[An autopsy case of sudden death caused by untreated sepsis after complete remission of acute promyelocytic leukemia]

The patient was 63 year-old man. He had been diagnosed as acute promyelocytic leukemia (APL) and treated until 4 month before his death with complete remission. The patient suddenly died 9 days after he complained of occipital headache. Autopsy and histopathologic findings were as follows: the left pleura was thick and calcificated with abscess, compatible with the findings of old tuberculosis complicated with bacterial infection. Furthermore, polynuclear leukocytes and gram-positive micro-organisms were accumulated in the lungs, and pyogenic meningitis, pyonephritis, splenitis were also found. Bacteologically, Streptococcus pneumoniae was detected from cadaver's blood and cerebrospinal fluid. Therefore, we concluded that the patient was died of septic shock caused by systemic infection of Streptococcus pneumoniae. The mortality of septic shock is high and in some patients, causative organisms may not be isolated. In the present case, although the original inflammation was left pleuritis due to Streptococcus pneumoniae, correct clinical diagnosis was not made before death as the patient had lacked any complaints except for occipital headache. This case revealed that the cause of sudden death was sepsis induced by Streptococcus pneumoniae instead of a relapse of APL. This case also illustrated the importance of reviewing the previous history of a patient and doing postmortem bacteologic examination in a case of suspected sepsis.

Immunohistochemistry of neuron-specific enolase in neurons of the medulla oblongata from human autopsies

Neuron-specific enolase (NSE) is a glycolytic enzyme specifically expressed in neurons. NSE has been used as a marker for neuronal damage in brain injury. We studied the immunohistochemical localization of this enzyme in the medulla oblongata obtained from human forensic autopsy specimens. Neurons in the dorsal motor nucleus of vagal nerve expressed statistically significantly less NSE immunoreactivity in the cytoplasm than in the hypoglossal nucleus (XII), solitary nucleus, spinal trigeminal nucleus, and lateral cuneate nucleus. Cases of carbon monoxide intoxication by burning showed a higher incidence of NSE immunoreactivity in the cell nucleus of the XII than other cases, while there was no statistically significant correlation between NSE immunoreactivity in the cell nucleus and the Nissl amount. This indicates that the accumulation of NSE immunoreactivity in the cell nucleus might be a vital reaction rather than a postmortem artifact.

[Hemorrhagic shock death caused by not so severe injury during the medication of anticoagulants]

A 73-year-old man receiving anticoagulants (warfarin potassium) orally with a history of prosthetic heart valve replacement was struck by a truck. When admitting to the hospital, he complained of lumbago with laboratory findings of anemia and prolongation of prothrombin times. Twenty-two hours after the accident, he died suddenly in the hospital and forensic autopsy was performed 9 hours after his death. Autopsy findings revealed marked subcutaneous and intramuscular hematoma in the lumbar and gluteal region and anemic change of viscera. Furthermore, 854 ng/ml of warfarin which was well accordance with the therapeutic levels was detected in the serum obtained from cadaver by using gas chromatography-mass spectrometry. Therefore, we concluded that the man had died of hemorrhagic shock caused by the force acting to the lumbar region accompanied by the influence of anticoagulant action of warfarin. To our knowledge, this is the first report to detect the warfarin from cadaver's serum. In dealing with the unnatural death of the patient receiving the anticoagulants, it is valuable to survey the medications and detect the presence of anticoagulants in cadaver.

A case of fatal benzalkonium chloride poisoning

Five elderly persons with senile dementia accidentally ingested Hoesmin, a 10% aqueous solution of benzalkonium chloride (BAC). The condition of one patient, an 84-year-old woman whose lips and oral cavity became erythematous, gradually deteriorated. Although gastric lavage was performed, the patient died 3 h after ingestion of Hoesmin. Autopsy revealed corrosive changes of the mucosal surfaces of the tongue, pharynx, larynx, esophagus and stomach which may have come in contact with BAC. In addition, BAC was detected in the serum. We conclude that the patient died of BAC poisoning. Fatal BAC poisoning is rare and autopsy findings in only a few cases of BAC poisoning have been reported. Our findings emphasize the risk of oral ingestion of BAC.

Staining for histologic diagnosis of aluminum osteopathy--application of confocal laser scanning microscopy to observation for offminum in bones from aluminum-treated, subtotally nephrectomized rats

To histologically detect excess aluminum (Al) taken up by bones in a rat model of renal failure prepared by 5/6-nephrectomy, non-decalcified bone tissue sections from specimens of the tibia, femur, rib and ilium were stained with a newly developed lumogallion reagent and examined for aluminum by confocal laser scanning microscopy. The assay revealed that Al contents in the tibia and femur of Al-treated rats tended to be a few-fold higher, compared to controls. With the lumogallion stain technique, Al in bones could be detected and identified at Al concentrations of > or = 9.0 micrograms/g in bone tissues. The reaction of the metal with lumogallion is specific and proved to be positive even at concentrations of excess Al so low as to be undetectable by conventional methods. The present observation disclosed that, unlike the generally accepted view, the Al was accumulated not in the calcification front but was distributed diffusely or as aggregates at high concentration in osteoid tissues. Z mode scans of the slides permitted steric delineation of the state of Al accumulation in bone tissues. The method described herein is considered a useful means for clinical diagnosis of aluminum osteopathy.

Autopsy case of duodenal obstruction from impacted mushroom

We report an autopsy case of duodenal bulb obstruction caused by a shiitake mushroom. A 74-year-old woman with depression was admitted to the hospital after suffering nausea and abdominal fullness for 3 days. Because the physical findings and laboratory data on admission revealed marked dehydration, lactated Ringer's solution was administered. Twelve hours later, the patient suddenly died. Autopsy showed an enlarged stomach filled with 850 ml of partially digested food. In the anal side of the pylorus, a 9-cm-diameter shiitake mushroom had become impacted, causing complete obstruction. We conclude that the patient suffered from duodenal bulb obstruction caused by the impacted mushroom and subsequently died of ileus. This case illustrates a rare cause of duodenal obstruction and emphasizes that ingested food can cause obstructive ileus and death.

Immunohistochemical study of neuron-specific enolase in human brains from forensic autopsies

Immunohistochemistry using anti-human neuron-specific enolase (NSE) mouse monoclonal antibody was performed in human brains from autopsy cases, which enabled us to assess the neuronal damage besides hematoxylin and eosin or Klüver-Barrera stain. Neurons in cerebral neocortex which showed necrotic changes such as prominent cytoplasmic vacuolization or cellular shrinkage with nuclear pyknosis showed a tendency to be less stained by anti-NSE antibody. Anti-NSE immunostaining was statistically significantly less in the neocortex from CO intoxication than from other causes of death, although morphological necrotic changes were less observed in CO intoxication. Hippocampal CA1 neurons clearly lost NSE immunoreactivity with the progression of necrotic changes. Neurons in CA2 