim.


FIGURE 3. A, Left thoracic cavity with brown turbid effusion. B, Left thoracic cavity with left lobe of liver (L) extending through tear within left hemidiaphragm (D). C, Mucosal surface of gastric fundus with perforation and mucosal hemorrhage. D, Microscopic section of stomach wall through region of perforation (P) with transmural acute inflammation and foreign material present within gastric muscular wall, (H&E 20).

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Sudden Death Following Diaphragmatic Herniation

wall, subsequent perforation, and the presence of over 2000 mL of turbid gastric contents in the left pleural space. The forensic significance of the case lies in an awareness of delayed traumatic diaphragmatic hernia and its potential role in the cause of death. The presence of diaphragmatic herniation without a history of trauma would certainly be problematic. An investigative history of the decedent would be crucial to correct determination of manner of death. Any history of blunt chest and abdominal trauma, especially trauma that resulted in injuries associated with diaphragmatic rupture would be of vital importance. Physical activity resulting in increased abdominal cavity pressure should not in and of itself result in diaphragmatic herniation, and would only occur in the setting of a previously compromised diaphragm. Without history of prior traumatic injury, one must consider the possibility of nontraumatic diaphragmatic hernia resulting from a previously undiagnosed congenital diaphragmatic hernia.5

with a ticking time bomb in their chest, waiting for the right conditions to herniate and cause fatal injury. In these cases, an indepth history must be obtained, especially in regards to previous trauma as this may greatly influence determination of cause and manner of death.

CONCLUSION Traumatic diaphragmatic rupture may be very difficult to diagnose in the clinical setting, and delay in visceral herniation may take months to years to occur. This may result in a patient


REFERENCES 1. Cameron E, Mirvis S. Ruptured hemidiaphragm: unusual late presentation. J Emerg Med. 1996;14:53Y58. 2. Iochum S, Ludig T, Walter F, et al. Imaging of diaphragmatic injury: a diagnostic challenge? Radiographics. 2002;22:S103YS118. 3. Duzgun A, Ozmen M, Saylam B, et al. Factors influencing mortality in traumatic ruptures of diaphragm. Ulus Travma Acil Cerrahi Derg. 2008;14:132Y138. 4. Scaglione M, Grassi R, Pinto A, et al. Delayed presentation of traumatic left-sided diaphragmatic avulsion: a case report. Acta Radiol. 2000;41:165Y166. 5. DeAlwis K, Mitsunaga E. Sudden death due to nontraumatic diaphragmatic hernia in an adult. Am J Forensic Med Pathol. 2009;30:366Y368.



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CASE REPORT

Cave Canem Bite Mark Analysis in a Fatal Dog Pack Attack Cristoforo Pomara, MD, PhD,* Stefano D_Errico, MD,* Valerio Jarussi, DVM,Þ Emanuela Turillazzi, MD, PhD,* and Vittorio Fineschi, MD, PhD*

Abstract: Deaths resulting from animal attacks are rare, and according to The Humane Society of the United States, more than 300 individuals died of dog attacks in the United States from 1979 to 1996. The case of a fatal dog-pack attack on an 83-year-old woman is presented. Wide lacerations of the scalp, several tooth puncture wounds, and bruises reproducing bite marks were recorded on the whole body. Exsanguinations due to brachial artery laceration subsequent to multiple dog bites were indicated as the main cause of death. An integrated study in association with a veterinary doctor was performed on 27 dogs of different breed (24 Cane Corso, 1 Dalmatian, 2 German Shepherds) collecting dental formula and dental casts. Dental casts were superimposed on the victim_s wound samples collected at autopsy and analyzed for compatibilityV the patterns taken from the jaws of 3 suspected dogs could be clearly adapted on the bite marks. At the end of investigation, the son of the victim indicated the 3 dogs of his own as the responsible ones and he was condemned for manslaughter. Bite marks analysis provided conclusive evidences in identifying the offending animals. The results may be important to give details about bite circumstances and predisposition of specific breeds of dogs to bite or inflict severe bites. Key Words: dog bites, bite marks analysis, forensic veterinary (Am J Forensic Med Pathol 2011;32: 50Y54)

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he annual incidence of dog bites is approximately 12.9 per 10,000 persons and injuries from dog bites account for approximately 1% of all emergency visits to hospital in the United States.1Y5 Deaths resulting from animal attacks are rare and according to The Humane Society of the United States, more than 300 individuals died of dog attacks in the United States from 1979 to 1996.6 Most victims of fatal dog attacks are children (G1 year of age) and elderly women who were found to be the least able to protect themselves from a dog attack.7Y24 Deaths may result from envenomation, anaphylaxis, suffocation, crushing injuries, or from hemorrhage from vascular disruption. In the United States, Pit bull-type dogs and Rottweilers were involved in more than half of dog-attack deaths (67%); they were followed by German Shepherds, Husky-type dogs, and Malamutes (1,6,10,12,13,18Y22,25); typical continental breeds related fatalities are also reported.9,23,24 We present the case of a fatal dog-pack attack on an 83year-old woman. An integrated study in association with a veterinary doctor was performed, collecting dental formula and

dental casts from the jaws of suspected dogs. Dental casts were superimposed on the victim_s wound samples collected at autopsy and analyzed for compatibility and identification of the suspected dogs.

CASE REPORT An 83-year-old woman was found unconscious, lying on her face on the ground, outside the farm where she lived with her sons and her 27 dogs. She was still alive when she was found by 1 of her sons who rushed her to the nearest hospital to receive medical care. The son of the old lady reported to the physicians that his mother has been victim of a dog pack attack and that she was alone with the dogs at the place and time of the attack. He also reported that dog pack was not that of his own. At the emergency department, the patient was unconscious; a diagnosis of hemorrhagic shock, requiring blood transfusions was made on the base of clinical data, showing hypothermia and laboratory findings of anemia (Red Blood Cells: 2.7 106 uL, Hb 7.9 g/dL, Hct 23.4%). Color flow Doppler ultrasound on the ischemic left arm was performed showing the absence of radial pulse and tear of the brachial artery, which was immediately repaired by vascular surgeon. Few minutes after surgery the patient died, despite resuscitation maneuvers. A complete postmortem examination was performed a few days after death.

Autopsy Findings

Manuscript received July 31, 2009; accepted March 27, 2010. From the *Department of Forensic Pathology, University of Foggia; and †Department of Medical Veterinary, Azienda Sanitaria Locale FG, Foggia, Italy. Correspondence: Vittorio Fineschi, MD, PhD, Department of Forensic Pathology, University of Foggia, Ospedale Colonnello D_Avanzo, Via degli Aviatori, 1, 71100 Foggia, Italy. E-mail: [email protected]. Copyright * 2011 by Lippincott Williams & Wilkins ISSN: 0195-7910/11/3201Y0050 DOI: 10.1097/PAF.0b013e3181edf0e2

External examination of the victim showed a welldeveloped body of an 83-year-old woman, 145 cm in length and 45 kg in weight. Wide lacerations of the scalp with exposure of the underlying galea capitis were recorded; several tooth puncture wounds, resembling stab wounds, were detected on the neck (Fig. 1, A and B). Lacerations, multiple small puncture wounds, and abrasions were observed on the whole body (upper and lower extremities, thoracic and abdominal regions, back district) (Fig. 1, C and D). Clusters of 4 to 5 superficial linear parallel abrasions between puncture wounds (single or in pairs), reproducing Bbite marks[ were recorded, especially on upper and lower extremities (Fig. 2, AYC). The wounds were documented by photographs and the distance between pairs of punctures was measured (from 4 cm to 6.5 cm) as well as between bruises. These measures were typically related to different canine dentition, and to the pattern of attack with punctures and lacerations (canines), and tissue avulsion (incisors). Then, the samples that better reproduced bite marks were collected and fixed in 10% buffered formalin. Before formalin fixation, the sectioned tissues containing patterned injuries were sutured to a synthetic rigid ring to minimize shrinkage. Internal examination showed non-lethal bite marks with extreme bleeding around soft tissues except for severely crushed left brachial biceps and left brachial artery showing a laceration about 1.5 cm long at the level of the proximal third which was surgically repaired (Fig. 2D). Exsanguinations due to brachial artery laceration subsequent to multiple dog bites were indicated as the main cause of death.

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FIGURE 1. Lacerations of the scalp and several tooth puncture wounds of the neck were detected (A, B). Multiple small puncture wounds and abrasions were observed on the whole body (C, D).

The victim_s own dogs were immediately suspected and investigated. An integrated study in association with a veterinary doctor was performed on 27 dogs of different breed (24 Cane Corso, 1 Dalmatian, 2 German Shepherds) usually packing free outside the farm and regularly registered and identified by means of microchip number. Measurement of all canine jaws and description of dental characteristics (missing or fractured teeth, supernumerary teeth, etc) were performed recording a dental plan (dental formula) for each dog. Then, dental plans

were compared with wound samples to verify the distance between canines or to search for peculiar dental formula; it was possible to indicate just 7 dogs among 27 as strongly suspected to be responsible for the attack (Table 1). To detect the offending dogs among the 7, a dental cast of each dog was made. An impression of the teeth of each of the 7 dogs was made using dental alginate impression material following the manufacturer_s guidelines. After removing the tray out of the dogs_ mouth the hardened impression material was

FIGURE 2. Bite marks were recorded on upper and lower extremities (AYC). Left brachial artery showing a laceration about 1.5 cm long at the level of proximal third, surgically repaired (D). * 2011 Lippincott Williams & Wilkins



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TABLE 1. The 27 Different Breed Dogs Usually Packing Free Outside the Farm, Regularly Registered, and Identified by Means of Microchip Number

TABLE 2. The 3 Suspected Dogs Identified by the Bite Marks Analysis

Microchip Number

Breed

Sex

977 200 005 412 767 977 200 004 760 899 982 009 100 384 443 977 200 004 995 003 977 200 004 779 256 977 200 005 076 293 977 200 005 068 682

Cane corso German shepherd Dalmatian Cane corso Cane corso Cane corso Cane corso

9 S S 9 S 9 9


Microchip Number

Breed

Sex

977 200 004 995 003 977 200 005 076 293 977 200 005 068 682

Cane corso Cane corso Cane corso

9 9 9

At the end of investigation, the son of the victim indicated the 3 dogs of his own as the responsible ones, and he was condemned for manslaughter.

DISCUSSION rinsed thoroughly under running water. Plaster casts were prepared using dental calcined gypsum. The dental casts were superimposed on the victim_s wound samples collected at autopsy and analyzed for compatibility (Fig. 3A): the patterns taken from the jaws of 3 suspected dogs could be clearly adapted on the bite marks (Table 2). The position of the 6 incisors in the upper jaw of the dog identified with number 977 200 004 995 003 showed to be identical to that of the wound on the victim_s left leg. Single puncture was due to the absence of the right upper canine. The position of the 2 canines and the position of the 6 incisors in the upper jaws of the 2 dogs identified with number 977 200 005 076 293 and 977 200 005 068 682 showed to be identical to that of the wound on the right leg and right gluteus (Fig. 3, BYD). Blood and 4 samples of each case were collected to eventually perform genetic investigation.

In the case presented, a fatal Italian Cane Corso pack attack on an 83-year-old woman is described. The Cane Corso is an ancient Italian breed, which is derived from the now extinct roman Molosser. It is a medium to large-sized dog, robust and sturdy, nevertheless elegant dog, generally owned to guard and protect people. In 1994, the ENCI accepted the Italian Cane Corso as the 14th Italian breed and in 1996 it became a recognized breed of the Federation Cynologique Internationale in the group 2, section 2.1 (Molosside breed, Mastiff type). An average of approximately 19 deaths from dog attacks was reported annually in the United States during the time period 1979 to 2005. Deaths have been reported in 49 states with Alaska reporting the highest death rate from dog attacks. The number of deaths and the death rate from dog attacks appear to be increasing.6,26 Approximately 70% of severe attacks involved bites on the head and neck, a location for which death

FIGURE 3. Plaster casts prepared using dental calcined gypsum. The dental casts were superimposed on the victim_s wound samples collected at autopsy and analyzed for compatibility (A). The position of the 6 consumed incisors in the upper jaw of the dog identified with number 977 200 004 995 003 showed to be identical to that of the wound on the victim_s left leg. Single puncture was due to the absence of right upper canine. The position of the 2 canines and the position of the 6 incisors in the upper jaws of the 2 dogs identified with number 977 200 005 076 293 and 977 200 005 068 682 showed to be identical to that of the wounds on right leg and right gluteus (BYD).

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because of hemorrhage and shock is likely.1,2,7,8,13,21,23 Penetrating injuries to the neck can also lead to tracheal injury with life-threatening airway compromise. Injuries to the axillary and internal carotid arteries, the spinal cord, and the skull are also reported showing the devastating effects of blunt force in vicious dog attacks.23,27Y29 The fatal attack is characterized by repetitive, uninhibited biting, and by the dog being relatively unresponsive to attempts to terminate the attack. Unlike less serious attacks, attacks which result in death usually occur when no one but the victim is present. Causes of dog attacks include the following: (1) the dog senses that its position in the family is being threatened, most often when children and new babies are in the household, making them the most vulnerable to the attack; (2) the dog is fearfulVthe so-called fear biting is preceded by warning growls or postures, often unrecognized by children; (3) the dog senses that its territory of food is being threatened, again making unaware children most susceptible to the attack; (4) physical activity or vocalization may stimulate aggressiveness in dogs, especially when in packs; (5) a dog_s medical illness may lead to aggressive behavior (rabies, brain neoplasm, encephalitis, diabetes mellitus).14 Dog pack attacks with human predation appear to be extremely rare accounting for 6.9% of all fatal dog attacks.16,22,30Y32 When attacks involve more than 1 dog there may be extensive injuries to the head, face, neck, torso, and extremitiesVin these cases head and neck injuries are more frequently involved as well as abdomen and trunk, causing significant blood loss. There may be also injuries to the buttocks and limbs, particularly if dogs are hunting in a pack, as biting the hindquarters is a technique that dogs use to immobilize the prey. Nonfatal bites tend to be found on the hands, lower limbs, and face.9,16,19 Fatalities are more likely to occur in unwitnessed attacks and result from exsanguinations from vessel trauma, air embolism from damage to veins in the neck, and/or blunt craniofacial trauma from crushing of the skull.1,13,14 It has been suggested that in a pack situation, once an aggressive act is initiated, whether as a playful nip or a serious bite, dogs which singly taken are docile, may join in and the pack instinct escalates the attack until the victim is killed or the dogs are driven off.30 Other factors that are believed to facilitate the initiation of attacks on humans by dogs include a possible genetic predisposition toward aggressiveness; male gender, intact reproductive status, poor health, late and inadequate training and socialization; lack of supervision, defense of territory or puppies, hunger, predatory experience, pack-dog experience, assertion of social dominance, age, size, and behavior of victims; and absence of other people in the vicinity.22 Bite mark analysis has been shown to be useful in distinguishing between wolf and dog attacks and more recently in a number of large cat attacks.33,34 Dog dentition is conventionally represented by a dental formula by quadrants, because dentition is bilaterally symmetrical. Thus, the canid dental formula is incisor 3/3, canines 1/1, premolars 4/4, and molars 2/3. Depending on the function of each tooth, certain types of injuries may be produced. The incisors of canids are relatively small, are used for nipping, and will produce small parallel grooves on bone. Canines are long and sharp, have small serration along one of the borders, are used to stab and tear and produce either punctures or gouges. The premolars are small, gripping teeth, which are used to hold onto prey and will produce striations on bone. The molars have small, round (bunodont) cusps and are used for crushing.8 The canine lower dental arch is narrower and shorter than the upper and natural gaps exist between the teeth in most breeds, which may be reflected in the bite mark impressions.15,19 Guidelines for the analysis of bite

marks are important for investigation and should be respected. To standardize the analysis of bite marks, the American Board of Forensic Odontology established specific guidelines.35 New approaches with digital technique overlaying the bite mark and patterns of a suspect animal facilitate an exact investigation. Bite mark and study casts can be compared using 3-dimensional pictures.36Y38 The most important step was to recognize a patterned injury as a bite mark. The forensic evaluation of the fatal dog attack required an integrated approach in association with veterinary pathologists involving review of the circumstances of death, examination of death scene, and autopsy examination of the victim.32,39 Finally, odontological analysis of bite marks, provided conclusive evidences in identifying the offending animals. Identification of people bitten by animals remains incomplete, and inconsistencies in data collection preclude meaningful conclusions about bite circumstances and predisposition of specific breeds of dogs to bite or inflict severe bites.40 There is a need for a national reporting system on dog bites to fully capture the extent of fatalities and to look at the risk factors surrounding the attack.26


REFERENCES 1. Calkins CM, Bensard DD, Patrick DA, et al. Life threatening dog attacks: a devastating combination of penetrating and blunt injuries. J Pediatr Surg. 2001;36:1115Y1117. 2. Mitchell RB, Nanez G, Wagner JD, et al. Dog bites of the scalp, face, and neck in children. Laryngoscope. 2003;113:492Y495. 3. Weiss H, Friedman D, Coben J. Incidence of dog bite injuries treated in emergency departments. JAMA. 1998;279:51Y53. 4. Tan RL, Powell KE, Lindemer KM, et al. Sensitivities of three county health department surveillance systems for child-related dog bites: 261 cases. J Am Vet Med Assoc. 2000;225:1680Y1683. 5. Wiseman NE, Chochinov H, Fraser V. Major dog attack injuries in children. J Pediatr Surg. 1983;8:533Y536. 6. Shields LB, Bernstein ML, Hunsaker JC, et al. Dog bite-related fatalities: a 15-year review of Kentucky Medical Examiner cases. Am J Forensic Med Pathol. 2009;30:223Y230. 7. Tsuji A, Ishiko A, Kimura H, et al. Unusual death of a baby: a dog attack and confirmation using human and canine STRs. Int J Legal Med. 2008;122:59Y62. 8. Boglioli LR, Taff ML, Turkel SJ, et al. Unusual infant death: dog attack or post-mortem mutilation after child abuse? Am J Forensic Med Pathol. 2000;21:389Y394. 9. Bux RC, McDowell JD. Death due to attack from chow dog. Am J Forensic Med Pathol. 1992;13:305Y308. 10. Sacks JJ, Sattin RW, Bonzo SE. Dog bite-related fatalities from 1979 through 1988. JAMA. 1989;2262:1489Y1492. 11. Winkler WG. Human deaths induced by dog bites, United States, 1974Y75. Public Health Rep. 1977;92:425Y429. 12. Dog bite-related fatalities-United States 1995Y1996. MMWR Morb Mortal Wky; Rep. 1997;46:463Y467. 13. Wright JC. Severe attacks by dog: characteristics of the dogs, the victims, and the attack settings. Public Health Rep. 1985;100:55Y61. 14. Lauridson JR, Meyers L. Evaluation of fatal dog bites: the view of the medical examiner and animal behaviourist. J Forensic Sci. 1993;38: 726Y731. 15. Clark MA. Fatal and near fatal animal bite injuries. J Forensic Sci. 1991;36:1256Y1261. 16. Avis SP. Dog pack attack: hunting humans. Am J Forensic Med Pathol. 1999;20:243Y246.



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17. Pinckney LE, Kennedy LA. Traumatic deaths from dog attacks in the United States. Pediatrics. 1982;69:193Y196. 18. Sacks JJ, Lockwood R, Hornreich J. Fatal dog attacks 1989Y1994. Pediatrics. 1996;97:891Y895. 19. Tsokos M, Byard RW, Puschel K. Extensive and mutilating craniofacial trauma involving defleshing and decapitation. Unusual features of fatal dog attacks in the young. Am J Forensic Med Pathol. 2007;28:131Y136.


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extremity arterial injuries secondary to dog bites. Ann Emerg Med. 1990;19:983Y986. 30. Kneafsey B, Condon KC. Severe dog-bite injuries, introducing the concept of pack attack: a literature review and seven case reports. Injury. 1995;26:37Y41. 31. Borchelt PL, Lockwood R, Beck AM, et al. Attacks by packs of dogs involving predation on human beings. Public Health Rep. 1983;98: 57Y66.

20. Sacks JJ, Sinclair L, Gilchrist J, et al. Breeds of dogs involved in fatal human attacks in the United States between 1979 and 1998. J Am Vet Med Assoc. 2000;217:836Y840.

32. De Munnynck K, Van de Voorde W. Forensic approach to fatal dog attacks: a case report and literature review. Int J Legal Med. 2002;16: 295Y300.

21. Loewe CL, Diaz FJ, Bechinski J. Pitbull mauling deaths in Detroit. Am J Forensic Med Pathol. 2007;28:356Y360.

33. Wong JK, Blenkinsop B, Sweet J, et al. A comparison of bitemark injuries between fatal wolf and domestic dog attacks. J Forensic Odontostomatol. 1999;17:10Y15.

22. Raghavan M. Fatal dog attacks in Canada, 1990Y2007. Can Vet J. 2008;49:577Y581. 23. Oshima T, Mimasaka S, Yonemitsu K, et al. Vertebral artery injury due to fatal dog bites. J Forensic Leg Med. 2008;15:529Y532.

34. Kieser J, Tompkins G, Buckingham D, et al. Bitemarks: presentation, analysis, and evidentially reliability. In: Tsokos M, ed. Forensic Pathology Reviews. Totowa, NJ: Humana Press; 2005:144Y152.

24. Di Donato S, Ricci P, Panarese F, et al. Cane Corso attack. Two fatal cases. Forensic Sci Med Pathol. 2006;2:137Y141.

35. American Board of Forensic Odontology (ABFO) Inc. Guidelines for bite mark analysis. Diplomates Reference Manual Section III: Policies, Procedures, Guidelines & Standards Manual. 2009:110Y126.

25. Lang ME, Klassen T. Dog bites in Canadian children: a five year review of severity and emergency department management. Can J Emerg Med. 2005;7:309Y314.

36. Pretty IA, Sweet D. Adherence of forensic odontologists to the ABFO bite mark guidelines for suspect evidence collection. J Forensic Sci. 2001;46:1152Y1158.

26. Langley RL. Human fatalities resulting from dog attacks in the United States, 1979Y2005. Wilderness Environ Med. 2009;20:19Y25.

37. Pretty IA, Sweet D. Digital bite mark overlaysVan analysis of effectiveness. J Forensic Sci. 2001;46:1385Y1391.

27. Mcheik J, Vergnes P, Bondonny J. Treatment of facial dog bite injuries in children: a retrospective study. J Pediatr Surg. 2000;35:580Y583.

38. Thali MJ, Braun M, Markwalder TH, et al. Bite mark documentation and analysis: the forensic 3D/CAD supported photogrammometry approach. For Sci Int. 2003;135:115Y121.

28. Verela JE, Dolich MO, Fernandez LA, et al. Combined carotid artery injury and laryngeal fracture secondary to dog bite: case report. Am Surg. 2000;66:1016Y1019.

39. Lessig R, Wenzel V, Weber M. Bite mark analysis in forensic routine case work. EXCLI J. 2006;5:93Y102.

29. Snyder KB, Pentecost MJ. Clinical and angiographic findings in

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40. Patronek GJ, Slavinski SA. Animal bites. J Am Vet Med Assoc. 2009;234:336Y345.



CASE REPORT

Ocular Findings in Raised Intracranial Pressure A Case of Terson Syndrome in a 7-Month-Old Infant Othon J. Mena, MD, Ian Paul, MD, and R. Ross Reichard, MD

Abstract: We present the case of a 7-month-old female infant who was found crying and limp. She was transported to a hospital where a possible subarachnoid hemorrhage was diagnosed radiologically. Before further studies could be pursued, her condition worsened and she died. The autopsy demonstrated diffuse subarachnoid hemorrhage of the brain and along the spinal cord. The brain, spinal cord, and eyes were retained and examined postfixation. An aneurysm of the middle cerebral artery was identified. Examination of the eyes demonstrated bilateral optic nerve sheath hemorrhage and extensive retinal hemorrhages extending to the ora serrata. A rapid increase in intracranial pressure secondary to subarachnoid hemorrhage following rupture of an aneurysm can result in sequelae similar to those found in inflicted traumatic brain injury. In this case, the rise in intracranial pressure resulted in marked hemorrhage within the optic nerve sheaths as well as intra- and preretinal hemorrhages. Patients with subarachnoid hemorrhage, or other causes of rapidly increased intracranial pressure, may develop ocular hemorrhage (Terson syndrome). This case illustrates the importance of ruling out natural disease before attributing the autopsy findings to trauma, as well as the importance of postmortem fixation of pediatric brains and eyes prior to examination. Key Words: Terson syndrome, intracranial pressure, subarachnoid hemorrhage, aneurysm (Am J Forensic Med Pathol 2011;32: 55Y57)

nerve sheaths were markedly hemorrhagic. Anterior opening of the spinal canal showed diffuse extension of the subarachnoid hemorrhage along the entire length of the spinal cord. No other gross abnormality was identified. Law enforcement contacted the office to determine if any criminal charges should be pursued. Due to no obvious signs of trauma or foul play, it was recommended that no criminal investigation should be pursued pending further examination. The brain, spinal cord, and eyes were retained for formalin fixation and further examination at a later time. Approximately 2 weeks after the initial examination, the retained organs were again examined. At the level of the left lateral sulcus, and arising from distribution of the middle cerebral artery, a 2.1-cm grossly vascular lesion was identified (Fig. 1). No other lesion was grossly seen. Histologically, the lesion consisted of a tortuous vessel with variable thickening and thinning of the wall, consistent with an aneurysm. There was a marked amount of red blood cells both within and outside the vessel walls. A focus of attenuation and interruption of the vessel wall, consistent with a site of rupture, was identified. The vessel wall had degenerative changes consisting of myxoid changes within it and irregular medial hypertrophy with scattered foci of calcification. An elastin stain showed nonuniformity and irregular absence of the internal elastic lamina.

A

7 month-old female infant with a history of only atopic dermatitis was found crying and limp following a usual nap. Paramedics were summoned, and after resuscitative efforts, she was transported to a local hospital. Radiologic evaluation showed a possible subarachnoid hemorrhage. However, before further studies could be pursued, her condition deteriorated, and she died approximately 18 hours after arrival to the hospital. The external examination showed a well-nourished and hydrated infant consistent with her age. The dermatitis was most pronounced at the extremities and scalp, and consisted of drying and flakiness of the skin. Full body radiographs showed no evidence of skeletal deformity or acute and subacute injury. Internal examination of the torso showed no congenital defect, evidence of trauma, infectious disease, or other abnormality. Intracranial examination showed diffuse cerebral edema and subarachnoid hemorrhage, which was most pronounced on the base of the brain. Prior to removal of the brain, a postmortem vertebral artery angiogram was performed. The angiogram did not reveal any abnormality of the vertebral arteries. The optic

Manuscript received September 10, 2008; accepted November 13, 2008. From the New Mexico Office of the Medical Investigator, Albuquerque, NM. Reprints: Othon J. Mena, MD, County of San Diego Medical Examiner_s Office, 5570 Overland Ave, San Diego, CA 92123. E-mail: othon.mena@ sdcounty.ca.gov. Copyright * 2011 by Lippincott Williams & Wilkins ISSN: 0195-7910/11/3201Y0055 DOI: 10.1097/PAF.0b013e3181edee5b


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FIGURE 1. Coronal sections of brain with 2.1 cm aneurysm in distribution of right middle cerebral artery. www.amjforensicmedicine.com


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FIGURE 4. The majority of the hemorrhage along the optic nerve sheath was intradural and subdural, with a small amount being subarachnoid (hematoxylin and eosin, 100) (black arrow indicates dura, white arrow indicates subarachnoid membrane).

The optic nerve sheath had extensive intradural and subdural hemorrhage, and mild to moderate subarachnoid hemorrhage (Fig. 4).

DISCUSSION FIGURE 2. Subarachnoid hemorrhage was present along entire length of spinal cord.

Examination of the spinal cord confirmed the presence of extensive subarachnoid hemorrhage (Fig. 2). The eye examination demonstrated multiple retinal hemorrhages extending to the ora serrata (Fig. 3). Microscopically, the hemorrhages were both preretinal (subhyaloid) and intraretinal. The retinal hemorrhage involved primarily the optic nerve fibers, and focally extended to the inner nuclear layer, without extension into the outer layers.

FIGURE 3. Multiple retinal hemorrhages extended to the ora serrata. The entire optic nerve sheath was darkened by marked hemorrhage.

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It is well known that retinal hemorrhages are associated with inflicted traumatic brain injury. Nevertheless, other causes associated with them include raised intracranial pressure, intracranial subarachnoid hemorrhage, vaginal delivery, blood dyscrasias, and others.1,2 In the early 20th century, Terson syndrome was originally described as vitreous hemorrhage in association with intracranial hemorrhage, more specifically subarachnoid hemorrhage.3 Since the original description, Terson syndrome has been expanded to encompass any intraocular hemorrhage associated with intracranial hemorrhage and intracranial pressure elevation.2,4 Different mechanisms have been proposed to explain the occurrence of ocular hemorrhage following a rise in intracranial pressure, whether it is due to an intracranial hemorrhage or any other cause. It has been suggested that a rapid rise in intracranial pressure leads to decreased venous drainage of the eyes, resulting in vitreous hypertension and retinal or vitreous hemorrhage.5,6 In 1974, it was proposed by Muller and Deck that the rise in intracranial pressure on the subarachnoid compartment dilates the optic sheath, leading to compression of the central retinal vein (Fig. 5). The hemorrhage would then originate from ruptured intradural vessels and bridging vessels, following compression and obstruction of the retinochoroidal anastomoses. Compression of the central retinal vein would also result in blocked or reduced eye venous drainage, resulting in retinal venous hypertension and retinal vein rupture.5 There is evidence that there is no connection between the optic nerve sheath subarachnoid space and the vitreous body, and that the optic nerve sheath hemorrhage is not necessarily an extension of intracranial subarachnoid hemorrhage.6 Some of the reasons for this are that intraocular hemorrhage can be seen accompanying raised intracranial pressure without intracranial hemorrhage, and the subdural compartment is generally the compartment with the bulk of the hemorrhage.5,6 Therefore, raised intracranial pressure regardless of the cause (eg, severe brain injury) may result in intraocular hemorrhage. * 2011 Lippincott Williams & Wilkins



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FIGURE 5. Schematic proposed by Muller and Deck (1974), illustrating the intraorbital and intracanalicular portion of the optic nerve and its sheath. Bridging vessel rupture would result in optic nerve sheath hemorrhage. Reprinted with permission from J Neurosurg. 1974;41:164.

The findings of the case presented initially mimicked the presentation of inflicted traumatic brain injury. However, a complete and thorough autopsy examination was instrumental in determining that the cause was in fact natural. Thus, this case represents a rare example of a nontraumatic cause of ocular hemorrhage and a case of Terson syndrome in an infant. Whether there is a head injury or an intracranial hemorrhage due to a spontaneously ruptured aneurysm or any other cause, the most significant factor leading to ocular and optic nerve serve sheath hemorrhage appears to be a rapid increase in intracranial pressure. REFERENCES 1. Kaur B, Taylor D. Current topic: retinal hemorrhages. Arch Dis Child. 1990;65:1369Y1372.


2. Jay V, Smith CR. Check sample, American Society of Clinical Pathologists (ASCP), Forensic Pathology, 1998;40(9). 3. Ou R. Terson Syndrome (e-medicine Web MD Web site). July 3, 2008. Available at: http://www.emedicine.com/oph/topic753.htm#ref1. Accessed August 29, 2008. 4. Giangiacomo J, Frasier LD. Ophthalmic Manifestations. In: Giardino MP, Alexander R, eds. Child Maltreatment. 3rd ed. Saint Louis, MO: GW Medical Publishing Inc;2005:83Y89. 5. Muller PJ, Deck JH. Intraocular and optic nerve sheath hemorrhage in cases of sudden intracranial hypertension. J Neurosurg. 1974;41: 160Y166. 6. Medele RJ, Stummer W, Mueller AJ, et al. Terson_s syndrome in subarachnoid hemorrhage and severe brain injury accompanied by acutely raised intracranial pressure. J Neurosurg. 1998;88:851Y854.



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ORIGINAL ARTICLE

Forensic Aspect of Cause of Subendocardial Hemorrhage in Cardiopulmonary Resuscitation Cases Chest Compression or Adrenaline Werasak Charaschaisri, MD,* Kesanee Jongprasartsuk, MD,Þ Suthat Rungruanghiranya, MD,þ and Larry Kaufman, MD§

Abstract: Subendocardial hemorrhage (SEH) is a striking feature seen in many forensic autopsy cases. It was believed earlier to represent an agonal phenomenon without any particular reference to the cause of death. However, the latest study showed that even minor SEH might have an influence on cardiac function and might be involved in the mechanism of death. To rule out the possible cause of SEH from defibrillation, autopsies were performed in 240 adults admitted to Department of Forensic Medicine, Faculty of Medicine, Srinakarinwirot University and Department of Forensic Medicine, Faculty of Medicine, Chulalongkorn University between July 2006 and June 2008. All the subjects were subdivided into 2 groups: one group receiving resuscitation and the other group receiving no resuscitation. In the former group, 76 patients had attempted cardiopulmonary resuscitation with adrenaline and 44 patients without adrenaline. While in the latter group, 120 patients received no resuscitation attempt. Approximately, 43.4% of resuscitation with adrenaline cases (33/76) demonstrated SEH in contrast to 4 cases of resuscitation without adrenaline (9.1%, P G 0.05). This demonstrates an increasing trend of SEH in cases with prolonged resuscitation and higher level of adrenaline utilizations. (Am J Forensic Med Pathol 2011;32: 58Y60)

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ubendocardial hemorrhage (SEH) is a striking postmortem finding, which may be seen after primary cardiac injuries,1Y3 cardiopulmonary resuscitation (CPR),4Y6 and even as the result of noncardiac events. Noncardiac circumstances associated with SEH include head injuries,4,7Y9 infectious diseases,10,11 intoxications (eg, heroin, cocaine, amphetamine, acetaminophen, or heavy-metal poisoning such as arsenic),1,4,12,13 hemorrhagic diathesis,4 abdominal trauma,14 asthma,4 hypoxia, and hypovolemic shock.15Y17 Intriguingly, it is hypothesized that intracranial catastrophes produce such cardiac findings via hypersecretion of catecholamine.7,8 The mechanism of SEH becomes more confusing as it relates to CPR. This may be because of the inherent nature and procedure of modern advanced cardiac life support (ACLS), as this consists of a combination of possible aspects, and each of them may be thought to lead to SEH. These would include di-

Manuscript received August 28, 2008; accepted May 27, 2009. From the *Faculty of Medicine, Srinakarinwirot, Ongkarak, Nakornnayok; †Department of Forensic Medicine, Faculty of Medicine, Chulalongkorn University; ‡Division of Pulmonary and Critical Care Medicine, Faculty of Medicine, Srinakharinwirot University, Bangkok, Thailand; and §Department of Medicine, University of Hawaii, Hilo, HI. Correspondence: Werasak Charaschaisri, MD, BFM, Faculty of Medicine, Srinakharinwirot, Ongkarak, Nakornnayok 26120, Thailand. E-mail: [email protected]. Copyright * 2011 by Lippincott Williams & Wilkins ISSN: 0195-7910/11/3201-0058 DOI: 10.1097/PAF.0b013e3181edee46

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rect cardiac trauma from chest compressions5 and/or defibrillation plus the contribution by indirect causality of adrenalin administration.6 Therefore, in cases of sudden death we sought to identify which of these factors most contribute to the development of SEH, specifically to the role of chest compressions and adrenalin.

METHODS The data in this study were collected by the Department of Forensic Medicine of both Srinakharinwirot and Chulalongkorn University Hospitals between July 2006 and June 2008. This was an observational, correlative, and retrospective analytical study whereby notifications of sudden deaths were subsequently divided into the following 3 groups: GROUP 1: cases receiving Basic Life Support (BLS) only (chest compressions only). GROUP 2: cases receiving ACLS (chest compressions + adrenalin). GROUP 3: cases receiving neither BLS nor ACLS. Inclusion criteria where the patients who were 918-years-old, had no abnormal bleeding, or had no chest trauma. Exclusion criteria included brain injury, asthma, sepsis, and/or exsanguinations. In addition, all had toxicological screening for arsenic, acetaminophen, alcohol, amphetamine, heroin, and cocaine. An important further exclusion criterion was those victims found to have had defibrillation attempts during resuscitative efforts. Cases meeting the above criteria underwent full autopsies with particular attention given to SEH, epicardial hemorrhage, presence and/or pattern of rib/sternal fractures, and heart weight was recorded. Demographic data were collected for age, weight, height, and sex. Those receiving resuscitative efforts had cause of death, duration of CPR, and dosage (in ampoules) of adrenalin recorded.

Statistical Analysis Parametric 2-tailed unpaired t test, nonparametric Fisher exact test, W2 test, multivariable analysis, and binary logistic regression were used. A P value of G0.05 was considered statistically significant.

RESULTS A total of 240 subjects met study criteria and are included for analysis. Exactly 2 (120/240) of the victims of sudden death had neither BLS nor ACLS. Although 76 subjects received chest compressions and adrenalin, 44 people received chest compressions only (ie, BLS). Interestingly, subjects who had neither BLS nor ACLS displayed any evidence of SEH. Am J Forensic Med Pathol

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Of the 44 victims receiving BLS, only 4 (9.1%) demonstrated SEH. The average duration of CPR for this group was 30.3 minutes. Though 3 subjects tested positive for alcohol (40, 102, and 158 mg%) and 1 subject had a blood culture positive for Streptococcus viridians, none of these cases illustrated SEH. More revealing was the results of the ACLS group. Of the 76 (43.4%) subjects receiving both chest compressions and adrenalin, 36 resulted in SEH being present on necropsy. Further scrutiny shows a statistically significant contribution of adrenalin dosage and the presence of SEH (Table 1). The average dosage of adrenalin (14 ampoules vs. 3.9) in the SEH positive versus SEH negative subjects was significant (P G 0.05). Though 2 subjects tested positive for amphetamines and another 2 had positive blood cultures (Klebsiella pneumonia and Pseudomonas aeruginosa), none of these patients had evidence of SEH. The average duration of CPR between those receiving BLS and ACLS with high dose adrenalin (14 ampoules) was nearly the same at 30.3 minutes and 31.8 minutes, respectively. The group receiving ACLS-low dose adrenalin had an average length of CPR of only 13.7 minutes and no SEH. Interestingly, the group having BLS 30.3 minutes had an incidence of SEH higher (9.1%) than the ACLS-low dose adrenalin yet much less than the ACLS-high dose adrenaline (Table 2) and brings to question the impact of duration of CPR associated with higher rates of the development of SEH. We were unable to find any significant correlation with presence or absence of rib and/or sternal fractures (P 9 0.05)

SEH in Cardiopulmonary Resuscitation

TABLE 2. The Statistic Data of the Advance Cardiac Life Support (ACLS) Group in Comparison to the Basic Life Support (BLS) Group Adrenaline No Adrenaline Using Group Group (Mean, SD) (Mean, SD)

Factors Age (yr) Weight (kg) Height (cm) Heart weight (g) Duration of CPR (min) Positive for fracture ribs Positive for fracture sternum Epicardial pethechiae Subendocardial hemorrhage

P

39 (12.1) 61.1 (12.2) 165.4 (4.8) 323.3 (60.2) 21.8 (9.7) 15 19

41.1 (15.2) 62.2 (13.8) 169.5 (6.7) 346.2 (70.4) 17.9 (4.9) 9 9

90.05* 90.05* 90.05* 90.05* 90.05* 90.05† 90.05†

23 33

11 4

90.05† G0.05†

*Parametric, 2-tailed unpaired t test. †Nonparametric Fisher exact test and W2 test. SD indicates standard deviation; CPR, cardiopulmonary resuscitation.

nor the finding of epicardial hemorrhage (P 9 0.05) on the development of SEH.

DISCUSSION TABLE 1. The Statistic Data of the ACLS Group (N = 76) Mean, SD Positive Samples for SEH

Factors Male Female Age (male) Age (female) Age (yr) Weight (kg) Height (cm) Heart weight (g) Duration of CPR (min) Dosage of adrenaline (ampule) Positive for fracture ribs Negative for fracture ribs Positive for fracture sternum Negative for fracture sternum Positive for epicardial hemorrhage Negative for epicardial hemorrhage

Negative for SEH

P

60 16 60 16 76 76 76 76 76 76

22 11 32.8 (13) 48.7 (18.2) 38.1 (15.8) 66.8 (14.3) 167.9 (6.4) 348.3 (58.2) 31.8 (4.2) 14 (3.6)

38 5 41.7 (11.8) 42 41.7 (11.1) 58.1 (11.4) 167.2 (5.7) 307 (61.5) 13.7 (2.3) 3.9 (1.2)

90.05*

15 58 19

9 27 11

6 31 8

90.05*

54

23

31

23

15

8

49

18

31

90.05† 90.05† 90.05† 90.05† G0.05† G0.05†

90.05*

90.05*

*Nonparametric Fisher exact test and W2 test. †Parametric, 2-tailed unpaired t test. SD indicates standard deviation; SEH, Subendocardial hemorrhage; CPR, cardiopulmonary resuscitation.


SEH has been reported on autopsy studies and shown to be associated with a number of conditions including primary cardiac injuries,1Y3 CPR,4Y6 and those cases due to noncardiac events (head trauma,4,7Y9 intoxications,1,4,12,13 infections,10,11 etc). SEH associated with CPR has not been rigorously examined as to which particular aspect of CPR most closely correlates with the development of SEH. We protocolized our study in an attempt to separate out 2 key-factors of CPR, ie, chest compressions and administration of adrenalin as to their respective contribution to SEH. We found only 9.1% of those victims of sudden death who received chest compressions but no adrenalin to have SEH on necropsy. Furthermore, the incidence of SEH was directly related to the dose of adrenalin with an average ampoule of 14, yielding a 43% incidence of SEH while 3.9 ampoule average during ACLS, even with chest compressions, producing a 0% incidence (P G 0.05). However, we could not exclude what the duration of CPR contributed to the finding of SEH. The group with CPR only but duration of 30.3 minutes was associated with a higher incidence (9.1%) than the group with chest compressions and low-dose adrenalin (0%). Duration of CPR may have some unique contributory factor in leading to SEH even when not associated with higher dosage of adrenalin. We found the length of CPR of nearly 30 minutes to have a 9.1% and 43.4% incidence (chest compressions only vs. chest compressions + adrenalin, respectively), whereas CPR of 13.7 minute duration and low-dose adrenalin 3.9 ampoules producing no discernible SEH.

CONCLUSIONS Though our numbers may be too small for concrete conclusions to be drawn, it would appear that both high-dose adrenalin and longer duration of CPR (930 minutes) yields the highest incidence of SEH on autopsy findings. This seems to www.amjforensicmedicine.com


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parallel the numerous studies on survival and nonsurvival from cardiac arrest in the literature with approximately 30 minutes being significant cut-off in outcomes.18

9. Marion DW, Segal R, Thompson ME. Subarachnoid hemorrhage and the heart. Neurosurgery. 1986;18:101Y106.

REFERENCES 1. Knight B. Forensic Pathology. London, United Kingdom: Arnoldt; 1996. 2. Chiu CJ, Mersereau WA, Scott HJ. Subendocardial hemorrhagic necrosis. The role of direct mechanical trauma on the endocardium. J Thorac Cardiovasc Surg. 1972;64:66Y75.


10. Kleinman WM, Krause SM, Hess ML. Differential subendocardial perfusion and injury during the course of gram-negative endotoxemia. Adv Shock Res. 1980;4:139Y152. 11. Blood-Siegfried J, Nyska A, Lieder H, et al. Synergistic effect of influenza a virus on endotoxin-induced mortality in rat pups: a potential model for sudden infant death syndrome. Pediatr Res. 2002;52: 481Y490. 12. Karch SB, Billingham ME. The pathology and etiology of cocaine-induced heart disease. Arch Pathol Lab Med. 1988;112:225Y230.

3. Zhu BL, Fujita MQ, Quan L, et al. A sudden death due to cardiac conduction system injury from a blunt chest impact. Leg Med (Tokyo). 1999;1:266Y269.

13. Price LM, Poklis A, Johnson DE. Fatal acetaminophen poisoning with evidence of subendocardial necrosis of the heart. J Forensic Sci. 1991;36:930Y935.

4. Harruff RC. Subendocardial hemorrhages in forensic pathology autopsies. Am J Forensic Med Patho. 1993;14:284Y288.

14. Burton RR, MacKenzie WF. Cardiac pathology associated with high sustained +Gz:I. Subendocardial hemorrhage. Aviat Space Environ Med. 1976;47:711Y717.

5. Reinecke P, Notnagel C, Jehle J, et al. Circular hemorrhagic subendocardial necrosis after heart arrest and resuscitation. Z Kardiol. 2001;90:437Y441. 6. Karch SB. Resuscitation-induced myocardial necrosis: catecholamines and defibrillation. Am J Forensic Med Pathol. 1987;8:3Y8.

15. Sheehan HL. Subendocardial hemorrhages in shock. Lancet. 1940;1:831Y832. 16. McGovern VJ. Hypovolemic shock with particular reference to the myocardial and pulmonary lesions. Pathology. 1980;12:63Y72.

7. Smith RP, Tomlinson BE. Subendocardial hemorrhages associated with intracranial lesions. J Pathol Bacteriol. 1954;68:327Y334.

17. Martin AM, Hackel DB, Entman ML, et al. Mechanisms in the development of myocardial lesions in hemorrhagic shock. Ann NY Acad Sci. 1969;156:79Y90.

8. Koskelo P, Punsar S, Sipilae W. Subendocardial hemorrhage and E.C.G. changes in intracranial bleeding. BMJ. 1964;5396:1479Y1480.

18. Hoke RS, Chamberlain D. Skeletal chest injuries secondary to cardiopulmonary resuscitation. Resuscitation. 2004;63:327Y333.

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ORIGINAL ARTICLE

Suicide by Asphyxiation Due to Helium Inhalation Matthew O. Howard, PhD,* Martin T. Hall, PhD,Þ Jeffrey D. Edwards, MSW,* Michael G. Vaughn, PhD,þ Brian E. Perron, PhD,§ and Ruth E. Winecker, PhD¶ Abstract: Suicide by asphyxiation using helium is the most widely promoted method of Bself-deliverance[ by right-to-die advocates. However, little is known about persons committing such suicides or the circumstances and manner in which they are completed. Prior reports of suicides by asphyxiation involving helium were reviewed and deaths determined by the North Carolina Office of the Chief Medical Examiner to be helium-associated asphyxial suicides occurring between January 1, 2000 and December 31, 2008 were included in a new case series examined in this article. The 10 asphyxial suicides involving helium identified in North Carolina tended to occur almost exclusively in non-Hispanic, white men who were relatively young (M age = 41.1 T 11.6). In 6 of 10 cases, decedents suffered from significant psychiatric dysfunction; in 3 of these 6 cases, psychiatric disorders were present comorbidly with substance abuse. In none these cases were decedents suffering from terminal illness. Most persons committing suicide with helium were free of terminal illness but suffered from psychiatric and/or substance use disorders. Key Words: asphyxia, helium, suicide, right-to-life (Am J Forensic Med Pathol 2011;32: 61Y70)

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ublication, in 1991, of the right-to-die manifesto and suicide Bhow-to[ guide, Final Exit: The Practicalities of SelfDeliverance and Assisted Suicide for the Dying,1 raised a maelstrom of controversy regarding the appropriateness of suicide as a response to terminal or Bhopeless[ physical illness and exposed divisions within the right-to-die movement itself. In the 1990s, many right-to-die advocates were engaged in public education as to the purported virtues of advanced directives, living wills, and legalized physician-assisted suicide.2 At the same time, other elements of this movement, including the Self-Deliverance New Technology (NuTech) Group, were developing technologies to Bempower people to die on their own terms by controlling the timing and manner of their own death.[2 NuTech members, including Derek Humphreys, author of Final Exit, sought to identify a suicide method that was swift, painless, failure-proof, inexpensive, and nondisfiguring. The group also considered it vital that the method be simple, leave little or no indication that the death was unnatural in nature, and not require a physician_s assistance or prescription.2 With its detailed descriptions of diverse suicide methods and specific endorsement of the plastic bag asphyxiation method, publication of Final Exit brought an easily understood and genManuscript received January 19, 2010; accepted March 3, 2010. From the *School of Social Work, University of North Carolina at Chapel Hill; †Department of Behavioral Medicine, School of Medicine, University of Kentucky; ‡School of Public Health, Saint Louis University; §Department of Psychiatry, School of Medicine, University of Michigan; and ¶North Carolina Office of the Chief Medical Examiner, NC. Supported by NIH grants DA15929, DA15556, DA021405 (M.O.H.) and DA007304 (M.T.H.). Correspondence: Matthew O. Howard, PhD, Frank Daniels Distinguished Professor, Tate-Turner-Kuralt Building, 325 Pittsboro, CB 3550, Chapel Hill, NC 27599Y3550. E-mail: [email protected]. Copyright * 2011 by Lippincott Williams & Wilkins ISSN: 0195-7910/11/3201Y0061 DOI: 10.1097/PAF.0b013e3181ed7a2d


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erally effective suicide method to the masses. The book was a commercial success, appearing on the New York Times bestseller list and selling more than 1.5 million copies in the decade following its publication. In 2007, Final Exit was named one of the 25 most influential books of the past quarter-century by book critics and editors of USA today.3 Concerns that suicides in nonterminally ill depressed persons might follow exposure to methods elucidated in Final Exit were soon raised,4 and dramatic increases in plastic bag asphyxial suicides were observed in New York City5 and the United States6 in the year following publication of Final Exit. Investigators concluded that Bmost persons exposed to Final Exit were not terminally ill and had used it as a suicide manual I (and that) it is likely that a psychiatric disorder would have been diagnosed in most of these people.[5 Efforts by NuTech and others to develop a more effective suicide method and widely disseminate it to the public have continued to the present. In 2000, a supplement to Final Exit was published that presented the first description of heliumassisted plastic bag asphyxiation.7 Advocates emphasized the enhanced lethality of this approach, reduction in time required for death to occur to less than 5 minutes, and elimination of the need for a sedative prescription. Proponents of the method also noted that materials needed to complete such suicides are readily accessible and that asphyxiation due to helium inhalation is often undetected by autopsy (where findings are typically nonspecific) or toxicological analysis (because special sampling and assay methods are required). Thus, such suicides are likely to remain undetected in cases where the helium delivery apparatus and plastic bag are removed before the death scene is examined and no other information is available implicating death by helium-assisted asphyxiation. Modifications of the helium method were published in 20028 and 2009,9 a DVD including a step-by-step demonstration of the method is available for purchase,10 and instructional videos depicting the method are accessible on the internet. A schematic of the helium delivery apparatus is presented in Figure 1.9 Given the recent development, broad dissemination, and notable lethality of helium-assisted suicide, we endeavored to better understand characteristics of suicides by this method. First, we reviewed findings of extant studies examining suicides by asphyxiation due to helium inhalation. Second, we report new findings from the largest series of these suicides heretofore examined. Results of this investigation may lead to improved identification of helium-assisted suicides by medical examiners, enhanced screening and prevention efforts on the part of physicians and other professionals treating individuals at risk for suicide, and shed new light on unintended deleterious consequences of widespread dissemination of detailed suicide methods to the general public.

MATERIALS AND METHODS The current report presents findings from 2 related studies. The first is a review of published investigations of suicides by asphyxiation due to helium inhalation. The second is a case series of suicides by asphyxiation due to helium inhalation occurring in www.amjforensicmedicine.com


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Howard et al


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testing for all medical examiner cases in the state, blood samples are delivered to the NCOCME in standard collection vials. Immediately upon arrival, 5 mL of blood from the standard autopsy vial is transferred to a headspace vial for later analysis. Medical records associated with these deaths were manually reviewed and abstracted including the OCME Report of Investigation, State of North Carolina Death Certificate, Report of Autopsy, Toxicology Report, Case Encounter Form, Pathologist_s Notes, and Supplemental Report of Cause of Death. On January 5, 2010, the University of North Carolina Institutional Review Board determined that the reported research does not require Institutional Review Board approval under pertinent federal regulations. Characteristics of the 10 cases identified are presented in Table 2.

RESULTS Review of Published Cases

FIGURE 1. Schematic of plastic bag asphyxiation suicide using helium gas in final exit. Reprinted with permission from Final Exit: The Practicalities of Self-deliverance and Assisted Suicide for the Dying.9

North Carolina between 2000 (the year in which the method was first described) and December 31, 2008.

Identification of Published Reports A broad search of the general medical literature was undertaken for any relevant reports addressing suicide by asphyxiation due to helium inhalation. This process entailed searching the PubMed database for the period January 1, 1957 to November 1, 2009 using the search phrase Bsuicide and helium.[ Seven pertinent records were identified as follows: 6 English-language case studies11Y16 and a Danish-language case study.17 A search of EMBASE using the identical approach for the period January 1, 1988 to November 1, 2009 identified the same 7 reports. The 6 English-language reports relevant to this review were published between 2002 and 2007 and present a total of 14 cases.11Y16 The Danish study included a synoptic abstract in English indicating that the decedent was a 35-year-old man who had committed suicide with a plastic bag and helium using a Bnew and highly lethal technique.[17 The case reports included in this review constitute the entirety of published research on helium-assisted suicide and are presented in Table 1.

Identification of Suicides by Asphyxiation Due to Helium Inhalation in North Carolina All deaths determined by the North Carolina Office of the Chief Medical Examiner (NCOCME) to be asphyxial suicides due to helium inhalation that occurred between January 1, 2000 and December 31, 2008, were included in this study. These suicides were identified through a search of the manner and cause of death fields of the electronic records maintained by the NCOCME. The presence of helium was confirmed by toxicological testing in 9 of 10 identified cases. Only the first reported case (ie, 2001) was not subjected to toxicological testing for helium. Specimens from suspected helium asphyxiation cases autopsied at the NCOCME are collected in 20 mL headspace vials. In some cases, given that one central laboratory conducts

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The first death attributed to suicide by asphyxiation due to helium inhalation reported in the medical literature occurred in September 2000,11 shortly after the description of the method was published. Several investigators asserted that suicides by the helium method had not been seen in their localities prior to publication of the 2000 Supplement to Final Exit.11,12,15,16 The 14 decedents whose cases were presented in the 6 published reports ranged in age from 19 to 81 (M age = 50.0, SD = 21.8, median = 48.5). Between these extremes, decedents were approximately evenly divided between those in their 20s, 30s, 40s, 60s, and 70s. Medical and psychiatric histories were scant or entirely unreported for some cases, but revealed a history of depression, prior suicide attempt(s), paranoid schizophrenia, or some combination thereof in 4 (25.6%) cases. In 4 (25.6%) additional cases, psychiatric dysfunction may have contributed to the suicide, given that 3 of these decedents were determined to be in good health (ages 49, 49, and 76) and one mentioned the recent death of his wife as a reason for his suicide in a note left at the death scene. In 5 other cases (including 4 decedents in their 20s or 30s), no medical or psychiatric histories were reported. A terminal disease process was present in only 2 of 14 (14.3%) cases. In 2 (14.3%) additional cases involving men ages 71 and 78, Bfailing health[ and Bunspecified health problems[ were possible contributing factors. Medical disorders were not implicated in 10 of 14 (71.4%) suicides. In all reported cases, routine toxicological testing did not reveal the presence of helium and manner and cause of death determinations relied heavily on death scene investigations. Autopsy findings tended to be absent or nonspecific in the 12 cases that involved an autopsy. In 8 cases (57.1%), a suicide note was found, and in 4 cases (28.6%) right-to-die literature was found at the death scene. A number of helium delivery devices were employed. Five cases involved use of a mask; 4 of these cases were reported in 2002 or 2003, before plastic bag asphyxiation (without use of a mask) became preferred by advocates of the helium method.8 Characteristics of the plastic tubing used, use of rubber bands and Velcro straps to secure plastic bags to the neck, types of helium canisters employed, and use of multiple plastic bags in 1 case were consistent with published descriptions of heliumassisted suicide.8

Characteristics of Suicides by Asphyxiation due to Helium Inhalation in North Carolina Asphyxial suicides in North Carolina involving helium inhalation tended to occur almost exclusively in non-Hispanic, white men who were relatively young (M age, 41.1; SD, 11.6; * 2011 Lippincott Williams & Wilkins


Helium-Delivery Apparatus Death Scene

Toxicology Findings


Blood and urine tests were negative, but it was not clear what substances were assayed.

Negative for ethanol, medications, and illicit drugs for both decedents.



(Continued on next page)

External exam Toxicology tests not unremarkable except for performed due to decomposition. decomposition.

Not clear that an autopsy was conducted.

External exams unremarkable. Internal exams not performed per family_s wishes.

Remarkable only for early Unremarkable for both decompositional decedents. changes.

Does not appear an Blood/urine tests for autopsy was conducted. medications and It was noted at death psychoactive substances scene that decedent_s were negative. skin color was unremarkable and no external signs of poisoning were observed.

Autopsy Findings


Gilson et al (2003), Tucson, Arizona (continued)

Medical/Psychiatric History

History of depression Found with surgical mask Decedent discovered on and a prior suicide over face and clear living room floor of attempt. Unclear plastic bag over head. home with suicide whether depression/ Next to body was note and copy of her suicide attempt refillable industrial will. The book Final antedated carcinoma tank of helium. Clear Exit, Final Exit diagnosis. plastic tube led from videotape, and Spring plastic bag to helium 2000 Hemlock tank valve. society newsletter were found on a nearby coffee table. Cases 1 and 2: man, 49 No specific information Each decedent had 3 Couple found lying and woman, 48, who presented; decedents plastic bags over their supine by police on were common-law were reportedly in heads, which were floor of master married. good health. secured by elastic straps bedroom in their Motivation for around their necks. residence. Couples_ suicide unclear. attorney had called police after receiving a mailed suicide note. No right-to-die materials found. Cases 3 and 4: husband, Husband reportedly in Both decedents were Couple found dead in 78; wife, 76 Bfailing health[ and wearing filter bed by neighbor. Bdepressed[; wife in cartridge-style masks Suicide notes were Bgood health[ other attached to helium tanks found close to bodies. than a recent minor with plastic tubing. Notes referring to the elective surgery. Hemlock society were found in apartment. No other right-to-die materials found. Case 5: man, 81 Advanced squamous Plastic bag over head with Found by daughter in cell carcinoma of plastic tube running bed. Family unable throat, cachectic. from inside plastic bag to provide information to helium tank. as to whether Bright-to-die[ literature or suicide note were found at death scene. Case 6: man, 71 Decedent mentioned Plastic bag over head Found expired in chair in unspecified health secured with elastic living room of home problems and the band and Velcro strap by police. A suicide recent death of his at neck. Plastic tube note found, but no wife as principal from helium tank right-to-die literature. reasons for his connected to the mask suicide. inside plastic bag.

Woman, 60, white, suffering from adenoid cystic carcinoma with related eye involvement and diplopia. Death occurred 9/2000

Characteristics of Decedent

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Gilson et al (2003), Tucson, Arizona12

Ogden and Wooten (2002), South Carolina11

Authors/Date/ Location

TABLE 1. Published Case Reports of Suicides by Asphyxia Due to Helium Inhalation

Am J Forensic Med Pathol Suicide by Asphyxiation Due to Helium Inhalation

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Helium-Delivery Apparatus Death Scene

Medical history Plastic bag over head with Found dead in empty unknown; motivation plastic tube running bathtub of his for suicide unclear. from helium tank to apartment by landlord. bag with tube passing Right-to-die literature through a sink where and suicide note were warm water was not found. running. History of prior suicide Decedent wore air filter Decedent found supine attempts (number gas mask coated with a in backseat of car with and nature not substance similar to helium tank on floor described). No correction fluid. A and valve between description of helium tank obtained knees. Many signed medical history. Had from a local supply suicide notes and a searched methods company was attached page from the BChurch of suicide on the via clear plastic tubing of Euthanasia[ website internet. to the mask. Duct tape entitled BHow to kill sealed mask to skin yourself [ were left in of face covering nose an envelope on the and mouth. driver_s seat. A hand-written map to a local general store was also found in the envelope with a list including tubing, mask and duct tape. A letter was found in decedent_s residence describing where her body was located. No information A helium gas canister was Decedent was found dead presented. connected to a plastic in Blying[ position in bag with polypropylene unidentified location. tubing. The bag was A nearly empty bottle over the decedent_s head of tequila, blister pack and affixed to neck with of travel sickness a rubber band. medication, and pack of Ibuprofen tablets were found.

Medical/Psychiatric History Autopsy Findings

Toxicology Findings Remarkable only for ethanol (234 mg/dL) in decomposition fluid.

Nonspecific findings Routine tests revealed a included Ban aqueous BAC of 0.9 mg/g; swelling of the diphenhydramine in heart brain and of the lungs serum (0.81 Hg/mL) and and an acute hyperemia urine (2.2 Hg/mL). of the kidneys.[ No Ibuprofen found in urine evidence of severe and gastric content. illness or injury. A positive test for helium by novel assay method was reported.

Conjunctival petechial Routine toxicology hemorrhages bilaterally. unremarkable. Presents Nares and oral cavity a method by which contained frothy specimens can be collected white edema fluid. and analyzed for the R lung = 670 g; presence of helium. L lung = 620 g. Lungs congested with severe pulmonary edema. No evidence of trauma, injury, or explanation for death other than helium inhalation.

Unremarkable except for decompositional changes.

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Man, 23

Woman, 19, well-nourished

Case 7: man, 25



Auwaerter et al (2007), Freiburg, Germany14

Gallagher et al (2003), Indiana13

Authors/Date/ Location

TABLE 1. (Continued)

Howard et al Volume 32, Number 1, March 2011



Schon and Ketterer (2007), Bern, Switzerland16

Grassberger and Krauskopf (2007), Vienna, Austria15

History of paranoid schizophrenia; otherwise, no medical history reported.

Not reported

Not reported.

Not reported

Case 1: man, 28

Case 2: man, 39

Case 3: man, 39


Man, 64, white

Plastic bag over head connected via plastic tubing to a 10 L helium tank affixed to neck with rubber band. A gas canister labeled Bhelium[ was found on a table at side of room opposite from where body was found. The helium canister was not connected to the 17 L blue plastic garbage bag that was found over the decedent_s head. In addition to the plastic ribbon used to tie the bag, the decedent had inserted a rubber band into the bag_s collar. The bag was secured tightly around decedent_s neck. Decedent found expired in hotel room lying supine on bed with garbage bag over head. No alcohol bottles, medications or drug paraphernalia were found. A rental receipt for the helium canister was found, but no suicide note or self-help materials. An inquiry at the decedent_s home town revealed that another person in the area had committed suicide using the same method within the same week.

Decent found expired in his apartment reclining in a chair. Mouth contained frothy white edema fluid. A suicide note was left which named his mental illness as the primary reason for his suicide. No right-to-die literature found in domicile. Found expired in an empty bathtub wearing a plastic mask over face. Right-to-die literature and suicide note were found. Found supine on floor of his apartment with plastic bag over head. A suicide note was found. External/internal exams unremarkable except for advanced decompositional changes. No external injuries/ petechial hemorrhages found, except for a ligature mark impression attributed to a rubber band around neck. Nose, mouth, and airways filled with frothy reddish fluid. Lungs/brain edematous. Internal organs acutely congested. Pulmonary emphysema and hypertrophy/dilation of right atrium/ventricle noted. No other potential causes of death were identified.

Autopsy remarkable. only for early decompositional changes.

External exam unremarkable. Engorgement of right atrium and ventricle, pulmonary edema, and a few subpleural petchiae.

No obvious evidence of alcohol/ drug abuse, but no toxicology assays performed.

Negative except for traces of benzodiazepines in urine.

Tests of decomposition fluid identified a BAC of 1 mg/L.

Blood/urine tests for 6 classes of illicit drugs were negative. Not clear whether ethanol was assayed.

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Plastic tubing led from industrial helium tank into plastic mask.

Found with plastic bag over head sealed at neck with duct tape. A 10 L tank of party balloon helium was connected to the bag via plastic tubing. Am J Forensic Med Pathol Volume 32, Number 1, March 2011 Suicide by Asphyxiation Due to Helium Inhalation



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66

Man, 47, never-married, white (non-Hispanic) graduate school education

Man, 31, married, white (non-Hispanic), 13 yr of education

Man, 37, married, white (non-Hispanic); 16 yr of education

2003

2005


2001

Year of Death

Helium-Delivery Apparatus


Medical and psychiatric history and acute precipitants of suicide are unclear. Found with white plastic trash bag around head with tube hooked to helium tank valve at one end and the other end within the plastic bag. Tubing was connected to the helium tank with electrical tape. The bag was secured to neck with bag tie, which was knotted in a bow knot on right anterior neck. A clear vinyl plastic tube extended into the bag through a hole made in the rear of the bag space, held in place by black electrical tape.

Long history of Plastic bag over head, depression treated by secured with velcro tie his physician. Depression around neck. Plastic listed as a contributing tubing was taped to top cause of suicide. Little of head, extended down information available left arm under shirt sleeve about medical or and exited at left cuff. The psychiatric history tubing was connected to or acute precipitants a T-valve and attached of suicide. to 2 helium tanks. Suicide note mentioned Clear blue, thin plastic bag Bchronic pain[ as a over head secured with reason for suicide. 2 large yellow rubber However, medical and bands around neck. Clear psychiatric history are plastic tube taped to inside not known. of plastic bag, extending out of bag, looping around left arm and connected to helium tank.

Medical/Psychiatric History Autopsy Findings

Trace levels of 7-aminoclonazepam, and temazepam (0.016 mg/L) were identified in a 1 mL sample of vitreous humor.

Toxicology Exam Findings

Decedent found in his Pathological diagnosis: bilateral Two 8.0 mL aortic blood apartment. Had left a pulmonary congestion. No samples were positive suicide note describing significant external/internal for helium as was one how he planned the suicide. injuries. Lungs: R lung: 750 g; lung sample. No No medications found in L lung: 640 g. Parenchyma of ethanol detected in an apartment. both lungs show extensive 18.0 mL aortic blood congestion w/o obvious sample. consolidation or focal lesions. Brain: 1500 g. Leptomeninges thin, delicate and congested. Cerebral hemispheres unremarkable w/mild generalized edema w/o evidence of hermiation. Microscopic exams of lungs, kidneys, and brain show vascular congestion. No evidence of injury. Death occurred in motel. Pathological diagnoses: 10 mL aortic blood Decedent found supine pulmonary vascular congestion sample revealed trace in bed. Medications found and edema, slight diffuse levels of at scene were an OTC sleep cerebral swelling, moderate cyclobenzaprine and aid, Ibuprofen, and coronary atherosclerosis. propoxyphene and hydrocodone. Receipts R lung: 920 g; L lung 700 g. was positive from a local hardware store Lungs on section demonstrate (0.91 mg/L) for were found for helium marked vascular congestion diphenhydramine. tank, tubing, and tape No Bronchial branches contain and helium. suicide note or right-to-die clear fluid and intra-alveolar Diphenhydramine was materials were found. edema. Brain: 1500 g with believed to have mild diffuse swelling and contributed to the narrowing of sulci. No death. No ethanol or evidence of acute trauma. organic bases were identified.

Found in living room of his Early decompositional home by a co-worker and changes noted at death police. Two bottles of scene; no autopsy temazepam and a will and conducted. suicide note found at scene.

Death Scene Description

TABLE 2. Characteristic of Suicides by Asphyxiation Due to Helium Inhalation in North Carolina: 2000Y2008

Howard et al Am J Forensic Med Pathol

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History of symptoms, Plastic bag over head with treatment, and elastic strap securing bag hospitalization for around neck. An empty paranoia/suicidal helium canister found on ideation. Not clear floor beside decedent. whether patient suffered A cylinder of helium and from psychotic illness. plastic tubing were found in decedent_s bedroom closet.

Found in bedroom at parent_s Pathological diagnosis: Post-mortem exam home sitting in chair. The pulmonary vascular revealed an ethanol following medications congestion and edema, level of .40 mg/dL and were found in home: cerebral edema, and early the presence of helium Trazodone (100 mg), decompositional changes. in 15.0 mL and 5.0 mL Geodon (80 mg), Risperdal R lung: 640 g; L lung: aortic blood samples, (3 mg), Trileptal (300 mg), 590 g Brain: 1,500 g, respectively. and Zoloft (50 mg). microscopic lung sections show variable degrees of pulmonary vascular congestion and intra-alveolar hemorrhage. 2005 Man, 39, never married, No history of suicide Found with plastic bag over Found lying supine in bed Final anatomic diagnosis: Positive for helium in white (non-Hispanic), attempts per family. Little head secured with a metal at home by mother. No congestion of lungs with 4.0 mL subclavian 12 yr of education information available clip to hold bag tight around suicide note left, but early pulmonary edema. vessel blood sample, about medical or neck. Plastic tubing ran insurance policy and will Brain: 1,325 g. Vessels over but negative for psychiatric history and from a nearby helium tank to were found on coffee table. right hemisphere congested. ethanol in 17.0 mL acute precipitants the back of the plastic bag. R lung: 610 g; L lung: subclavian blood of suicide. Duct tape covered front of 560 g Lungs boggy with sample. bag and had 0.5 cm circular congestion. Microscopic hole in it. Tube was sections show that alveolar connected to helium tank, spaces were partially filed which was turned on and with clear edema fluid. near decedent_s hand. 2005 Man, 34, unmarried, History of alcohol Had clear plastic bag over head Found dead in driver_s seat Pathological diagnoses: 20.0 mL and 6.0 mL white (non-Hispanic); dependence and bipolar with tubing connecting it to a of a car parked in the yard pulmonary edema and vascular aortic blood samples 9 yr of education disorder. Prior psychiatric helium tank. A velcro closure of a relative_s house. A congestion; atherosclerotic were positive for treatment for both secured the bag around neck. picture of his girlfriend coronary artery disease, focal, ethanol (70 mg/dL) disorders. Was living in was found on dashboard. mild to moderate. R lung: and helium, respectively. car and taking Zoloft. 960 g; L lung 820 g. Lungs Ethanol was listed heavy and congested. Lung as a contributing sections revealed areas of cause of suicide. atelectasis, pulmonary edema, and collections of pigment-laden intra-alveolar macrophages. 2006 Woman, 60, never married Obese (5’9[, 303 lbs). No Decedent had clear plastic bag Decedent found in front Pathological diagnoses: Plastic A 20-mL-blood sample white (non-Hispanic), medical or psychiatric over head with 2 inch plastic passenger seat of car in bag over head with evidence from pleural cavity 12 yr of education history information tubing attached to helium motel parking lot where of helium inhalation; was positive for helium available except that EKG tank in back car seat and she had stayed. Letters to pulmonary vascular congestion and ethanol (40 mg/dl). leads were found on right inside of plastic bag. A tan different people and (R lung: 430 g; L lung: 400 g); Elevated BAC may have lower leg, left lower leg elastic band was used to Ba very organized[ suicide decomposition. Sectioned been partially or totally and left arm. No acute secure bag to neck. The note were found in car. lungs showed vascular due to decomposition. precipitants of suicide plastic tubing was taped to Note referred to pgs. congestion with patchy were identified. lower margin of plastic bag. 132Y137 in Final Exit 3rd intra-alveolar edema. No edition which describe evidence of acute trauma. helium-assisted suicide. Decedent had set e-mail to respond to messages with BReturn to Sender due to Suicide.[ (Continued on next page)

2005 Man, 21, never married, white (non-Hispanic) 12 yr of education


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Man, 45, never married, white (non-Hispanic)

Man, 56, married, white (non-Hispanic), 12 yr of education

2007

2008

Helium-Delivery Apparatus Death Scene Description

Autopsy Findings

Toxicology Exam Findings

Previously disabled in Clear blue plastic bag covered Found expired at home sitting No autopsy. A 13.0 mL subclavian motor vehicle accident head and was wrapped with in chair in basement. No blood sample was with neck and back duct tape. Black tubing was suicide note left. negative for ethanol, injuries. Was reportedly connected at one end to the but positive for helium. depressed due to recent inside of bag and at the separation from wife and other end to a 65 lb helium pending sale of home. tank used to fill balloons Wife reported that for parties. decedent was taking prescribed antidepressants, Neurontin, Oxycontin, and Vicodin. History of alcohol and drug Clear plastic bag was found Found sitting in chair in No autopsy, but blue nail beds 19.0 mL subclavian abuse and diabetes. over head. Two black tubes parent_s home. Patient was and burst capillaries in lower blood sample was Decedent has been very led from helium tank into the pulseless and not legs bilaterally were observed negative for ethanol depressed per family_s plastic bag. Had purchased breathing. The book Final at death scene. and positive for helium. report. Family noted these materials at local Exit was lying open and a history of social, hardware store. The helium face down on the bed. medical and emotional tank was from a party store A suicide note was left problems. Was taking balloon-filling kit. describing how severely Coumadin, Clonidine, depressed the decedent had Aspirin, Verapamil, felt and apologizing for Atenolol, and Lovastatin. the suicide. History of depression and Decedent had a bag over his Found in car in garage at No autopsy. 18.0 mL subclavian blood substance abuse. head with a tube attached home by wife with car sample was positive for to it and to a helium tank running and exhaust piped helium and negative for positioned on car into the vehicle. A suicide ethanol. Carbon passenger seat. note was found. monoxide detected at G5.0% saturation.

Medical/Psychiatric History



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OTC indicates over-the-counter; BAC, blood alcohol concentration; EKG, electrocardiogram.

Man, 41, married (but recently separated from wife), white (non-Hispanic), 14 yr of education


2007

Year of Death

TABLE 2. (Continued)

Howard et al Volume 32, Number 1, March 2011




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Suicide by Asphyxiation Due to Helium Inhalation

range, 21Y60; median, 40.0). In 6 of 10 cases, decedents suffered from significant psychiatric dysfunction; in 3 of these 6 cases, psychiatric problems were present comorbidly with substance abuse. Medical histories identified chronic pain, disability, and chronic pain associated with injuries suffered in a motor vehicle accident, and diabetes (with probable coronary artery disease in 3 decedents). One decedent was found with electrocardiogram leads attached to her body, but autopsy and toxicological findings were negative for potential explanations for the death other than helium-assisted suicide. In none of the 10 cases were decedents suffering from terminal illness. Helium delivery devices were consistent with those recommended in Final Exit (eg, use of T-valves, 2 helium tanks, Velcro and other neck fasteners), and all were associated with use of a plastic bag rather than mask.8 In 5 cases, a suicide note was found; in 2 cases, a will was left; in 1 case, insurance papers were left; and in 2 cases, right-to-die materials were found. Autopsies were performed in a majority of cases and typically revealed evidence of pulmonary vascular congestion and mild cerebral edema. Ethanol and diphenhydramine were considered contributing causes of death in 1 case each.

Of particular concern, are recent national reports of notable increases in the prevalence of suicide due to suffocation (a category that includes deaths by plastic bag asphyxiation with or without helium assistance as well as hanging and strangulation) since the 1990s and especially since 2000.25Y27 Such increases have been observed in respondents of widely varying ages, including adolescents, and both genders. Observers have noted that the reasons for these increases are poorly understood, that declining rates of suicide observed in the 1990s have been largely reversed, and that recent increases in suicides due to suffocation account for most of the recent overall increases in rates of suicide.28 It is possible that greater awareness of the plastic bag asphyxiation method and the enhanced lethality of the method when used with helium may account for the significant increases in suicides due to suffocation reported since 2000. Given the national growth in adolescent, young adult, and adult suffocation suicides since 2000,25,26 and relatively young age, psychiatric dysfunction, and absence of terminal illness characteristic of many identified cases, it is possible that many persons committing suicide by the helium method are neither hopelessly nor terminally ill, but rather psychiatrically disordered. Although the author of Final Exit cautions readers to be certain they are hopelessly ill, and not just depressed and to talk to their doctor,8 depressive illness and substance dependency often impair the very capacities required to make these assessments and undertake these actions. Prospective studies are needed to better understand the prevalence, incidence, predictors, and characteristics of asphyxial suicides due to helium inhalation. It is important to learn more about decedents_ medical and psychiatric histories and the circumstances in which depressed and/or suicidal persons encounter descriptions of the helium method (eg, internet demonstrations of the process). At present, professionals working with persons at risk for suicide should routinely assess whether patients have read or viewed instructional materials describing specific methods of suicide such as helium-assisted plastic bag asphyxiation. Inquiries of this nature do not increase subsequent risk for suicide and can provide critically important information to guide appropriate preventative actions where indicated.29,30 Medical examiners should also increase their index of suspicion for suicides by asphyxiation associated with helium inhalation. Medical ethicists and the general public may also want to carefully weigh the unintended adverse consequences of widely disseminated suicide methods likely to appeal to some depressed persons (irrespective of their physical health status or age) against the putative benefits associated with making these methods more widely known and available.

DISCUSSION Despite reports identifying a plethora of prosuicide internet sites providing detailed instructions in methods of suicide including helium-assisted asphyxiation,18 media accounts of heliumassisted suicides,19Y21 and the recent arrests of Final Exit Network members for allegedly assisting in asphyxial suicides involving helium,22 scientific investigations of such suicides are largely absent from the medical literature. This dearth of information is unfortunate given the tragic consequences of such acts and because it is possible that suicides by the helium method are underestimated and increasingly common for reasons described later in the text. The methods by which helium-assisted suicides are carried out have been carefully detailed and widely publicized and the approach is promoted as simple, painless, and quick.8 Materials needed for helium-assisted suicides are easily obtained and inexpensive. One well-known internet vendor currently sells disposable helium tanks for less than $50, and reports that customers who bought helium tanks also often bought the book Final Exit.23 Unless there is a high index of suspicion for helium involvement in a death, the death may be erroneously attributed to natural causes or underlying illness because standard toxicological assays are unlikely to detect helium and autopsy findings are generally nonspecific.14,16 Standard toxicological assays using GC/MS employ helium as the carrier gas and therefore cannot detect helium unless another gas (eg, nitrogen) is substituted for the helium. Auwaeter et al14 and Gallagher et al13 developed useful methods of collecting, preserving, and analyzing gas samples taken from decedents_ for qualitative detection of helium. In all North Carolina cases, helium-delivery devices were found at the death scene, and toxicological testing was conducted in 9 of 10 cases. However, it is possible that an unknown number of such suicides went undetected, if and when helium-delivery devices and plastic bags were removed from the death scene prior to investigation. The author of Final Exit states that a person may choose to leave right-to-die materials to be found to make an ethical statement that they are committing Brational suicide[ or, conversely, make plans to have the helium delivery apparatus and plastic bag removed following their death if they prefer to keep the suicidal nature of the death concealed.8 Toxicological testing for helium has been conducted at the NCOCME in suspected cases since 2003 by a novel testing procedure using a dual cell thermal conductivity detector.24 * 2011 Lippincott Williams & Wilkins

ACKNOWLEDGMENTS The authors thank P. Barnes, Administrative Services Manager, and other staff of the North Carolina Office of the Chief Medical Examiner for their assistance. REFERENCES 1. Humphry D. Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying. New York, NY: Delta; 1991. 2. Cote R. In Search of Gentle Death: A Brief History of the NuTech Group. Mt. Pleasant, SC: Corinthian; 2008. 3. The most memorable books of the last 25 years: 25 books that leave a legacy. April 9, 2007. Available at: http://www.usatoday.com/ life/top25-books.htm. Accessed November 6, 2009. 4. Sacks MH, Kemperman I. Final exit as a manual for suicide in depressed patients. Am J Psychiatry. 1992;149:842.



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5. Marzuk PM, Tardiff K, Hirsch CS, et al. Increase in suicide by asphyxiation in New York City after the publication of final exit. N Engl J Med. 1993;329:1508Y1510. 6. Marzuk PM, Tardiff K, Leon AC. Increase in fatal suicidal poisonings and suffocations in the year final exit was published. Am J Psychiatry.1994;151:1813Y1814. 7. Humphry D. Supplement to Final Exit: The Latest How-to and Why of Euthanasia/Hastened Death. Junction City, OR: Norris Lane and ERGO; 2000. 8. Humphry D. Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying. 3rd ed. New York, NY: Delta; 2002. 9. Humphry D. Final Exit: The Practicalities of Self-deliverance and Assisted Suicide for the Dying. 3rd ed. Addendum. Junction City, OR: ERGO; 2009.


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19. Tyson AS. Military investigates West Point suicides. Washington Post. January 30, 2009. 20. Ward D. Helium in an Bexit bag[ new choice for suicide: at least 19 people in B.C. have used method since 1999. Vancouver Sun. December 8, 2007. 21. Lam A. Asian Americans_ rising suicide ratesVthree students take their lives. New American Media. August 13, 2009. 22. Bowers P. Final exit: compassion or assisted suicide? Time. March 2, 2009. 23. Disposable helium tank for sale at Amazon.com. Available at: http://wwsw.amazon.com/BuyCostumes-Disposable-Helium-Tank/dp/ B000WR8QQG/ref=pd_sbs_hpc_3. Accessed November 6, 2009. 24. Poklis JL, Garside D, Gaffney-Kraft M, et al. A qualitative method for the detection of helium in postmortem blood and tissues. In: Proceedings from the Society of Forensic Toxicologists; October 17Y21. 2005; Nashville, TN.

10. Humphry D. Final Exit on DVD: The Art of Self-deliverance From a Terminal Illness. Junction City, OR: ERGO; 2006. ISBN: 978Y0Y9768283Y0Y3.

25. Lubell KM, Swahn MH, Crosby AE, et al. Methods of suicide among persons aged 10Y19 yearsVUnited States, 1992Y2001. MMWR Morb Mortal Weekly Rep. 2004;53:471Y474.

11. Ogden RD, Wooten RH. Asphyxial suicide with helium and a plastic bag. Am J Forensic Med Pathol. 2002;23:234Y237.

26. Lubell KM, Kegler SR, Crosby AE, et al. Suicide trends among youths and young adults aged 10Y24 yearsVUnited States, 1990Y2004. MMWR Morb Mortal Weekly Rep. 2007;56:905Y908.

12. Gilson T, Parks BO, Porterfield CM. Suicide with inert gases: Addendum to Final Exit. Am J Forensic Med Pathol. 2003;24:306Y308. 13. Gallagher KE, Smith DM, Mellen PF. Suicidal asphyxiation by using pure helium gas: case report, review, and discussion of the influence of the internet. Am J Forensic Med Pathol. 2003;24:361Y363. 14. Auwaeter V, Perdekamp MG, Kempf J, et al. Toxicological analysis after asphyxial suicide with helium and a plastic bag. Forensic Sci Int. 2007;170:139Y141. 15. Grassberger M, Krauskopf A. Suicidal asphyxiation with helium: Report of three cases. Wien Klin Wochenschr. 2007;119:323Y325. 16. Schon CA, Ketterer T. Asphyxial suicide by inhalation of helium inside a plastic bag. Am J Forensic Med Pathol. 2007;28:364Y367. 17. Barnung SK, Feddersen C. Suicide by inhaling helium inside a plastic bag [in Danish]. Ugeskr Laeger. 2004;166:3506Y3507. 18. Recupero PR, Harms SE, Noble JM. Googling suicide: suicide information on the internet. J Clin Psychiatry. 2008;69:878Y888.

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27. Hu G, Wilcox HC, Wissow L, et al. Midlife-suicide: an increasing problem in U.S. Whites, 1999Y2005. Am J Prev Med. 2008;35:589Y593. 28. Barber C. Trends and rates in methods of suicide: United States, 1985Y2004. Harvard Injury Control Research Center ([email protected]). Report based on data from the Web-based Injury Statistics and Reporting System (WISQARS), National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, U.S. Vital Statistics. Available at: http://www.cdc.gov/ncipc/wisqars. 29. Gould MS, Marrocco FA, Kleinman MS, et al. Evaluating iatrogenic risk of youth suicide screening programs: a randomized controlled trial. JAMA. 2005;293:1635Y1643. 30. American Psychiatric Association. Practice guidelines for the assessment and treatment of patients with suicidal behaviors. In: Practice Guidelines for the Treatment of Psychiatric Disorders Compendium. 2nd ed. Arlington, VA: American Psychiatric Association; 2004:835Y1027.



ORIGINAL ARTICLE

Fatal Cocaine Interactions A Review of Cocaine-Related Deaths in Bexar County, Texas D. Kimberley Molina, MD and Veronica M. Hargrove, MS Abstract: Although cocaine is a widely abused illicit substance that is known to cause death, deaths due to its use appear to occur in a minority of those who use it. This report was designed to review drug-related deaths due to cocaine, and the concomitant use of other drugs/ medications. A retrospective review of drug deaths at the Bexar County Medical Examiner_s Office in San Antonio, Texas, was undertaken for cases where cocaine was one of the drugs implicated in causing death. Analysis was performed comparing the concentrations of cocaine and benzoylecgonine present and the absence or presence of other drugs. The data obtained showed that cocaine was toxic over a large range with deaths occurring at concentrations ranging from 0.01 to 78 mg/L. Analyses also indicated an increased lethality when cocaine is used in combination with ethanol, heroin, opiates, and antidepressant/antipsychotic medications, which is consistent with previous reports and research. Antihistamine data showed that there may be relationship between increased toxicity and coingestion, although more research is necessary. Key Words: cocaine, toxicity, death, ethanol, antidepressant, antipsychotic, opiate, narcotic, heroin, antihistamine (Am J Forensic Med Pathol 2011;32: 71Y77)

T

he effects of cocaine are well known throughout the medical and lay community, including the possibility that the use of cocaine can result in death. Cocaine is derived from Erythroxylon coca, a plant indigenous to South America, Mexico, and the West Indies. Historically, it was used for religious and ceremonial purposes and anesthesia, as well as being an additive in several beverages, including wines and Coca Cola. Today, the leaves are still chewed by South and Central Americans to help alleviate altitude sickness and to increase physical endurance. The United States first began to regulate cocaine use in 1906 with the passage of the Pure Food and Drug Act. Cocaine is a potent central nervous system (CNS) stimulant. It inhibits the reuptake of norepinephrine and epinephrine and increases the release of norepinephrine from adrenergic nerve terminals.1 Within the CNS, cocaine inhibits dopamine and serotonin reuptake resulting in the euphoria, or Bhigh,[ perceived by cocaine users. Cocaine also increases aspartate and glutamate within the brain, resulting in increased extracellular dopamine concentration.1 In addition to the CNS, cocaine can affect the cardiovascular system. The sympathomimetic properties of cocaine result in tachycardia, hypertension, and vasoconstriction that may lead to cardiac and/or cerebral ischemia. Cocaine also acts upon the cardiac sodium channels resulting in prolongation of the QT interval. Clinical signs and symptoms of cocaine use include hyperthermia, anxiety, agitation, vasoconstriction, tachycardia, hyperManuscript received July 21, 2009; accepted July 28, 2009. From the Bexar County Medical Examiner’s Office, San Antonio, TX. Reprints: D. Kimberley Molina, MD, Bexar County Medical Examiner’s Office, 7337 Louis Pasteur, San Antonio, TX 78229. E-mail: kmolina@ co.bexar.tx.us. Copyright * 2011 by Lippincott Williams & Wilkins ISSN: 0195-7910/11/3201Y0071 DOI: 10.1097/PAF.0b013e3181ed79fe


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tension, platelet aggregation, and cardiac dysrhythmias. Cocaine use has been shown to cause death resulting from seizures (convulsions), cerebrovascular accidents (strokes), myocardial infarctions (heart attacks), cardiac dysrhythmias (abnormal heart beats), and respiratory arrest. In 2007, approximately 2.3% of the US population reported to having used cocaine at least once in the past year, corresponding to 6.9 million people.2 Accurate national statistics regarding cocaine-related deaths are not kept; however, in San Antonio, Texas (population 1.1 million), during the same period (2007) there were approximately 60 deaths due to drug intoxications involving cocaine. By extrapolating the national data of cocaine use, one can hypothesize that approximately 25,300 people used cocaine at least once in San Antonio, Texas, in 2007 and, of those, 60 people died, or approximately 0.002%. While these statistics are simply estimates and do not reflect actual events, they do highlight the well-known reality that a small percentage of people who use cocaine actually die of that use. Medical examiners know that deaths due to cocaine can occur in people who chronically use cocaine as well as in people who have never used before; thus, the questions become: Is there a way to predict the lethality of cocaine? Is there a dose relationship? Could drugs taken concurrently with cocaine increase or decrease toxicity and lethality? This study was designed to provide further information regarding these theories and to examine the pharmacologic principles behind them.

MATERIALS AND METHODS A database review was performed to identify all cases of drug-related deaths at the Bexar County Medical Examiner_s Office in San Antonio, Texas, for a 16-year period beginning from January 1, 1993 and ending on December 31, 2005, in which cocaine was one of the drugs implicated in causing death. At the time of examination, a full toxicology panel was performed on all cases including screens for opiate/opioid, cocaine, alcohol, alkaline, and acid/neutral drugs. The cocaine and opiate screens were performed by fluorescence polarization immunoassay. All positive samples were then extracted by solid phase extraction, confirmed, and quantitated by gas chromatography (GC) paired with mass spectrophotometry. The alcohol quantitation was performed by direct injection method and analyzed by GC/flame ionization detector (FID). All samples positive for ethanol were confirmed by fluorescence polarization immunoassay. The alkaline and acid/neutral drug screens were performed using a liquid-liquid extraction, quantitated by GC/ FID, and confirmed by GC/mass spectrophotometry. The complete toxicologic data for the cocaine-related deaths was compiled and analyzed for cocaine and benzoylecgonine (BE) concentrations and the presence of additional drugs including ethanol. Additional drugs were combined into the following subgroups: ethanol, heroin, opiate medications, anxiolytics, antihistamines, cannabinoids, antidepressant/antipsychotic medications, inhalants, sympathomimetics, anticonvulsants, cardiac medications, and other. www.amjforensicmedicine.com


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The data were analyzed for pure cocaine deaths (only cocaine present), cocaine plus 1 additional drug, and cocaine plus multiple additional drugs. Statistical analysis was performed using a Mann-Whitney, 1- and 2-tailed U tests. Because of the nonparametric nature of the data, medians and ranges are reported rather than means and standard deviations.

RESULTS A total of 461 cocaine-related deaths were identified during the study period. The average age of the decedents was 35.3 years, ranging from 15 to 73 years. Men accounted for the majority of the cases (78.5%), whereas women accounted for 21.5%. The median concentration of cocaine in all deaths was 0.19 mg/L with a median BE concentration of 1.5 mg/L. For men, the median concentrations for cocaine and BE were 0.19 mg/L and 2.0 mg/L, respectively, and were 0.19 mg/L and 1.4 mg/L, respectively, for women. There was not a significant difference in the concentrations of cocaine or BE between men and women (P 9 0.05; Mann-Whitney U test). Cocaine was most commonly used in conjunction with ethanol (42% of cases had ethanol present) followed by opiate/opioid medications, which were present in 29% of cases. Heroin and antipsychotic/antidepressant medications were present in 13% and 12% of cases, respectively. Anxiolytic medications (benzodiazepines, barbiturates, etc) and antihistamines were found in 9% and 7% of cases, respectively. The remaining medications were found in less than 5% of the cases. The data are summarized in Table 1. Of the 461 cocaine-related deaths, 143 (31%) were purely due to cocaine (no other drugs were present), 146 (32%) were due to cocaine plus 1 additional drug, and 172 (37%) were due to cocaine plus more than 1 drug (Table 2).

Cocaine Only The concentrations of cocaine and BE in cocaine only deaths were nonparametric in distribution with the curve being skewed to the right. The median cocaine and BE concentrations were 0.89 mg/L and 4.0 mg/L, respectively, with a first quartile limit of 0.19 mg/L for cocaine and 1.3 mg/L for BE and a third quartile limit of 3.8 mg/L for cocaine and 7 mg/L for BE. The concentration of cocaine in cocaine-only deaths ranged from 0.01 to 78 mg/L with BE concentrations ranging from 0.02 to 90 mg/L.

TABLE 1. Summary of Occurrence of All Categories of Drugs Drug/Drug Class

No. Cases With Drug Present (% of Total)

Ethanol Opiate/opioid medications Heroin Antipsychotics/antidepressants Anxiolytics Antihistamines Dextromethorphan Sympathomimetics Cardiac medications Cannabinoids Anticonvulsants Inhalants Isopropanol

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194 (42%) 135 (29%) 61 (13%) 56 (12%) 42 (9%) 31 (7%) 11 (2%) 8 (2%) 7 (2%) 2 (G1%) 2 (G1%) 1 (G1%) 1 (G1%)

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TABLE 2. Percentage of Cases With Drugs Present No. Cases With Drug Present (% of Total)

Number of Drugs Present Cocaine only Cocaine plus 1 additional drug Cocaine plus more than 1 drug

143 (31%) 146 (32%) 172 (37%)

One Drug/Drug Class Plus Cocaine Of the 146 deaths where only 1 other drug was present in addition to the cocaine, the majority occurred with ethanol (49.3%), followed by opiate/opioid medications (28.8%), antipsychotic/antidepressant medications (6.8%), heroin (5.6%), and antihistamines (4.8%) with anxiolytics, cardiac medications, anticonvulsant medications, sympathomimetics, and dextromethorphan accounting for the remaining cases (4.8%). No deaths occurred with cocaine and cannabinoids alone or with cocaine and inhalants alone. The data are summarized in Table 3. Analyses were performed comparing the concentrations of cocaine and BE of the only cocaine group with those where only 1 additional drug was present. Because of small sample sizes, comparison could not be made between the only cocaine group and the cardiac, anxiolytic, anticonvulsant, sympathomimetic, and dextromethorphan groups. The remaining analyses are summarized later. All groups showed a nonparametric distribution (rightward skew) of the data.

Ethanol Cases which had cocaine and ethanol only present had a median cocaine concentration of 0.35 mg/L and a median BE concentration of 1.5 mg/L. The concentration of cocaine was lower in the cocaine plus ethanol group than in the cocaine-only group, but this difference did not reach statistical significance (P = 0.197). The concentration of BE was lower in the cocaine plus ethanol group at a statistically significant level (P = 0.0001).

Heroin and Opiate/Opioid Medications Cases which had only cocaine and opiate/opioid medications present had a median cocaine concentration of 0.08 mg/L and a median BE concentration of 1.4 mg/L. Cases which had only cocaine and heroin present had a median cocaine concentration of 0.12 mg/L and a median BE concentration of 1.0 mg/L. Analysis showed statistically significant lower concentrations of cocaine in the heroin and opiate/opioid groups when compared with the pure cocaine group (P = 0.006 and P G 0.0001, respectively) as well as statistically significant lower concentrations of BE (P = 0.004 and P G 0.0001, respectively). The opiate/ opioid medication group included morphine, oxycodone, methadone, hydrocodone, propoxyphene, and tramadol.

Antipsychotic/Antidepressant The antipsychotic/antidepressant group included cases with citalopram, fluoxetine, amitriptyline, nortriptyline, desipramine, thioridazine, imipramine, and sertraline present in addition to the cocaine. Cases which had only cocaine and an antipsychotic/ antidepressant medication present had a median cocaine concentration of 0.17 mg/L and a median BE concentration of 1.1 mg/L. The concentration of cocaine was less in the antipsychotic/ antidepressant group when compared with the cocaine-only group, but this difference failed to reach a level of statistical significance (P = 0.2). The concentration of BE was also found to be less when compared with the cocaine-only group, and this difference did reach significance (P = 0.03). * 2011 Lippincott Williams & Wilkins



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Fatal Cocaine Interactions

TABLE 3. Summary of Deaths Due to Cocaine Plus 1 Additional Drug/Drug Type Additional Drug/Drug Type

No. Cases

Median Cocaine Concentrations (Range mg/L)

Median BE Concentrations (Range mg/L)

Cocaine only Ethanol Opiate Heroin Antipsychotics/antidepressants Antihistamines Anxiolytics Anticonvulsants Sympathomimetics Cardiac medication Dextromethorphan

143 72 42 8 10 7 3 1 1 1 1

0.89 mg/L (0.01Y78) 0.35 mg/L (0.01Y82) 0.08 mg/L (0.01Y3.7) 0.12 mg/L (0.01Y0.83) 0.17 mg/L (0.03Y4.1) 0.33 mg/1L (0.03Y0.99) 0.06 mg/L (0.01Y0.11) 4.7 mg/L 0.91 mg/L 0.11 mg/L 0.48 mg/L

4.0 mg/L (0.02Y90) 1.5 mg/L (0.02Y24) 1.4 mg/L (0.03Y6.2) 1.0 mg/L (0.02Y3.7) 1.1 mg/L (0.29Y7.9) 2.4 mg/L (0.61Y3.8) 1.5 mg/L (0.23Y2.8) 3.7 mg/L 2.9 mg/L 1.2 mg/L 5.2 mg/L

BE indicates benzoylecgonine.

Antihistamines The antihistamine group included cases where diphenhydramine, doxylamine, hydroxyzine, and promethazine were present in addition to cocaine. Cases which had only cocaine and an antihistamine medication present had a median cocaine concentration of 0.33 mg/L and a median BE concentration of 2.4 mg/L. The concentration of cocaine was less in the antihistamine group when compared with the cocaine-only group, but this difference failed to reach a level of statistical significance (P = 0.1). The concentration of BE was also found to be less when compared with the cocaine-only group, and this difference did reach significance (P = 0.0002).

Multiple Drugs/Drug Classes Plus Cocaine In 172 (37%) cases, more than 1 drug was present in addition to cocaine. Although most of these combinations were present in only a small number of cases (less than 10), 2 combinations accounted for 42% of the 172 cases. These combinations were cocaine plus ethanol and opiate/opioid medications and cocaine plus ethanol and heroin.

ethanol groups (P G 0.001). When comparing the cocaine concentrations between the cocaine, ethanol, and opiate/opioid group and the cocaine plus opiate/opioid group, no significant difference was present, though the BE concentration was significantly lower in the former group than the later (P = 0.002).

Cocaine Plus Ethanol and Heroin Cases which had cocaine, ethanol, and heroin present had a median cocaine concentration of 0.09 mg/L and a median BE concentration of 0.42 mg/L (Table 4). Statistical comparison of the cocaine and BE concentrations was made between the cocaine plus ethanol and heroin group and the cocaine only, cocaine plus ethanol, and cocaine plus heroin groups. This analysis showed significantly lower cocaine and BE concentrations between the cocaine, ethanol, and heroin group and the cocaine-only and the cocaine plus ethanol groups (P G 0.001). When comparing the cocaine and BE concentrations between the cocaine, ethanol, and heroin group and the cocaine plus heroin group, a significant difference was not found.

DISCUSSION

Cocaine Plus Ethanol and Opiate/Opioid Medications

Dose Effect

Cases which had cocaine, ethanol, and opiate/opioid medications present had a median cocaine concentration of 0.08 mg/ L and a median BE concentration of 0.48 mg/L (Table 4). Statistical comparison of the cocaine and BE concentrations was made between the cocaine plus ethanol and opiate/opioid group and the cocaine-only, cocaine plus ethanol, and cocaine plus opiate/opioid groups. This analysis showed significantly lower cocaine and BE concentrations between the cocaine and ethanol/ opiate/opioid group and the cocaine-only and the cocaine plus

Data from this study show a nonparametric distribution of cocaine concentrations in deaths due purely to cocaine intoxication with a range from 0.01 to 78 mg/L. In this study, 50% of deaths occurred at concentrations less than 0.89 mg/L and 75% at concentrations less than 4 mg/L. Because a good majority of deaths occurred at lower concentrations, one might conclude that dose, or at least concentration, does not relate to toxicity. The issue of proving a dose relationship with cocaine is complex. Although a lethal dose 50 for cocaine in laboratory animals has

TABLE 4. Cocaine and BE Concentrations in Deaths Due to Cocaine, Ethanol and Heroin, and Cocaine Ethanol and Narcotic Medications Drug/Drug Type Combination Cocaine, ethanol, and heroin Cocaine, ethanol, and opiates/opioids

No. Cases

Median Cocaine Concentrations (Range mg/L)

Median BE Concentrations (Range mg/L)

39 39

0.09 mg/L (0.01Y7.6) 0.08 mg/L (0.01Y3.8)

0.42 mg/L (0.03Y13) 0.48 mg/L (0.06Y16)

BE indicates benzoylecgonine.




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been described, human studies are difficult to perform. Bertol et al, in their study looking at cocaine-related deaths, found that the concentrations of cocaine and BE in cocaine-related deaths were significantly increased when compared with deaths where cocaine was present but not causative of death,3 whereas Karch et al found no such difference when comparing similar populations.4 Blaho et al developed a Stimulant Intoxication Scale (SIS) to quantify the signs and symptoms of cocaine intoxication to assess the relationship between cocaine toxicity and cocaine concentration.5 They failed to find a statistically significant relationship between the SIS score and the cocaine and/or cocaine metabolite concentrations nor any element of the SIS and the cocaine/metabolite concentrations.5 Proving a causal dose relationship in humans would require that both the dose of cocaine and the concentration be known entities, both of which are difficult to ascertain. Cocaine used as a recreational drug is not a regulated product, and there are no standardized quality control procedures in place regarding its production. Each manufacturer, each batch, each day may result different purities of cocaine resulting in the same amount (weight) of cocaine equating to a different dose of cocaine. Obtaining an accurate postmortem cocaine concentration is also difficult as cocaine is metabolized both in vivo and in vitro. Most medical examiner_s offices use sodium fluoride as a preservative to minimize the in vitro component; however, antemortem samples are often used which are not always preserved appropriately. In addition, metabolism can also occur after death but before the collection and preservation of blood. Thus, the cocaine concentrations at the time of death may have been greater than the toxicology results report. The route of administration of cocaine may also play a role in its concentration and toxicity since metabolism can be affected depending upon whether the drug was injected, ingested, inhaled, or insufflated. The variable of tolerance, whether an individual is a chronic or naive user, must be considered. Chronic cocaine use can cause physiologic changes in the heart as well as other organs, which cause a person to be more susceptible to the physiologic effects of cocaine. For instance, chronic cocaine use can lead to cardiac hypertrophy (enlargement), which is an independent risk factor for developing an arrhythmia; a risk that would be further increased by repetitive cocaine use, which also causes dysrhythmias. The presence or absence of other natural diseases, may also affect how one responds to cocaine. Blaho et al further argue that it is impossible to obtain reliable information from the users regarding all of these variables,5 making definitive analysis a nonviable possibility.

found lower concentrations of cocaine in the ethanol positive group, but the results were not statistically significant.6 Several other studies have shown that ethanol and cocaine act synergistically to increase hepatotoxicity, cardiotoxicity, and neurotoxicity.7Y11 Busse and Riley studied the effects of cocaine and ethanol in rats and found that with repetitive dosing, ethanol increased the lethality of cocaine intoxicated rats; although the same was not found after a single dose of each.12 They hypothesize that the creation of cocaethylene, a toxic metabolite produced only in the presence of cocaine and ethanol, was the cause of the increased toxicity.12 However, Blaho et al, in their study of emergency room visits for cocaine use, found no relationship between cocaethylene and cocaine-related symptoms or severity.5 Laizure et al found that in rats pretreated with ethanol the cocaine clearance was decreased, which may explain some of the increased toxicity.13 Other studies have demonstrated that ethanol may decrease cocaine lethality. Ethanol is also known to inhibit the glutamate N-methyl-D-aspartic (NMDA) receptor site and activate gammaaminobutryic acidA (GABA)A.14 The activation of GABAA may result in an increase in the seizure threshold, thus protecting the CNS from the pro-seizure (decreased seizure threshold) effects of cocaine. In addition, Shimosoto et al showed that NMDA antagonism decreased the incidence of seizures induced by cocaine,15 and Matsumoto et al demonstrated that NMDA/glycine site antagonists appear to have a protective effect in the event of cocaine toxicity.16 It can be hypothesized that the inhibitory effect of ethanol on the NMDA receptor may result in some protection from cocaineinduced seizures, resulting in a decreased lethality of cocaine. Regarding BE, the present study found results similar to the findings of Karch et al, in that the concentration of BE was lower in the cocaine plus ethanol group.6 In the present study this difference reached statistical significance while in the study of Karch et al it did not.6 The differences seen in BE concentrations between the cocaine-only and the cocaine and ethanol groups may be due to the effect of ethanol on cocaine metabolism. There are 2 main enzymes responsible for cocaine metabolism and the formation of its primary metabolites, BE and ecgonine methyl ester (EME). Carboxylesterase hCE1 is responsible for the metabolism of cocaine to BE, and hCE2 is responsible for the metabolism of cocaine to EME.13 When ethanol is present hCE1 preferentially converts cocaine to cocaethylene rather than to BE.13 This change in metabolism would cause the cocaine to be metabolized to cocaethylene instead of to BE, leading to lower BE concentrations in individuals who also ingested ethanol. Roberts et al found that in rats given cocaine and pretreated with ethanol there was a 2- to 3-fold increase in peak hepatic concentrations of cocaine, norcocaine, and EME along with a decrease in BE by 2-fold.17

Cocaine and Other Drugs Because of sample size constraints, only ethanol, opiate/ opioid medications, heroin, antipsychotic/antidepressant medications, and antihistamines could be analyzed in this study. Although other drugs, including anxiolytics, inhalants, and sympathomimetics, may also contribute to cocaine toxicity, no conclusions could be drawn based upon this study alone; therefore, the discussion is limited to those drugs in which this study adds to the current literature.

Cocaine and Ethanol This study supports the hypothesis that ethanol may increase the toxicity of cocaine. The data show that the concentrations of cocaine and BE in the cocaine-only group were greater than those found in the cocaine plus ethanol group. This is consistent with an autopsy study by Karch et al who compared 72 cases of cocaine-related deaths, 25 of which had ethanol and cocaine present and 47 had cocaine without ethanol.6 They

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Cocaine and Opiate/Opioid Medications and Cocaine and Heroin The present study supports the findings of Polettini et al, that cocaine enhances the toxicity of heroin,18 although, for this study, it could be argued that opiates/opioids enhance the toxicity of cocaine. Polettini et al found lower concentrations of morphine in cases of heroin deaths in the presence of cocaine than without cocaine.18 This study found the corollary that lower concentrations of cocaine are present when opiates/opioids are also present than when opiates/opioids are absent. Blumberg and Ikeda studied the effects of cocaine and opiates/opioids in mice and found that, when combined, morphine increases the effects of cocaine.19 They also found that this augmentation can be blocked by an opiate antagonist.19 These studies, in addition to the current one, * 2011 Lippincott Williams & Wilkins



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support the hypotheses that either cocaine enhances opiate/opioid toxicity, opiates/opioids enhance cocaine toxicity, or both. Studies and case reports have linked opiates, including heroin, with seizures,20Y27 though the exact mechanism of how opiates cause seizures is not known. Saboory et al showed that, at high concentrations, opiates enhanced seizure activity via the K and J receptors, within the hippocampus24; Zieglgansberger et al hypothesized that opiate induced seizures may be the result of disinhibition of hippocampal neurons25; and Crain et al proposed it was because of enhancement of excitatory neurotransmission.26 Carlsson et al found that fentanyl decreases the cerebral blood flow and metabolic rate for oxygen in rats, which may lead to cerebral hypoxia and seizures.27 If both opiates and cocaine have pro-seizure effects, then the use of both together could act synergistically to increase the risk and/or intensity of seizure activity. Tseng et al showed that cocaine causes central respiratory depression in rats, which may be yet another mechanism of death secondary to cocaine use.28 Plunkett et al further showed that morphine potentiates the respiratory depression caused by cocaine in guinea pigs.29 Opiates/opioids may also augment the respiratory depression seen with seizure activity during a cocaine induced seizure, which may further increase the risk of death. Polettini et al argue 2 additional possible interactions regarding cocaine and heroin.18 Both heroin and cocaine are hydrolyzed by the same enzyme system, and there may be some competitive inhibition at that enzyme site, resulting in increased duration of action of either cocaine or heroin or both. In addition, they argue that both cocaine and heroin result in increased dopamine release, which has been associated with an increased risk of death (see following discussion on antipsychotics).

and showed that antidepressants with high affinity and specificity to serotonin transporters increase cocaine convulsions and the severity of those convulsions.32 One exception was sertraline that did not alter cocaine-induced convulsions and actually attenuated lethality.32 This is thought to be due to sertraline_s high affinity to sigma receptors, which, as discussed earlier, have been shown to decrease cocaine lethality.30 Heard et al showed that mice treated with the antipsychotic medication ziprasidone had higher death rates when combined with cocaine than those rats who used cocaine alone.33 They postulated that patients taking antipsychotics have an increased susceptibility to cocaine toxicity since long-term administration of antipsychotic medications alters the density of dopamine, glutamate, and serotonin receptors in the brain, all of which are associated with cocaine toxicity.33 Long-term or chronic antipsychotic administration was also shown to cause an increased sensitivity to cocaine.33 Antipsychotic and antidepressant medications may also share cardiac interactions with cocaine. Numerous antidepressant and antipsychotic medications have been shown to increase the QT interval.34Y36 The apparent mechanism of action of medication induced QT prolongation involves the blockade of the outward potassium currents in the heart, causing prolongation of the cardiac action potential.35 This action may act synergistically with the cardiac channel and sympathomimetic effects of cocaine resulting in an increased risk of cardiac dysrhythmias.

Cocaine and Antidepressants/Antipsychotics As with the opiates/opioids discussed previously, this study supports the hypothesis that antipsychotic/antidepressant medications increase the toxicity of cocaine. This is supported by the concentrations of both cocaine and BE being lower in the deaths with antipsychotic/antidepressant medications present than in the cocaine-only group. Although a previous formal study looking at this effect in humans has not been performed, the compounding effects of cocaine plus antidepressants and/or antipsychotics are pharmacologically logical when one considers the mechanism of action of each of these drugs/drug class. Cocaine acts by inhibiting the reuptake of norepinephrine, epinephrine, dopamine, and serotonin resulting in increased concentrations of each of these monoamines. Most antidepressants and antipsychotics have a similar mechanism of action, resulting in increased concentrations of many of the same monoamines. The lethality of cocaine seems to depend primarily on its interaction with dopaminergic receptor sites.30 In addition, dopamine (D1) antagonists have been shown to protect against cocaine-induced lethality.30,31 Ritz and George further showed that sigma receptor agonists and muscarinic (M1) receptor antagonists can also attenuate cocaine-induced lethality, although the attenuation is not as dramatic as with dopamine antagonists.30 Antidepressants and antipsychotics often affect the dopaminergic system, usually resulting in increased dopamine levels, which may augment cocaine toxicity and lethality. O_Dell et al found that antidepressants enhance cocaine toxicity in mice presumably by affecting the reuptake of the catecholamines, dopamine, and norepinephrine, as well as serotonin.32 They stipulate that cocaine convulsions are mediated by serotonin and that cocaine lethality is mediated by dopamine * 2011 Lippincott Williams & Wilkins

Cocaine and Antihistamines There is a paucity of data regarding the effects of cocaine and antihistamines. The present study supports the hypothesis that antihistamine medications, when taken concurrently with cocaine, increase the toxicity of cocaine. This is evidenced by the concentrations of both cocaine and BE being less in the deaths with antihistamines present than in the cocaine-only group. Previous studies have shown that both cocaine and H1 antihistamines affect dopamine neurotransmission within the brain leading to positive reinforcement behavior.37,38 Diphenhydramine and cocaine were found to act as positive reinforcers in the monkey, although the 2 drugs also displayed a stronger, synergistic effect when combined.37,38 It is possible that this dopaminergic action may also lead to toxicity by the mechanisms discussed previously in the section regarding antidepressant/ antipsychotic medications. First generation H1-antihistamines, which enter the CNS, can result in CNS stimulation, especially when taken in overdose, which can lead to convulsions and death. It can be hypothesized that this may be an additional mechanism of cocaine-antihistamine interaction, resulting in a decreased seizure threshold and increased risk of convulsions. Like cocaine, antihistamines can cause cardiovascular effects, including rhythm disturbances. Cocaine and H1antihistamines could act synergistically on the heart creating conduction abnormalities and subsequent death. Both cocaine and some antihistamines (tripelennamine, chlorpheniramine, diphenhydramine, and phenindamine) have been shown to be potent inhibitors of neuronal uptake of norepinephrine.39,40 By this mechanism, it could be hypothesized that cocaine plus an antihistamine would have a synergistic stimulatory action on the heart by leading to an increase amount of norepinephrine at the receptor causing an increase heart rate and blood pressure that could lead to dysrhythmias or heart attacks. However, not all antihistamines have been shown to have this effect; Davis and McNeill reported that pyrilamine and promethazine had www.amjforensicmedicine.com


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no effect on norepinephrine uptake.40 In addition, several antihistamines including astemizole, terfenadine diphenhydramine, and hydroxyzine have been shown to increase the QT interval, which may result in cardiac arrhythmias similar to those produced by cocaine.34,36 This QT prolongation may be another mechanism by which cocaine and antihistamines may result in fatal cardiac dysrhythmias.

13. Laizure SC, Mandrell T, Gades NM, et al. Cocaethylene metabolism and interaction with cocaine and ethanol: role of carboxylesterases. Drug Metab Dispos. 2003;31:16Y20.

CONCLUSION This study supports previous reports that cocaine used in combination with ethanol, heroin, opiate medications, and antidepressants/antipsychotics may result in increased toxicity, as evidenced by a decreased concentration of cocaine and BE present in deaths due to a combination of these drugs plus cocaine versus deaths due to cocaine alone. The coingestion of antihistamines and cocaine may result in increased toxicity, although more research is necessary. The question of a dose relationship between cocaine and toxicity is less clear. Although further research is necessary to resolve the dose question, many factors severely limit the ability to conduct research in humans. Understanding the issues related to how and why cocaine can result in death is essential for the forensic pathologist, not only in understanding the dynamics of these deaths but also in communicating with families and other interested parties.


14. Sivilotti ML. Ethanol, isopropanol and methanol. In: Dart RC, ed. Medical Toxicology. 3rd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2004:1211Y1215. 15. Shimosato K, Marley RJ, Saito T. Differential effects of NMDA receptor and dopamine receptor antagonists on cocaine toxicities. Pharmacol biochem Behav. 1995;51:781Y788. 16. Matsumoto RR, Brackett RL, Kanthasamy AG. Novel NMDA/glycine site antagonists attenuate cocaine-induced behavioral toxicity. Eur J Pharmacol. 1997;388:233Y242. 17. Roberts SM, Harbison RD, James RC. Inhibition by ethanol of the metabolism of cocaine to benzoylecgonine and ecgonine methyl ester in mouse and human liver. Drug Metab Dispos. 1993;21:537Y541. 18. Polettini A, Poloni V, Groppi A, et al. The role of cocaine in heroin-related deaths hypothesis on the interaction between heroin and cocaine. Forensic Sci Int. 2005;153:23Y28. 19. Blumberg H, Ikeda C. Naltrexone, morphine and cocaine interactions in mice and rats. J Pharmacol Exp Ther. 1978;206:303Y310. 20. Rao TL, Mummaneni N, El-Etr AA. Convulsions: an unusual response to intravenous fentanyl administration. Anesth Analg. 1982;61:1020Y1021. 21. Rosenberg M, Lisman SR. Major seizure after fentanyl administration: two case reports. J Oral Maxillofac Surg. 1986;44:577Y579.

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22. Tempelhoff R, Modica PA, Bernardo KL, et al. Fentanyl-induced electrocorticographic seizures in patients with complex partial epilepsy. J Neurosurg. 1992;77:201Y208.

2. United States Department of Health and Human Services. Substance Abuse and Mental Health Services Administration 2007 National Survey on Drug Use and Health. Available at http://www.oas. samhsa.gov/nsduhLatest.htm. Accessed December 8, 2008.

23. da Silva O, Alexandrou D, Knoppert D, et al. Seizure and electroencephalographic changes in the newborn period induced by opiates and corrected by naloxone infusion. J Perinatol. 1999;19:120Y123.

3. Bertol E, Trignano C, Di Milia MG, et al. Cocaine-related deaths: an enigma still under investigation. Forensic Sci Int. 2008;176:121Y123.

24. Saboory E, Derchansky M, Ismaili M, et al. Mechanisms of morphine enhancement of spontaneous seizure activity. Anesth Analg. 2007;105:1729Y1735.

4. Karch SB, Stephens B, Ho CH. Relating cocaine blood concentrations to toxicityVan autopsy study of 99 cases. J Forensic Sci. 1998;43:41Y45. 5. Blaho K, Logan B, Winbery S, et al. Blood cocaine and metabolite concentrations, clinical findings, and outcome of patients presenting to an ED. Am J Emerg Med. 2000;18:593Y598. 6. Karch SB, Stephens BG, Tseng A. Does ethanol enhance cocaine toxicity? J Clin Forensic Med. 1999;6:19Y23. 7. Boyer CS, Petersen DR. Potentiation of cocaine-mediated hepatotoxicity by acute and chronic ethanol. Alcohol Clin Exp Res. 1990;14:28Y31. 8. Foltin RW, Fischman MW. Ethanol and cocaine interactions in humans: cardiovascular consequences. Pharmacol Biochem Behav. 1988;31:877Y883. 9. McCance-Katz EF, Kosten TR, Jatlow P. Concurrent use of cocaine and alcohol is more potent and potentially more toxic than use of either aloneVa multiple-dose study. Biol Psychiatry. 1998;44: 250Y259. 10. Odeleye OE, Watson RR, Eskelson CD, et al. Enhancement of cocaine-induced hepatotoxicity by ethanol. Drug Alcohol Depend. 1993;31:253Y263. 11. Sobel BF, Riley AL. The interaction of cocaine and alcohol on schedule-controlled responding. Psychopharmacology (Berlin). 1997;129:128Y134. 12. Busse GD, Riley AL. Effects of alcohol on cocaine lethality in rats: acute and chronic assessments. Neurotoxicol Teratol. 2003;5:361Y364.

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25. Zieglgansberger W, French ED, Siggins GR, et al. Opioid peptides may excite hippocampal pyramindal neurons by inhibiting adjacent inhibitory interneurons. Science. 1979;205:415Y417. 26. Crain SM, Shen KF, Chalazonitis A. Opioids excite rather than inhibit sensory neurons after chronic opioid exposure of spinal cord-ganglion cultures. Brain Res. 1988;455:99Y109. 27. Carlsson C, Smith DS, Keykhah M, et al. The effects of high-dose fentanyl on cerebral circulation and metabolism in rats. Anesthesiology. 1982;7:375Y380. 28. Tseng CC, Derlet RW, Albertson TE. Cocaine induced respiratory depression in urethane-anesthetized rats: a possible mechanism of cocaine-induced death. Pharmacol Biochem Behav. 1991;39:625Y633. 29. Plunkett LM, Seifen E, Kennedy RH. Effects of morphine pretreatment on cocaine cardiotoxicity in anesthetized guinea-pigs. Arch Int Pharmacodyn The´r. 1989;297:60Y67. 30. Ritz MC, George FR. Cocaine toxicity: concurrent influence of dopaminergic, muscarinic and sigma receptors in mediating cocaine-induced lethality. Psychopharmacology (Berlin). 1997;129:311Y321. 31. Schechter MD, Meehan SM. Role of dopamine D1 receptors in cocaine lethality. Pharmacol Biochem Behav. 1995;51:521Y523. 32. O_Dell LE, George FR, Ritz MC. Antidepressant drugs appear to enhance cocaine-induced toxicity. Exp Clin Psychopharmacol. 2000;8:133Y141. 33. Heard K, Krier S, Zahniser NR. Administration of ziprasidone for




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10 days increases cocaine toxicity in mice. Hum Exp Toxicol. 2008;27:499Y503. 34. Yap YG, Camm AJ. Drug induced QT prolongation and Torsades de Pointes. Heart. 2003;89:1363Y1372. 35. Zareba W, Lin DA. Antipsychotic drugs and QT interval prolongation. Psychiatr Q. 2003;74:291Y306. 36. Redfern WS, Carlsson L, Davis AS, et al. Relationships between preclinical cardiac electrophysiology, clinical QT interval prolongation and torsade de pointes for a broad range of drugs: evidence for a provisional safety margin in drug development. Cardiovasc Res. 2003;58:32Y45. 37. Wang Z, Woolverton WL. Self-administraion of cocaine-antihistamine



combinations: super-additive reinforcing effects. Eur J Pharmacol. 2007;557:159Y160. 38. Wang Z, Woolverton WL. Super-additive interaction of reinforcing effects of cocaine and H1-antihistamines in rhesus monkeys. Pharmacol Biochem Behav. 2009;91:590Y595. 39. Matsuda Y, Masuda Y, Blattberg B, et al. The effects of cocaine, chlorpheniramine and tripelennamine on the cardiac responses to sympathetic nerve stimulation. Eur J Pharmacol. 1980;63:25Y33. 40. Davis RS, McNeill JH. The cardiac effects of cocaine and certain antihistamines and antidepressants. Arch Int Pharmacodyn The´r. 1973;201:262Y279.



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ORIGINAL ARTICLE

The Fulton County Medical Examiner’s Experience With the Federal Bureau of Investigation National Missing Person DNA Database Program 2004Y2007 Michael Heninger, MD and Randy Hanzlick, MD

Background: Medical examiners and coroners occasionally encounter unidentified human bodies, which remain unidentified for extended periods. In such cases, when traditional methods of identification have failed or cannot be used, DNA profiling may be used. The Federal Bureau of Investigation has a National Missing Person DNA database (NMPDD) laboratory to which samples may be submitted on such cases and from possible relatives or environments of unidentified decedents. This article describes the experience of the Fulton County Medical Examiner (FCME) in submitting samples to the NMPDD laboratory. Methods: A database was established at the FCME to track the submission of samples from unidentified decedents to the NMPDD laboratory for DNA testing along with the results and turnaround times. In December 2004, the FCME inventoried all cases for which samples were available and began to submit them to the NMPDD laboratory for testing. DNA testing and isolation rates, sample type, and turnaround times were tabulated in October 2006 for samples submitted between December 16, 2004 and December 16, 2005. An overall summary of data was also prepared concerning the status of all samples submitted as of April 17, 2007. Results: During the 1-year study period, samples from 77 unidentified decedents were submitted to the laboratory. As of October 2006 (22 months after submission of the first samples and 10 months after submission of the last samples), testing had been completed on 53% of the samples submitted, and 68% of those tested resulted in a mitochondrial DNA profile. Turnaround times ranged from 66 to 557 days, improved with time, and had a mean of 107 days for specimens submitted during the latter part of the study period. As of April 17, 2007, we had submitted samples involving 84 unidentified decedents. Seventy-five percent of the samples have now been tested. Data from the NMPDD laboratory have resulted in 4 identifications by comparison with putative relatives, 4 exclusions, and no cold hits through comparison NMPDD DNA profiles from missing persons. More extensive data are presented in the body of this article. Conclusions: The NMPDD laboratory provides useful and free services to medical examiners, coroners, and law enforcement agencies that require DNA services regarding missing and unidentified persons. Turnaround times have improved. The success of the system in getting cold hits will be heavily dependent on law enforcement filing missing persons reports and submission of reference samples from putative relatives of the decedent. We recommend collecting specimens for DNA

analysis early on in the postmortem investigation, submitting samples to the NMPDD laboratory or one of its participating laboratories when traditional methods for identification cannot be used or have failed, not burying bodies until a DNA profile has been obtained, and not cremating unidentified remains. Key Words: unidentified decedents, missing persons, DNA profiling, medical examiners, coroners, identification (Am J Forensic Med Pathol 2011;32: 78Y82)

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edical examiners and coroners are sometimes faced with having to identify deceased persons whose identity is not known at the time of death or when the body is found. In a small portion of these cases, the decedent’s identity remains unknown for an extended period, if not indefinitely. In such cases, when traditional means of identification such as visual recognition, fingerprints, and dental or radiographic comparisons have not been successful or cannot be performed, DNA profiling is the only remaining option. In some cases, DNA from decedents may be compared with reference samples from their suspected residence or from persons who are putative relatives of the decedents. In these cases, there is a potential Bmatch[ that can be ruled in or out in a planned manner with notification of those involved. In other cases, the only hope is that the DNA profile from the deceased may result in a Bcold hit[ against DNA profiles available within the Federal Bureau of Investigation’s (FBI’s) National Missing Person DNA database (NMPDD). This report describes the Fulton County Medical Examiner’s (FCME’s) experience with the FBI NMPDD program for specimens submitted, results, turnaround times, and other observations.

METHODS

Manuscript received April 21, 2007; accepted May 13, 2007. From the Fulton County Medical Examiner’s Center; and Emory University School of Medicine, Atlanta, GA. Reprints: Randy Hanzlick, MD, Fulton County Medical Examiner’s Center, 430 Pryor St SW, Atlanta, GA 30312. E-mail: Randy.hanzlick@ fultoncountyga.gov. This article was presented in part at the annual meeting of the National Association of Medical Examiners, San Antonio, TX, October 2006. Copyright * 2011 by Lippincott Williams & Wilkins ISSN: 0195-7910/11/3201-0078 DOI: 10.1097/PAF.0b013e3181f23ded

The FCME is located in Atlanta, Ga, and serves the one million citizens of Fulton County. Each year, approximately 2200 reports of death are received and approximately 1400 are fully investigated and result in certification of the cause and the manner of death. Each year, on average, 3 to 5 cases remain unidentified for extended periods and account for approximately 0.3% of deaths investigated by the office. In mid 2004, all of the records maintained at the FCME’s office were reviewed, and all unidentified decedent cases were inventoried. An electronic database was created to manage these unidentified cases, including prior cases and cases that would be encountered in the future. After the inventory conducted in 2004, a plan was made to submit specimens to the FBI NMPDD laboratory, and the computer database in our office was expanded to track progress on all of the specimens sent there. Samples for DNA profiling were obtained from all cases in which specimens were available. Batches of specimens were sent to the

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TABLE 1. Overall Data for 102 Cases of Unidentified Remains of Which 77 Had Samples Available for DNA Profiling, Which Were Submitted to the FBI Between December 16, 2004 and December 26, 2005 Result

TABLE 3. Mitochondrial DNA Isolation Rates Among Cases Tested for mtDNA

No. Cases

Sample sent to the FBI for DNA testing mtDNA test completed mtDNA profile established No specimen available Cases identified Cold case hits Cases where identity was excluded Total unidentified cases

77 41 28 25 2 0 1 102

FBI NMPDD program beginning in December 2004. In October 2006, we analyzed the status and the results of each case that had been submitted between December 16, 2004 and December 16, 2005. We selected a closing date of December 16, 2005, to ensure that each sample in the study had been at the FBI NMPDD laboratory for a minimum of 10 months. This report contains analysis of the status of each case as of October 2006 along with turnaround times. We also report additional observations that have been made since the original analysis.

RESULTS One-Year Study Period From December 16, 2004 to December 16, 2005 One hundred two total cases were identified through inventory and review of records. These remains were recovered and examined at our office for a 31-year period spanning 1974 through 2005. In 25 cases, no specimens were available for DNA testing. Samples of unidentified remains from 77 individuals were submitted to the FBI NMPDD laboratory during the 1-year study period. Only 2 cases had identity established using mitochondrial DNA (mtDNA) and in both cases putative relatives were used to establish it. No cases have been identified by a cold hit (Table 1). The mtDNA testing was completed on 41 (53%) of the cases that had been at the FBI NMPDD laboratory for 10 to 22 months. In 28 cases (68% of those tested), mtDNA was isolated. Of the 11 cases that occurred before 1980, only 2 cases had samples available for DNA profiling, and neither case was tested during the study period (Table 2). In the decade between 1980 and 1989, 22 cases had 12 samples available, and in 7 of them the DNA testing was completed. In the decade between 1990 and

TABLE 2. Mitochondrial DNA Sample Availability and Test Completion Rate by Time of Case Occurrence Years Case Occurred

Total UID Cases

Cases With DNA Samples

mtDNA Tests Done

Pre-1980 1980Y1989 1990Y1999 2000Y2006 Total

11 22 35 34 102

2 12 29 34 77

0 7 (58%) 13 (44%) 21 (62%) 41 (53%)

UID indicates unidentified decedent.


Medical Examiner and FBI DNA Database

Years Cases Occurred

mtDNA Testing Completed

mtDNA Profile Isolated

1980Y1989 1990Y1999 2000Y2006 Total

7 13 21 41

2 (29%) 6 (46%) 20 (95%) 28 (68%)

1999, 35 cases had 29 samples available, and in 13 of them the DNA testing was completed. Between the year 2000 and the end of 2006, all 34 of the unidentified cases had samples available, and in 21 of them the DNA testing was completed. The higher completion rate on recent cases occurred because the laboratory gave priority to the more recent cases. Not every sample submitted and tested resulted in DNA isolation (Table 3). In cases from the remote past, the DNA isolation rate was less successful (29%). In samples submitted since year 2000, DNA isolation has almost always been successful (95%). A wide variety of specimens had been retained and were sent to the FBI NMPDD laboratory for testing (Table 4). Samples of bones and blood were the most common and were usually successful in providing mtDNA (82% and 100%, respectively). Only a few samples of soft tissues and paraffin blocks were sent. Paraffin blocks resulted in mixed mtDNA profiles from more than 1 person. For cases that occurred since year 2000, mtDNA was recovered from all but 1 case tested, regardless of the condition of the body (Table 5). Table 6 shows the data for samples obtained from 5 putative relatives of the various decedents. In 2 cases, mtDNA assisted with identification. In 2 others, relationship was ruled out. In the fifth, nuclear DNA profiling was required, which took an extended period. For the mtDNA tests, the turnaround time ranged from 69 to 170 days. One additional case request was canceled because it was a paternal sample and the maternal sample was exclusionary. The first shipment of samples to the FBI NMPDD laboratory includes samples from 40 cases (Table 7). The subsequent shipments involved fewer specimens. As might be predicted, fewer of the recently shipped cases have been completed because of insufficient time lapse, but the turnaround times on completed cases have improved because of emphasis on newer cases.

Updated Review of Data In addition to the cases described for the 1-year submission period reported in this study, we have recently tabulated the current status of all cases submitted to the FBI NMPDD laboratory between December 04, 2004 and April 17, 2007 (Table 8). Seventy-five percent of 84 submitted cases have been completed, with DNA profiles identified in 68% of tested cases. Twenty-one cases not tested include 3 in which identification was made using other methods and 2 that did not meet case submission criteria. The remaining 16 unfinished cases include 7 recently submitted cases and 9 cases that occurred before 1999.

DISCUSSION Study-Specific Discussion The unfinished DNA case work and lengthy turnaround times should not be viewed as an indictment of the NMPDD www.amjforensicmedicine.com


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TABLE 4. Sample Type Submitted and Whether mtDNA Was Isolated (Yes) or Not (No) Bone Years

Blood

mtDNA Tests

Yes

No

7 13 21 41

1 4 9 14 82%

2 1 3

1980Y89 1990Y99 2000Y06 TOTAL

Yes

Tooth No

9 9 100%

Yes 1 1 2 20%

No

Soft Tissue

Paraffin Block

Yes

Yes

4 4 8

No 1 1

1 1 33%

2

mtDNA Isolated

No

1* 1* 2* 100%

Total 2 (29%) 6 (46%) 20 (95%) 28 (68%)

*Mixed pattern.

laboratory’s efficiency or performance. The NMPDD program is relatively new (having begun in 2000) but is a valuable yet free service for its users. Early on, the NMPDD laboratory received few samples but since 2003 has been bombarded with samples, including those we submitted (Table 9). For the first time in 2006, the laboratory was able to process more samples than it received, allowing them to begin reducing case backlog. However, the laboratory scientists are also charged with the responsibility of testing samples submitted via the Combined DNA Index System program, which receives top priority for case work because it deals with living people and active court cases. Our data show that turnaround times are decreasing, and we should remain optimistic that such a trend will continue. The failure to isolate DNA in some cases probably relates most to the practices of the FCME before the DNA era. Skeletal remains were often cooked in detergents to deflesh and clean them. Unidentified intact remains were buried after identification measures failed. It was not a routine practice to retain stock tissues. Thus, samples were not available in some cases, or the potential use of available samples was hampered by the processing methods. It was routine to process tissues to paraffin blocks or to slides, but the experience with the NMPDD laboratory thus far has been that paraffin blocks produced mixed DNA profiles. Our best guess is that contamination occurs via the microtome or the fixative solutions through which the tissue are passed during histological processing. Our data show that when suitable specimens are available, successful DNA profiles can be accomplished on very old cases. Since the late 1990s, we have tailored our procedures to ensure DNA sample availability through the routine preparation of blood spot cards and collection of other samples as needed before anthropological processing takes place. We typically store skeletal remains above ground in a warehouse storage area, and we defer burial of intact bodies until a DNA profile has been established. We do not cremate unidentified remains, which we feel is the best practice. Remains can be discovered in a variety of conditions. The conditions that typically are encountered do not seem to be serious detriments in most cases. In recent well-managed cases, TABLE 5. Bodily Condition and mtDNA Recovery Rate for Cases Occurring Since Year 2000 Condition of Body Skeletal Intact Burned/charred Decomposed Embalmed Total

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Cases Tested

mtDNA Isolated

10 5 3 2 1 21

9 (90%) 5 (100%) 3 (100%) 2 (100%) 1 (100%) 20 (95%)


the condition of the body had little impact on the DNA isolation success rate (Table 5). DNA was isolated 95% of the time in cases discovered since 2000 regardless of the conditions. The quality of specimen collection and storage is probably more important than the length of time the remains are retained by the medical examiner or the condition of the remains when found. As of February 2007, the FBI NMPDD laboratory had received 1339 cases for DNA profiles and had completed 1048 (78%) of them.1 They reported 130 matches to known reference samples (approximately 10%). Using the NMPDD laboratory, we have identified approximately 5% of the cases of unidentified decedents for which samples were submitted to the laboratory. Creative solutions to individual cases must be sought. In one case reported by Sweet et al,2 mtDNA recovered from the teeth of skeletal remains that had not been identified was compared with the mtDNA from a Papanicolaou smear from a putative match. This match was made in the absence of the availability of dental records and living relatives. A recent report from our office indicates that approximately 44 of every 1000 deaths investigated involve an unidentified body.3 Most of these are quickly (within 2 days) identified using visual identification or fingerprints. Most cases identified without DNA are identified within 1 month of the body being found. Ultimately, approximately 2.6 per thousand cases (approximately 0.3%) remained unidentified, and it is these cases in which the services of the NMPDD laboratory are needed and appreciated. Two articles published many years ago attempted

TABLE 6. Data for Reference Samples Obtained From Putative Family Members Circumstances Skeleton Burned in vehicle Skeleton Skeleton

Decomposed

Specimen

TAT, d

Blood sample from putative sister shows same mtDNA Blood sample from putative mother shows same mtDNA Buccal swab from putative daughter shows dissimilar mtDNA Blood from putative mother shows dissimilar mtDNA. Sample also taken from father but not tested Blood from suspected son. Nuclear DNA needed

97 69 170 104

Sent 10/24/ 2005Vnot complete*

*Test results were received in March 2007 and showed parent/son relation. TAT indicates turnaround time.




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TABLE 7. Case Shipment and Processing Information Time When Sent

Cases and Shipments

Medical Examiner and FBI DNA Database

TABLE 9. Case Submission Data for the FBI NMPDD Laboratory

TAT Mean Completed Range, d TAT, d

Early 12/04

40 cases 1 shipment Late 12/04 to 1/05 17 cases 4 shipments 5/05 to 10/05 20 cases 10 shipments

24 (60%)

150Y605

316

11 (65%)

429Y557

317

6 (30%)

66Y151

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to measure this and report that 1.8% and 1.6% of investigated cases remain unidentified.4,5 We suggest that DNA samples be obtained as soon as possible after the body is examined postmortem and, if traditional identification methods cannot be used or have been unsuccessful 1 month into the investigation, that samples be submitted to the NMPDD or one of its participating laboratories. In the 1980s, Murphy et al4 reported St Louis Medical Examiner cases and the use of radiographs, circumstantial information, fingerprints, and dental records in the identification of 71 unknown human remains and reported rapid turnaround times for various methods, which ranged from 1 to 32 days. At that early date, DNA was not possible. In all of these cases, a putative identity was available, which greatly speeds up the process. Current DNA turnaround times will need to improve before they can meet those traditional identification method benchmarks.

TABLE 8. Specimen Status and Results as of April 17, 2007 Category

n (%)

Cases on which 1 or more DNA samples were submitted Cases with DNA testing completed Cases with DNA profile established Cases with inability to isolate DNA Cases with mixed DNA pattern Cases with DNA testing not completed Identified by other means before DNA testing was complete Did not meet case submission criteria (fetuses) Recently submitted cases Older cases before 1999 and as far back as 1974 Cases in which additional samples were sent after failed initial test Retesting of additional samples resulted in DNA profile Retesting failed to result in a DNA profile Recently submitted samples Matching and exclusions Cases in which DNA facilitated identity by comparison with relative Cases identified through a cold hit in the NMPDD Cases in which the decedent was ruled out as a relative Cases which turned out to be skeletal remains from the same case

84 63 (75) 43 (68) 18 (29) 2 (3) 21 (25) 3 2 7 9* 9 4 2 3 4

Cases Completed

40 40 43 119 297 460 340 1339

5 12 10 118 202 331 370 1048

Presented by John Stewart, PhD, at a missing persons workshop during the American Academy of Forensic Sciences meeting, San Antonio, February 2007. FY indicates fiscal year.

In Spain, the Phoenix program was initiated in 1999. Two independent mtDNA databases were generated, which were digitally compared. The Reference Database collected DNA from maternal relatives of missing persons. The Questioned Database included mtDNA from unknown remains and cadavers. Between 1999 and 2003, more than 1200 families submitted samples and 48 unidentified remains were analyzed. Matches were made in 6 cases and were confirmed with split tandem repeat testing, resulting in a 12.5% identification success rate.6 One of us (R.H.) recently published a report concerning the utility of an FCME office Web site containing information about unidentified decedents.7 Although no identifications had resulted from the Web site, it was useful because some inquiries occurred and potential identities of certain decedents could be ruled out. Since the publication of that article, however, we have now had at least 2 identifications that have resulted in part from the information contained on the Web site. The National Association of Medical Examiners has developed a pilot Unidentified Decedent Reporting System at http://udrs.orainc.com, which is designed to be a registry for all unidentified decedents in the United States and has public access and search capabilities. Recent data in our office indicate that approximately one third of cases that remain unidentified for a long period are homicides, and leads are nil when the victim’s identity is unknown.3 This provides another important reason for aggressively pursuing identification. Arthur Eisenberg, director of the DNA Identification Laboratory at the University of North Texas Health Science Center in Galveston describes the missing and unidentified person problems as a Bmass disaster over time.[1 Every day, hundredsVif not thousandsVof individuals are reported missing. Most of them are not going to end up in the medical examiner’s office as remains recalcitrant to identification. But a few of them have been killed or die otherwise and come to the attention of medical examiners and coroners. Their assailants are not held accountable when homicide is involved because without identification, there are no leads.

General Discussion 0 4 2

*Five of these were cases in which paraffin tissue blocks were the only available sample.


Cases Submitted FY2000 FY2001 FY2002 FY2003 FY2004 FY2005 FY2006 Total

Medical examiners and coroners are charged by legislation to investigate violent or otherwise suspicious deaths and to determine the cause and the manner of these deaths. Another extremely important medical examiner/coroner function is proper disposition of the remains of the deceased. Balancing the needs of the family to honor and dignify their deceased relatives with the needs of society to be informed is crucial. The first and www.amjforensicmedicine.com


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often single most important part of the investigation from the point of view of both of these perspectives is the determination of the identity of the deceased individual. The investigation of a suspicious death begins with the identification of the deceased individual. Clues as to the cause, the manner, and the circumstances of deathVincluding the list of possible perpetrators in homicidesVare based on knowing the decedent’s identity and thereby being able to obtain medical history, recent whereabouts, and contact with other persons. The most common visible way a deceased individual is honored is with a grave marker, and the most prominent feature engraved on these markers is the name of the individual, emphasizing that personal identity is an important and innate concept. In most deaths, the deceased individuals’ identity is obvious. They died at home surrounded by their relatives or in a hospital where their identity is well known. Often they carry identification on their person. When necessary, identity can be confirmed or established using standard scientific methods such as fingerprint, dental, or radiograph comparison or other unique physical features. Each death is unique. In some cases, remarkable serendipity intervenes. A 1992 Florida case involved the identification of the remains of an elderly female individual who had been decapitated and whose hands were amputated in an effort to obscure her identity. However, the dedicated perpetrators failed to remove the clothing with a tag containing her last name and the initial of her first name written in ink. This clue, along with missing person reports in the area, was used to discover her identity.8 Regardless of the efforts, cases will accrue in which no success is achieved in establishing identification. Because these cases are rare and are overshadowed by the other day-to-day work in medical examiner/coroner offices, they frequently find their way onto the Bback burners[ of investigation, are given low priority, and are not solved. Many experts estimate that the number of human remains that have not been identified in all of the governmental agencies in the United States involved in death investigation has reached 40,000 nationally since the mid 1980s. The National Crime Information Center (NCIC) is a computerized index of criminal justice information for law enforcement agencies that keeps track of people of interest to them including missing and unidentified persons. However, only approximately 6000 cases of unidentified decedents currently are entered into the NCIC.9 At any given time, there are approximately 100,000 missing persons on file in the NCIC system. Every state has set up a missing-children clearinghouse; some operate more effectively than others, but not all of our unidentified remains are those of children. In fact, most are adults. Current data and estimates suggest that as few as 600 and perhaps up to 1500 or more new cases of chronically unidentified decedents accrue each year in the United States.3,9 Laboratories that are processing samples for mtDNA and nuclear DNA and are regularly uploading data to the Combined DNA Index System and/or the NMPDD are the FBI laboratory in Quantico, Virginia; the California Department of Justice Labo-

ratory in Richmond; and the laboratory at the University of North Texas Center for Human Identification in Fort Worth. The California laboratory mainly does cases for California, whereas the other 2 provide services nationally. There are other regional mtDNA laboratories at the Arizona Department of Public Safety (Phoenix), the New Jersey State Police (Hamilton), the Minnesota Bureau of Apprehension (St Paul), and the Connecticut State Forensic Laboratory (Meriden). These laboratories mainly process case evidence for mtDNA, but either do or soon will be handling cases for the NMPDD program.

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CONCLUSIONS The NMPDD laboratory provides useful and free services to medical examiners, coroners, and law enforcement agencies that required DNA services regarding missing and unidentified persons. Turnaround times have improved. The success of the system in getting cold hits will be heavily dependent on law enforcement filing missing persons reports and submission of reference samples from putative relatives of the decedent. We recommend collecting specimens for DNA analysis early on in the postmortem investigation, submitting samples to the NMPDD laboratory or one of its affiliate laboratories when traditional methods for identification cannot be used or have failed, not burying bodies until a DNA profile has been obtained, and not cremating unidentified remains. Blood and bone, when properly collected and stored, one or both of which should be available in almost all cases, seem to be the best samples for testing. REFERENCES 1. Stewart JEB, Eisenberg A, Pokorak E (Chairs). Workshop 18. Missing persons: resources, techniques, and identification. 59th annual meeting of the American Academy of Forensic Sciences, San Antonio, TX, 2007. 2. Sweet D, Hildebrand D, Phillips D. Identification of a skeleton using DNA from teeth and a PAP smear. J Forensic Sci. 1999;44(3):630Y633. 3. Hanzlick R, Smith G. Identification of the unidentified deceased: turnaround times, methods, and demographics in Fulton County, Georgia. Am J Forensic Med Pathol. 2006;27:79Y84. 4. Murphy WA, Spruill FG, Gantner GE. Radiologic identification of unknown human remains. J Forensic Sci. 1980;25(4):727Y735. 5. Puerini S, Spruill FG, Puerini A. Forensic odontology: identification problems in Rhode Island. R I Dent J. 1977;10(2):5Y7. 6. Lorente JA, Entrala C, Alvarez JC, et al. Identification of missing persons: the Spanish BPhoenix[ program. Croat Med J. 2001;42(3):267Y270. 7. Hanzlick R. Identification of the unidentified deceased, and locating next of kin: experience with a UID website page, Fulton County, Georgia. Am J Forensic Med Pathol. 2006:27(2):126Y128. 8. O’Connor WG. Briefly unidentified: a study of a peculiar source of identification. J Forensic Sci. 1999;44(4):713Y715. 9. National Crime Information Center. Available at: http://www.fbi.gov/hq/ cjisd/missingpersons.htm. Accessed April 19, 2007.



ORIGINAL ARTICLE

The Importance of Tenascin and Ubiquitin in Estimation of Wound Age Hulya Guler, MD, Ekin O. Aktas, MD, PhD, Huseyin Karali, MD, and Safiye Aktas, MD, PhD

Abstract: Human wound age determination is of prime importance in forensic sciences. Ubiquitin is a small protein required for ATP-dependent, nonlysosomal intracellular protein degradation, which eliminates most of the intracellular defective proteins. Tenascin is an extracellular matrix glycoprotein. The aim of this study was to determine the importance of ubiquitin and tenascin in wound age. Ubiquitin and tenascin were immunohistochemically applied on formalin-fixed paraffin-embedded tissues of 170 wound biopsies taken from 89 autopsy cases with known wound age. Pearson correlation analysis was performed for statistical analysis. The mean age was 39.44 years. Tenascin was negative in 123 cases (72.4%) in all series, and it was negative in 98.3% in cases with wound age under 24 hours. It was positive in 91.8% in cases with wound age over 24 hours. Mean number of cells which expressed ubiquitin was 10.56%, while it was 4.25% in cases with wound age under 24 hours, and it was 26.14% in cases with wound age over 24 hours. The correlation analysis showed that both tenascin and ubiquitin were positively correlated with wound age. But in cases with wound age over 40 days, tenascin was found to be negative and ubiquitin was still expressed in fibroblasts. We concluded that tenascin and ubiquitin together was useful in determining wound age semiquantitatively. Key Words: wound age, ubiquitin, tenascin (Am J Forensic Med Pathol 2011;32: 83Y89)

W

ound age determination includes understanding of complex organization of cutaneous healing.1 This leads to using substances whose amount and localization change during healing.2 Human wound age determination is of prime importance in forensic sciences. The different reactions of tissues to different natures of wounds require modern diagnostic methods to determine wound age. The methods usable for this are histochemical methods defining wound age according to the changes in enzyme activity in the wound area, biochemical methods which determine the values of histamine and serotonin, and histologic methods which determine the age of the wound according to the chronological order of appearance of the cellular elements.3 The use of immunohistochemistry in estimating of wound age has been used in recent years.4,5 Only one marker has not been reported to be the determinant of wound age yet. Fibronectin was found to be effective to determine vitality after severe trauma by showing expression in early stages of the wound healing.5 The efficiency of immunohistochemical techniques for the diagnosis of vitality of wounds decreases for

Manuscript received August 3, 2009; accepted April 6, 2010. From the Dokuz Eylul University Institute of Oncology, Izmir, Turkey. Supported by Ege University Research Foundation. Correspondence: Safiye Aktas, MD, PhD, Dokuz Eylul University Institute of Oncology, Mithatpasa cad Inciralti, Izmir, Turkey 35340. E-mail: [email protected]. Copyright * 2011 by Lippincott Williams & Wilkins ISSN: 0195-7910/11/3201Y0083 DOI: 10.1097/PAF.0b013e3181edf2c0


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lesions occurred fairly close to death and within 10 days after death.6,7 Ubiquitin is a small protein required for ATP-dependent, nonlysosomal intracellular protein degradation, which eliminates most of the intracellular defective proteins with a rapid turnover. It has been suggested to play a key role in essential intracellular functions, such as heat shock response, protein breakdown, and regulation of immune responses.8,9 It is a shock protein and a common immunohistochemical marker. It is induced very rapidly by various types of traumatic stress, and this is why it is of great concern in forensic pathology especially neurodegenerative conditions.10 It is expressed both in intracellular and extracellular areas. Extracellular ubiquitin acts as a cytokine-like protein with anti-inflammatory properties.9 It is expressed in the nuclei of the neutrophile leukocytes, macrophages, and fibroblasts in wound area. Tenascin is an extracellular matrix glycoprotein.11 It is expression is restricted in adult tissues, although it is widely distributed in embryonic tissues.12,13 Although Mackie et al suggested that tenascin has an important and unique role in the wound healing process, it can not determine the wound age over 9 days.7 It has different isoforms which might be expressed as a result of alternative splicing of the premRNA, but the isoforms are distributed in a similar way in tissues.14 In early stages of wounds (3 minutesY8 hours), tenascin was found to be negative in 58 cases in their series.2 The aim of this study was to determine the importance of ubiquitin and tenascin in wound age estimation and form a semiquantitative scale for their expression according to wound age intervals.

MATERIALS AND METHODS This study was approved by the Ethics Committee of Ege University Faculty of Medicine.

Samples This study included 170 wound biopsies prospectively obtained from 89 forensic autopsy cases with known wound age (Figs. 1Y4). Cases which were autopsied 24 hours after death time were not included in the study. Median postmortem time was 18 hours (4Y24 hours). Age, sex, reason of death, and localizations, diameters, type, and morphologic description of the wounds were recorded. The wounds were examined morphologically on photographs, histologically and immunohistochemically. After external autopsy evaluation was done, the wounds were digitally photographed. After autopsy procedures were finished, biopsy samples 1 to 3 cm in length and at least 7 mm in depth were obtained from wound sites. All biopsy samples included normal adjacent skin at 1 edge. The tissues were fixed in formalin for 12 hours. After tissue processing in routine pathology they were embedded in paraffin. One slide was stained with hematoxylin eosin and 4 micrometer sections were obtained on polylysine-coated slides for immunohistochemistry. www.amjforensicmedicine.com


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FIGURE 1. Examples for gunshot wounds (AYF).

Immunohistochemistry

Evaluation

Immunohistochemistry was performed manually. Ubiquitin and tenascin were immunohistochemically applied on formalin-fixed paraffin-embedded tissues. The protocol was applied according to the manufacturer_s recommendations at room temperature. The slides were dewaxed with xylene 15 minutes; dehydrated in decreasing concentrations of alcohol (99%, 95%, 80%, 70%; each 5 minutes). The sections were immersed in 3% H2O2 in distilled water for 10 minutes at room temperature to block endogenous peroxidase activity. After washing in distilled water, heat induced antigen retrieval was applied in citrate buffer (pH 5.5) at 400 watt for 20 minutes. After cooling at room temperature, the slides were washed in distilled water and then in PBS (pH 7.4). PBS was used for all subsequent washes. After nonspecific binding was blocked with blocking reagent for 5 minutes, primary antibodies were applied at 1:100 dilutions at room temperature for 60 minutes (monoclonal antibodies to ubiquitin Novocastra NCL-Ubi-1 moue monoclonal 137705 and tenascin Novocastra mouse monoclonal 110406). Universal kit was used by rabbit/mouse streptavidin biotin technique, (Novostain Universal Detection Kit NCLRTU-D). Visualization of the bound primary antibodies was performed using diaminobenzidine solution (Liquid DAB-Plus Substrate Kit 12 mL Zymed) as a chromogene and counterstained with Mayer_s hematoxylin. One of the slides was incubated with PBS without the primary antibody as negative control. Positive control was evaluated on normal skin.

The expression intensity was nearly the same in all positive areas. The intensity was not taken into consideration. The staining percentage, localization, and pattern were evaluated. For ubiquitin expression, the expression positivity in inflammatory cells and/or fibroblasts was scored as percentage. For ubiquitin evaluation, the wounds of the cases were grouped according to wound age as; 0 to 12 hours: group 1; 24 to 120 hours (1Y5 days): group 2; 168 to 336 hours (7Y14 days): group 3; and 408 to 504 hours (17Y21 days): group 4. For ubiquitin evaluation, the wounds of the cases were groups according to wound age as: group 0: no wound (which might be considered as control group); group 1: 0 to 12 hours; group 2: 24 to 120 hours (1Y5 days); group 3: 168 to 336 hours (7Y14 days); and group 4: 408 to 504 hours (17Y21 days) (Fig. 5). Positivity in epidermis was considered as positive control. For ubiquitin; group 0 indicated no expression; group 1: G10% positivity in inflammatory cells and fibroblasts (0Y12 hours); D: group 2: 11% to 20% positivity (1Y5 days); E: group 3: 21% to 50% positivity (7Y14 days); F: group 4: 15% to 25% positivity (17Y21 days). For tenascin expression; pattern 0 demonstrated cases with no expression, pattern 1 dermoepidermal junction positivity, pattern 2 positivity in both dermoepidermal junction and around dermoepidermal junction, pattern 3 positivity in granulation tissue, pattern 4 positivity around granulation tissue and in deep reticular dermis, and pattern 5; positivity in deep dermis but not in granulation tissue.

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Tenascin and Ubiquitin

FIGURE 2. Examples for sharp weapon injuries (AYF).

Statistical Analysis Pearson correlation analysis was performed on SPSS 9.05. P values smaller than 0.05 was considered statistically significant.

RESULTS Seventy-four cases (83.15%) were male and 15 cases (16.85%) were female. The mean age was 39.44 years (range: 15Y85 years). Among 170 wound samples 74 (43.5%) were gunshot wounds, 20 (11.8%) were blunt injuries, and 76 (44.7%) were sharp weapon injuries or surgical excisions. The study included all the cases between the periods of the study so that it included broad range of wound types. Tenascin was negative in 123 cases (72.4%) in all series, while it was negative in 98.3% in cases with wound age under 24 hours. It was positive in 91.8% in cases with wound age over 24 hours. Pattern 0 indicates wound age approximately around day 0; pattern 1: day 1; pattern 2: day 3; pattern 3: day 6; pattern 4: day 10; and pattern 5: day 22 (Fig. 6). Mean number of cells which showed ubiquitin expression was 10.56%, while it was 4.25% in cases with wound age under 24 hours, and, it was 26.14% in cases with wound age over 24 hours. In correlation analysis, both tenascin (P = 0.0001) and ubiquitin (P = 0.0001) were positively correlated with wound * 2011 Lippincott Williams & Wilkins

age. But in cases with wound age over 40 days tenascin was found to be negative, and while ubiquitin still showed expression in fibroblasts. The wound age matching with studied parameters did not change with wound type (P 9 0.05). Comparison of wound ages according to months for tenascin and ubiquitin is shown in Figure 7. Comparison of tenascin and ubiquitin expression according to wound times is shown in Tables 1 and 2, respectively.

DISCUSSION To exactly diagnose the cause and manner of death, it is essential to describe the findings of wounds correctly and objectively.15 Determining wound time as if it was caused before, at the time or after death is an important question in forensic wound examination besides the other questions such as how it was caused; what caused it; what amount of force was required to produce it; what degree of injury has resulted from it and whether it has influenced death or caused disability.15 If there are multiple wounds, it must be clarified whether they were at the same time or not. Wound healing is an interactive process that involves soluble mediators, extracellular matrix components, keratinocytes, fibroblasts, endothelial cells, nerve cells, and leukocytes (whether the wound is sterile or not).16,17 Literature review showed us that there have been studies about www.amjforensicmedicine.com


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FIGURE 3. Examples for surgical incisions (AYI).

FIGURE 4. Examples for blunt injuries (AYD).

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FIGURE 5. Ubiquitin expression patterns (A) positivity in epidermis considered as positive control; (B) Group 0: no expression; (C) Group 1: G10% positivity in inflammatory cells and fibroblasts (0Y12 hours); (D) Group 2: 11% to 20% positivity (1Y5 days); (E) Group 3: 21% to 50% positivity (7Y14 days); (F) Group 4: 15% to 25% positivity (17Y21 days).

wound age determination by tenascin or ubiquitin. This is the first study in which the 2 proteins were explored together, and used in a scale to discriminate late wound ages. ICAM-1, VCAM-1, and selectins were found to be the indicators of the vitality of wound but they do not determine the time of wound in days. P-selectin was demonstrated to be expressed in very early stages of wounds (between 3 minutes and 7 hours after injury).18 Strong positive staining for ICAM-1 was observed 12 hours after the time of injury and as the earliest and 32 hours after the time of injury as the latest.19 Oshima and coworkers demonstrated the possible use of mRNA analysis for forensic wound examination in their study about interleukin 10, because mRNA was detectable by RTPCR over a longer postmortem time course.20 Among chemokines, ratios of 950% for IL-8 indicated a wound age of at least 1 day.21 Apoptotic cell number detected by in situ end labeling of fragmented DNA was found to indicate a postinfliction interval of approximately 3 weeks or more with a value exceeding 3 cells/0.0001 cm2.22 Tenascin is known to be produced by fibroblasts and mesenchymal cells.7 Its localization of expression changes according to wound age.7 In normal skin, tenascin has been detected in * 2011 Lippincott Williams & Wilkins

the basal lamina of the dermal capillaries and the hair follicles. In the literature, there have been 3 types of studies about wound evaluation. These are cell culture studies, animal models and surgery or autopsy cases. Our study has an adequate number of cases collected from autopsies with known wound age. The cases in which the wound age was hesitated were excluded. All of the cases had detailed clinical data and digital photographs. Macroscopic examination might be very helpful if a clinicopathologic scoring is planned. This study did not include macroscopic evaluation, because all the cases were with known wound age and the macroscopic views were all in concordance with the known age. The second important finding of this study was that tenascin and ubiquitin expression did not change according to the wound type. The wound types included in this study were gunshot wound, blunt injury, and sharp injury (weapon or surgical excision). The wound type did not effect the wound age determination by ubiquitin and tenascin. This finding strongly supports the possible use of these markers for wound age estimation. The reasons why tenascin and ubiquitin is chosen in this study includes their different types of activities. Ubiquitin is mainly included in inflammatory area, while tenascin is a www.amjforensicmedicine.com


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FIGURE 6. Tenascin expression patterns (A) positivity in epidermis is considered as positive control. B, Pattern 0; no expression (day 0); (C) Pattern 1; dermoepidermal junction positivity (day 1); (D) Pattern 2: positivity in both dermoepidermal junction and around (day 3); (E) Pattern 3; positivity in granulation tissue (day 6); (F) Pattern 4; positivity around granulation tissue and in deep reticular dermis (day 10).

TABLE 1. Comparison of Tenascin Positivity in Each of the Defined Groups Wound Type

Time

Tenascin

N

Percent

Gunshot wound

G24 h

Negative Positive Total Negative Positive Total Negative Positive Total Negative Positive Total Negative Positive Total Negative Positive Total

56 7 63 4 7 11 14 1 15 2 3 5 40 3 43 10 23 33

88.9 11.1 100.0 36.4 63.6 100.0 93.3 6.7 100.0 40.0 60.0 100.0 93.0 7.0 100.0 30.3 69.7 100.0

924 h

Blunt injury

G24 h

924 h

Sharp weapon injury or surgical excision

G24 h

924 h FIGURE 7. Comparison of wound ages according to months for tenascin and ubiquitin.

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TABLE 2. Comparison of Ubiquitin Positivity in Each of the Defined Groups Wound Type

Time

Ubiquitin

N

Percent

Gunshot wound

G24 h

Negative Positive Total Negative Positive Total Negative Positive Total Negative Positive Total Negative Positive Total Negative Positive Total

11 52 63 6 5 11 4 11 15 3 2 5 7 36 43 30 3 33

17.5 82.5 100.0 54.5 45.5 100.0 26.7 73.3 100.0 60.0 40.0 100.0 16.3 83.7 100.0 90.9 9.1 100.0

924 h

Blunt injury

G24 h

924 h

Sharp weapon injury or surgical excision

G24 h

924 h

component of extracellular matrix. These 2 properties are basic for injury and wound healing changing by time. In conclusion, that tenascin and ubiquitin together are useful in determining wound age semi quantitatively at the viewpoint of a forensic pathology application. This determination would not change in different wound types. Tenascin and ubiquitin together would give advantage determining wound ages over 40 days as well. Determination of mRNA analysis of several parameters including extracellular matrix, inflammation, and ubiquitin related proteins by quantitative RT-PCR or microarray analysis might give more information for time determination in wounds in forensic sciences. REFERENCES


immunohistochemical study of local injuries. Forensic Sci Int. 2003; 135:218Y225. 6. Ortiz-Rey JA, Suarez-Penaranda JM, Munoz-Barus JI, et al. Expression of fibronectin and tenascin as a demonstration of vital reaction in rat skin and muscle. Int J Leg Med. 2003;117:356Y360. 7. Mackie EJ, Halfter W, Liverani D. Induction of tenascin in healing wounds. J Cell Biol. 1988;107:2757Y2767. 8. Pickart CM, Eddins MJ. Ubiquitin: structures, functions, mechanisms. Biochimica et Biophysica Acta. 2004;1695:55Y72. 9. Majetschak M, Krehmeier U, Bardenheuer M, et al. Extracellular ubiquitin inhibits the TNF-alpha response to endotoxin in peripheral blood mononuclear cells and regulates endotoxin hyporesponsiveness in critical illness. Blood. 2003;101:1882Y1890. 10. Quan L, Zhu BL, Ishida K, et al. Intranuclear ubiquitin immunoreactivity of the pigmented neurons of substantia nigra in fatal acute mechanical asphyxiation and drowning. Int J Leg Med. 2001;115:6Y11. 11. Egging D, van Vlijmen-Willems I, van Tongeren T, et al. Wound healing in tenascin-X deficient mice suggests that tenascin-X is involved in matrix maturation rather than matrix deposition. Connect Tissue Res. 2007;48:93Y98. 12. Odaka K, Uehara T, Arano Y, et al. Noninvasive detection of cardiac repair after acute myocardial infarction in rats by 111 In Fab fragment of monoclonal antibody specific for tenascin-C. Int Heart J. 2008;49: 481Y492. 13. Kilian O, Dahse R, Alt V, et al. mRNA expression and protein distribution of fibronectin splice variants and high-molecular weight tenascin-C in different phases of human fracture healing. Calcif Tissue Int. 2008; 83:101Y111. 14. Latijnhouwers M, Jongh GJ, Bergers M, et al. Expression of tenascin-C splice variants by human skin cells. Arch Dermatol Res. 2000;292: 446Y454. 15. Ohshima T. Forensic wound examination. Forensic Sci Int. 2000;113: 153Y164. 16. Grellner W. Time-dependent immunohistochemical detection of proinflammatory cytokines (IL-1A, IL-6, TNF->) in human skin wounds. Forensic Sci Int. 2002;130:90Y96. 17. Gillitzer R, Goebeler M. Chemokines in cutaneous wound healing. J Leukoc Biol. 2001;69:513Y521.

1. Oehmichen M. Vitality and time course of wounds. Forensic Sci Int. 2004;144:221Y231.

18. Dressler J, Bachmann L, Koch R, et al. Estimation of wound age and VCAM-1 in human skin. Int J Leg Med. 1999;112:159Y162.

2. Ortiz-Rey JA, Sua´rez-Penãranda JM, Da Silva EA, et al. Immunohistochemical detection of fibronectin and tenascin in incised human skin injuries. Forensic Sci Int. 2002;126:118Y122.

19. Dressler J, Bachmann L, Strejc P, et al. Expression of adhesion molecules in skin wounds: diagnostic value in legal medicine. Forensic Sci Int. 2000;113:173Y176.

3. Psaroudakis K, Tzatzarakis MN, Tsatsakis AM, et al. The application of histochemical methods to the age evaluation of skin wounds: experimental study in rabbits. Am J Forensic Med Pathol. 2001;22: 341Y345.

20. Kondo T, Oshima T, Eisenmenger W. Immunohistochemical and morphometrical study on the temporal expression of interleukin-1> (IL-1>) in human skin wounds for forensic wound age determination. Int J Leg Med. 1999;112:249Y252.

4. Hayashi T, Ishida Y, Kimura A, et al. Forensic application of VEGF expression to skin wound age determination. Int J Leg Med. 2004; 118:320Y325. 5. Fieguth A, Franz D, Lessig R, et al. Fatal trauma to the neck:


21. Kondo T, Tanaka J, Ishida, et al. Ubiquitin expression in skin wounds and its application to forensic wound age determination. Int J Leg Med. 2002;116:267Y272. 22. Betz P. Histological and enzyme histochemical parameters for the age estimation of human skin wounds. Int J Leg Med. 1994;107:60Y68.



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ORIGINAL ARTICLE

An Experimental Model of Tool Mark Striations in Soft Tissues Produced by Serrated Blades Derrick J. Pounder, FRCPA and Lesley Cormack, BMSc

Abstract: Stab wounds produced by serrated blades are generally indistinguishable from stab wounds produced by nonserrated blades, except when visible tool mark striations are left on severed cartilage. We explored the possibility that similar striations may be produced on the soft tissues of internal organs. Loin of beef, bovine kidney, and pig heart, liver, and aorta were each stabbed 20 times with a coarsely serrated blade. The walls of the stab tracks were exposed and documented by photography, cast with dental impression material, and the casts photographed. Striations were identified in all of the tissues in every stabbing, but their consistency and quality varied between tissues. Striations were most easily seen in liver, heart, and aorta. Tool mark striations in soft tissues other than cartilage have not been described in homicidal stabbings, likely because they have not been sought. We suggest that the walls of stab wound tracks should be exposed, and tissue striations should be sought as a means of identifying the weapon as having a serrated blade.

wound track was opened using a scalpel blade, the 2 opposing walls of the wound track examined by naked eye, photographed under markedly oblique lighting, dried with paper towelling, cast with Provil Novo Medium C.D.2 fast set vinyl polysiloxane dental impression material (Heraeus Kultzer, South Bend, Indiana), and the cast photographed. For each stab, the wound track in the fresh tissue was searched for striation marks and graded as 0 if they were not present, 1 if they were present, but faint and not fully formed into a typical pattern, 2 if they were present and fully formed into a typical pattern but not readily obvious to an untrained eye, and 3 they were present, fully formed into a typical pattern and so prominent as to be evident even to an untrained eye. An initial series of 12 stab wounds was made in muscle with the stab orientated at different angles to the direction of the muscle fibers. The consistency of the appearance of striations was assessed by making 20 stab wounds in each tissue.

Key Words: stab wounds, serrated knives, striations, heart, liver (Am J Forensic Med Pathol 2011;32: 90Y92)

RESULTS

Manuscript received August 3, 2009; accepted September 18, 2009. From the Centre for Forensic and Legal Medicine, University of Dundee, Dundee, Scotland, United Kingdom. Correspondence: Derrick J. Pounder, FRCPA, Centre for Forensic and Legal Medicine, University of Dundee, Dundee DD1 4HN, Scotland, United Kingdom. E-mail: d.j.pounder)dundee.ac.uk. Copyright * 2011 by Lippincott Williams & Wilkins ISSN: 0195-7910/11/3201-0090 DOI: 10.1097/PAF.0b013e3181edf2de

Initial stabs to skeletal muscle indicated that striations were not produced unless the stab track was at right angles to the orientation of the muscle fibers. If the orientation was changed to 45- to the direction of muscle fibers then striations could not be seen. The subsequent 20 test stabs to muscle were all made perpendicular to the direction of the muscle fibers. Striations from the serrated blade were identifiable in all of the tissues (skeletal muscle, heart, liver, renal cortex, renal medulla and aortic wall) in all of the 20 stabs made to each tissue but with differing consistency (Table 1). In heart (left ventricle), striations similar to those described in cartilage (Fig. 1) were present where the stab track severed a band of myocardial fibers at right angles to their orientation, and consequently striations were not present throughout the depth of the stab track (Fig. 2). In liver, the striations were generally well developed (Fig. 3). In the kidney, the striations were more obvious in the medulla than the cortex (Fig. 4). In muscle, the striations were difficult to distinguish against the background of the muscle bundles (Fig. 5). The aorta, like the heart, showed variable development of striations (Fig. 6). In skeletal muscle, the striations were best documented by photography of the fresh specimen. Casting was not as effective because it exaggerated the natural texture of the muscle which overshadowed the striations (Fig. 5). Movement of bundles of muscle fibers within the muscle mass following the stabbing resulted in distortion of the striation pattern so that no grade 3 striations were observed. In the heart, the striations were equally well documented by photography of the fresh specimen and casting, the natural deep color of the tissue providing good contrast against which the striations could be seen and with little surface reflectance to interfere with photography (Fig. 2). The wound surface could be dried so that there was good adherence of the casting material to the surface. However, consistency of the development of striations was dependent upon the direction of the myocardial muscle bundles passing across the stab track.

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tab wounds produced by serrated blades are generally regarded as indistinguishable from stab wounds produced by nonserrated blades.1 Although a serrated blade may result in a stab wound with somewhat ragged edges to the skin margin, the wound does not appear serrated as such.2Y4 If it happens that the serrated blade is drawn obliquely across the skin surface then the points of the serrations can create parallel scratches or superficial cuts2 but this is a possible associated finding rather than an inherent feature of the stab wound. Should the serrated blade sever cartilage then the serrations will leave visible striations on the cartilage.5,6 Such striations in cartilage appear to be a universal and reliable finding when a stab from a serrated blade involves cartilage.7 We explored the possibility that similar striations to those found in cartilage might also be left on other organs and tissues commonly damaged in fatal stabbings.

MATERIALS AND METHODS Loin of beef, bovine kidney, and pig heart, liver, and aorta were sourced from a commercial butcher. The tissue was placed on a block of Oasis (florists foam) saturated with water, resting upon a wooden chopping board. The tissue was held in a fixed position by string passing through the tissue and tethered to nails at the 4 corners of the board. A straight spine coarsely serrated kitchen knife was used to stab the tissue. Following stabbing the


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Tool Mark Striations Produced by Serrated Blades

TABLE 1. Grading of 20 Stabs to Each Tissue Tissue Muscle Heart Liver Renal cortex Renal medulla Aorta

Grade 1

Grade 2

Grade 3

9 4 0 11 4 3

11 9 8 9 6 9

0 7 12 0 10 8

In liver, the striations were most readily evident by naked eye examination of the fresh tissue (Fig. 3). Photography was somewhat difficult because of prominent reflectance of the fresh tissue surface and casting was difficult because of poor adherence of the casting material with resulting bubble formation. In the kidney, as with the liver, the striations were best seen by naked eye examination of the fresh tissue. Surface reflectance limited photography and poor adhesion of the casting material to the surface of the tissue resulted in poor casts. Since the striations were most evident in the medulla (Fig. 4), the ease with which striations could be identified in any given stab track depended upon the extent to which the medulla was implicated. In the aorta, striations were best documented by casting (Fig. 6) because the pale color of the tissue made photography of the fresh specimen difficult. Curling of the aorta when it was dissected resulted in distortion of the striation pattern, and loose tissue from the outer wall of the aorta appeared to have been dragged into the stab canal during the stabbing action resulting in partial obliteration of the striation pattern.

DISCUSSION In this experimental study, we have observed striations on the walls of stab tracks produced using a coarsely serrated blade. For ethical reasons, the experiments were performed on animal tissues. However, dissecting the internal organs at autopsy using a coarsely serrated blade will readily demonstrate to any pathologist that these observations are applicable to human tissues. Not surprisingly different tissues, having different consistency, retain the striation marks to different degrees, with their observation most readily and consistently made in the liver. Surface reflectance makes photodocumentation of the striations in some tissues, particularly liver and kidney, a problem that can be partly ameliorated by gently blotting the surface of the tissue prior to photography. Some creativity is required in casting the striations, and we found that placing the aorta between 2 glass microscope slides prevented the specimen curling and facilitated casting. The aorta was particularly liable to dry out under

FIGURE 1. Cast of tool mark striations in cartilage from a serrated blade, for comparison purposes (mm scale). * 2011 Lippincott Williams & Wilkins

FIGURE 2. Tool mark striations in myocardium on part of the wall of a stab track produced with a coarsely serrated blade (mm scale).

the intense heat of the photographic lamps, resulting in curling and degradation of the striations so that the whole process of photodocumentation and casting needs to be carried out expeditiously. Differing casting materials may need to be used to enhance the casting of striations in different tissues. Previous research6 used a polysulphide dental impression material for casting. Polysulphides belong to the elastomer class of dental impression materials. Although it is economic, it does not produce the most accurate casts when compared with other elastomers, and due to the release of an alcohol during storage it is not the most stable.8Y10 We chose to use another elastomer, vinyl polysiloxane that involves the mixing of 2 prepolymers which react by cross linkage without the formation of by-products and consequently produce a very stable impression with no dimensional change on storage. The viscosity of the casting material is directly proportional to its ability to accurately reproduce the fine detail of the surface being cast. Although low viscosity casting material produces more accurate impressions, it is harder to manipulate and work with and for this reason we chose a medium viscosity material as an appropriate compromise between accuracy of impression and ease of manipulation. The principle disadvantage of addition cured vinylpolysiloxane elastomers is that they are exceptionally hydrophobic so that any surface moisture will produce imperfections in the impression. Consequently, the surface needs to be thoroughly dried prior to application of the casting material. A majority of homicidal stab wounds are to the anterior chest and in about a quarter or more of these the heart is involved,11,12 with the aorta and major blood vessels more commonly involved

FIGURE 3. Tool mark striations in liver on the wall of a stab track produced with a coarsely serrated blade (mm scale). www.amjforensicmedicine.com


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FIGURE 6. Cast of striations in aortic wall produced by a stab from a coarsely serrated blade (mm scale). The striations are more closely spaced on the left than on the right indicating that the spine of the blade was to the right and the cutting edge to the left. FIGURE 4. Cast of tool mark striations in renal medulla on the wall of a stab track produced with a coarsely serrated blade (mm scale).

than the heart itself.12 When there are stab wounds to the abdomen, the liver is implicated in about 3 quarters of cases.13,14 Fortuitously, striations are most readily identified in the liver, but are also well seen also in the heart and aorta, so that a search for them in fatal stabbings is likely to be of value in assessing whether the weapon used was serrated or not. Although stab wounds to the limbs implicating skeletal muscle may not be lethal in themselves, the limbs are the third most commonly affected area of the body in a stabbing attack.15 Stab wounds at right angles to the run of the muscle fibers would be worth exploring for evidence of striations, despite the difficulties in identifying them. When embarking on this study, we reasoned that if tool mark striations were produced on cartilage by serrated blades5Y7 then similar marks might be produced in other tissues, albeit other tissues might not retain them as well. The fact that such striations could be observed in all of the tissues we studied came as a surprise nevertheless. Homicidal stab wounds are not uncommon16 and we, as with all practicing forensic pathologists, have examined many, including stabs produced by serrated blades. We have never observed these striations in soft tissues in fatal human stabbings from serrated blades. Given the results of this

FIGURE 5. Cast of the wall of a stab track in skeletal muscle produced with a coarsely serrated blade (mm scale). Vertical striations are visible above and to the right of the label Bstriations[ but less easily seen elsewhere as a result of the interfering pattern of skeletal muscle bundles.

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study, we feel that they surely must have been present and that our failure to observe them may be explained by the fact that we were not aware of the possibility and did not look for them. Indeed, this may be an example of the old adage Bwe see only what we know.[ REFERENCES 1. Spitz W. Sharp force injury. In: Spitz W, ed. Spitz and Fisher_s Medicolegal Investigation of Death: Guidelines for the Application of Pathology to Crime Investigation. 4th ed. Springfield, IL: Charles C. Thomas; 2006:566. 2. Dolinak D, Matshes E, Law E. Sharp force injuries. In: Forensic Pathology: Principles and Practice. London, United Kingdom: Elsevier Academic Press; 2005:143Y162. 3. DiMaio V, DiMaio D. Wounds due to pointed and sharp edged weapons. In: Forensic Pathology. 2nd ed. London, United Kingdom: CRC Press; 2001:187Y228. 4. Hanzlick R, Graham M. Sharp force injury. In: Forensic Pathology in Criminal Cases. 2nd ed. New York, NY: Lexis; 2000:211Y221. 5. Bonte W. Tool marks in bone and cartilage. J Forensic Sci. 1975;20:315Y325. 6. Rao V, Hart R. Tool mark determination in cartilage of stabbing victim. J Forensic Sci. 1983;28:794Y799. 7. Pounder DJ, Cormack L, Broadbent E, et al. Class characteristics of serrated knife stab wounds to cartilage. Am J Forensic Med Pathol. Publication ahead-of-print doi: 10.1097/PAF.0b013e3181db7ee4. Accessed July 13, 2010. 8. Noort R. Impression materials. In: Parkinson M, Morrison J, eds. Introduction to Dental Materials. London, United Kingdom: Mosby Elsevier; 2007:196Y294. 9. Ferracane J. Impression materials. In: Allen A, ed. Materials in Dentistry, Principles and Application. Philadelphia, PA: J.B Lippincott; 1995:176Y195. 10. McCabe J, Walls A. Elastic impression materials: synthetic elastomers. In: Applied Dental Materials. 8th ed. Cambridge, MA: Blackwell Science; 1998:146Y148. 11. Gill J, Cantanese C. Sharp injury fatalities in New York City. J Forensic Sci. 2002;47:554Y557. 12. Moar J. Homicidal penetrating incised wounds of the thorax an autopsy study of 52 cases. S Afr Med J. 1984;65:385Y389. 13. Ambade V, Godbole H. Comparison of wound patterns in homicide by sharp and blunt force. Forensic Sci Int. 2006;156:166Y170. 14. Demetriades D, Hadjizacharia P, Constantinou C, et al. Selective nonoperative management of penetrating abdominal solid organ injuries. Ann Surg. 2006;244:620Y628. 15. Wong K, Petchell J. Severe trauma caused by stabbing and firearms in metropolitan Sydney, New South Wales, Australia. Aust NZ J Surg. 2005;75:225Y230. 16. Karlsson T. Sharp force homicides in the Stockholm area, 1983Y1992. Forensic Sci Int. 1998;94:129Y139.



ORIGINAL ARTICLE

Tool Mark Striations in Pig Skin Produced by Stabs From a Serrated Blade Derrick J. Pounder, FRCPA, Shivani Bhatt, MB, Lesley Cormack, BMSc, and Bill A. C. Hunt, FRCPath

Abstract: Stab wounds produced by serrated blades are generally indistinguishable from stab wounds produced by nonserrated blades, except when visible tool mark striations are left on severed cartilage. Using a pig-skin experimental model, we explored the possibility that similar striations may be left in skin. Stabs into pig skin were made using a straight spine coarsely serrated blade (121), a drop point finely serrated blade (20), a clip point irregular coarsely serrated blade (20), a drop point coarsely serrated blade (15), and as controls 2 nonserrated blades (40). Tool mark striations could be seen on the skin wall of the stab canal in all stabs made using serrated blades but in none with nonserrated blades. The striation pattern, reflecting the class characteristics of the serrated blade, was the same as that described in cartilage but less well defined. Fixation of the specimen with Carnoy_s solution best preserved visible striations, and fixation with formaldehyde after staining with 5% Neutral Red was also satisfactory. Casting with vinyl polysiloxane dental impression material greatly facilitated photo-documentation. Applying the technique to homicidal stabbings may help identify stab wounds produced with serrated blades. Key Words: stab wounds, serrated knives, striations, skin (Am J Forensic Med Pathol 2011;32: 93Y95)

I

t is generally accepted that simple in-out stab wounds produced by serrated blades are indistinguishable from stab wounds produced by nonserrated blades.1 The exceptions are stab wounds through cartilage which leave tool mark striations on the cartilage corresponding with the blade serrations.2Y5 Using a pig-skin model we explored the possibility that similar tool mark striations, indicative of the use of a serrated blade, might be found on the skin wall of the stab canal, which is not usually closely examined, if at all.

MATERIALS AND METHODS Serrated knives were purchased in department stores and their characteristics documented. Standard terminology with respect to knife blade anatomy has been used.5 Porcine skin was sourced from a commercial butcher and trimmed to 10 cm squares which included subcutaneous fat and fascia. The skin was tethered with string at the midpoints of the 4 sides and at the 4 corners to 8 nails set in a wooden chopping board, with the skin sitting upon a block of Oasis (florists foam) saturated with water, to allow for penetration of the blade through the skin. The stabbing was achieved slowly with the knife at 90- to the skin Manuscript received August 10, 2009; accepted September 18, 2009. From the Centre for Forensic and Legal Medicine, University of Dundee, Scotland, United Kingdom. Correspondence: Derrick J. Pounder, FRCPA, Centre for Forensic and Legal Medicine, University of Dundee, Dundee DD1 4HN, Scotland, United Kingdom. E-mail: d.j.pounder)dundee.ac.uk. Copyright * 2011 by Lippincott Williams & Wilkins ISSN: 0195-7910/11/3201Y0093 DOI: 10.1097/PAF.0b013e3181edf2fe


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surface and the knife then withdrawn. The section of skin with the stab was trimmed to a smaller size and the stab opened by inserting a scalpel blade spine first and rotating the scalpel so as to extend the ends of the stab canal to the margins of the skin without damaging the stab track. In initial experiments a dye (5% Neutral Red) was introduced into the stab canal prior to extending it, to identify the limits of the original wall of the stab canal, and to reduce translucency and reflectance of the surface so as to make any striations easier to see. The exposed stab canal surface was rinsed with water and blotted dry with paper towel. The cut surfaces were examined by naked eye and then photographed using markedly oblique lighting to accentuate any striations. After photo-documentation, the cut surfaces were cast using Provil Novo Medium C.D.2 fast set vinyl polysiloxane dental impression material (Heraeus Kultzer, South Bend, IN). The casts were photographed. Some specimens of skin were fixed, with the specimen kept flat by compression between foam in histology cassettes, using 10% formaldehyde, Carnoy_s solution (ethanol, chloroform, acetic acid 6:3:1), and Bouin_s and Zenker_s solutions to asses the utility of fixation. Subsequently, 10 specimens each were fixed in formaldehyde and Carnoy_s solution and observed daily for 3 days and then at 3 weeks.

RESULTS Stabs were made using a straight spine coarsely serrated blade (121), a drop point finely serrated blade (20), a clip point irregular coarsely serrated blade (20), a drop point coarsely serrated blade (15), and as controls 2 nonserrated blades (40). Tool mark striations could be seen on the skin wall of the stab canal in all of the 176 stabs made using serrated blades, 100 of which were performed with a straight spine coarsely serrated blade to specifically assess the reproducibility of the phenomenon. Striations were visible to the naked eye on both opposing walls of the stab canal, and this was facilitated by viewing from various angles under strong directional lighting. However, striations on the pale translucent and reflective tissue, when unstained, were difficult to photo-document (Figs. 1 and 2). Staining with Neutral Red offered some improvement but not sufficient for easy and reliable photo-documentation. Casting with dental impression elastomer presented handling challenges but resulted in optimal images (Figs. 3 and 4). Since the serrations are ground onto only one side of the blade, they are represented on one stab track wall as narrow furrows, and on the opposing wall as narrow ridges, with the casts then reversing both images (compare Figs. 3 and 4). The ridges are easier to see in both the tissue and casts, so that striations were more easily identified on one wall of the stab canal than the other. The overall pattern of striations was the same as that seen in serrated blade tool mark striations in cartilage, namely a prominent gap between the blade-spine wound end and the first striation followed by striations with consecutively shorter distances between them (Figs. 2Y4). The striation marks were not as well seen or as easy to cast as in cartilage (Fig. 5). www.amjforensicmedicine.com


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FIGURE 1. Vertical striations in pig skin on a stab canal wall produced with a serrated blade. India ink on the skin surface marks the ends of the stab (striations are about 2 mm in height; compare with Fig. 2).


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FIGURE 5. Cast of striations in cartilage on a stab canal wall produced with a serrated blade (mm scale).

FIGURE 6. Cast of striations and blade-tip chatter mark in pig skin on a stab canal wall produced with a serrated blade (mm scale). FIGURE 2. Vertical striations in pig skin on a stab canal wall produced with a serrated blade. The striations are more closely spaced on the leftYtowards the blade edgeVthan on the rightVtowards the blade spine (mm scale).

FIGURE 3. Cast of striations in pig skin on a stab canal wall produced with a serrated blade. The striations appear as furrows which become more closely spaced towards the blade-edge end of the stab (mm scale).

FIGURE 7. Cast of striations and blade-tip chatter mark in pig skin on a stab canal wall produced with a serrated blade (mm scale).

FIGURE 4. Cast of striations in pig skin on a stab canal wall produced with a serrated blade. The striations appear as narrow ridges which become more closely spaced towards the blade-edge end of the stab (mm scale). Contrast with Figure 3.

yellow color which made it more difficult to identify serrations, and Zenker_s solution caused obliteration of the striations. Carnoy_s solution turned the skin a pink color while the fat appeared a pale white, making it easier to identify the limits of the skin and also highlighting the serrations. Formaldehyde blurred the division between skin and fat and made striations difficult to see. Overall Carnoy_s solution was the best fixative for unstained skin to preserve the visible striations. If the stab track was first stained with Neutral Red then Carnoy_s solution immediately leached the stain which was removed completely by 3 weeks, leaving the specimen in appearance the same as if the Carnoy_s had been applied to unstained skin. Formaldehyde retained the Neutral Red staining, which enhanced visibility of the striations.

In some stabs produced using a coarsely serrated blade, an oblique mark was observed passing from the wound end corresponding to the spine of the blade upwards towards the surface of the skin. Comparison of this mark with the knives indicated that it represented the blade edge at the tip, reflecting a Bblade tip chatter mark[ (Figs. 6 and 7), produced when tissue was initially trapped in the concavity of the first scallop, causing the blade to jar slightly.5 Of the 4 fixatives used on skin which had not been stained with Neutral Red, Bouin_s solution stained the specimens a deep

Pig skin is the traditional model for human skin but is thicker at about 2 mm as can be seen from the illustrations (Figs. 3, 4, 6, 7). There is no doubt that the thickness of pig skin makes it easier to identify striations in the fresh tissue, facilitates specimen handling and simplifies the difficult task of casting. Therefore it seems likely that identification of tool mark striations in skin in a homicidal stabbing with a serrated blade will prove more difficult. Stabs in areas of the body with relatively thick skin well tethered to underlying tissues, such as on the

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DISCUSSION




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back of the torso and neck, are likely to prove most productive. The striation pattern in skin is not as well defined as in cartilage and the tool marks are unlikely to do more than demonstrate the use of a serrated blade and its overall serration pattern, but no more. Even so this would be a considerable advance on the present situation in which it is not generally possible to distinguish between stabs from serrated and nonserrated blades. Given the difficulties of specimen handling and casting, a practical strategy may be to fix the specimen in Carnoy_s solution, or fix the specimen stained with Neutral Red in formaldehyde for later laboratory examination and casting. Fixation may result in minor tissue shrinkage, but since the interest is in class rather than individualizing tool marks, this should not give rise to significant difficulties. The pattern of striation marks in skin is the same as that in cartilage2Y5 including in some instances the presence of a Bblade tip chatter mark.[5


Tool Mark Striations in Pig Skin

REFERENCES 1. Spitz W. Sharp force injury. In: Spitz W, ed. Spitz and Fisher_s Medicolegal Investigation of Death: Guidelines for the Application of Pathology to Crime Investigation. 4th ed. Springfield, IL: Charles C. Thomas; 2006:566. 2. Bonte W. Tool marks in bone and cartilage. J Forensic Sci. 1975;20: 315Y325. 3. Bonte W. Considerations on the identification of notch traces from stabbing injuries Ein German^. Archiv fu¨r Kriminologie. 1972;149:77Y96. 4. Rao V, Hart R. Tool mark determination in cartilage of stabbing victim. J Forensic Sci. 1983;28:794Y799. 5. Pounder DJ, Cormack L, Broadbent E, Millar J. Class characteristics of serrated knife stabs to cartilage. Am J For Med Pathol. Published Ahead-of-print. doi: 10.1097/PAF.0b013e3181db7ee4. Accessed July 9, 2010.



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BOOK REVIEW

TASER\ Conducted Electrical Weapons: Physiology, Pathology, and the LawVedited by Mark W. Kroll and Jeffrey D. Ho ublished in 2009, BTASER\ Conducted Electrical Weapons: Physiology, Pathology, and the Law[ offers a comprehensive review of the TASER devices and an overview of in-custody events that may or may not include the use of the devices. The editors, Drs Kroll and Ho, have invited more than 50 authors of varying expertise to contribute to the 32 chapters that are in this reference book. Backgrounds of a few of the authors include law enforcement, biomedical engineering,

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96


electrophysiology, clinical and academic medicine, military, toxicology, and the justice system. The history of the use of the conducted electrical weapons by law enforcement and a basic science review offer a prelude to the focus of most of the book, which is the questions and concerns about possible adverse effects of the TASERconducted electrical weapon. Some of the topics covered include research using animal and human models looking for lethal cardiac arrhythmias, electrocardiographic and blood chemical changes, and interaction with pacemakers and implantable defibrillator devices, as well as practical experience in various law enforcement agencies. The latter part of the book then evolves into an overview of pertinent topics such as stimulant abuse, excited delirium, postmortem brain analysis in

excited delirium deaths, sudden unexpected in-custody deaths, and the legal impact of such events. The reader is able to travel with ease from the simple to the complex with wellwritten chapters that are complemented with tables, graphs, photos, and appendices. The book is completed with thorough bibliographies. An honest and credible provision is the author’s contact information and disclosure of any relationship with TASER International, Inc. This book would be beneficial in preparation for trials, lectures, or completion of postmortem examinations of any in-custody death.


Ruth E. Kohlmeier, MD Odessa, TX

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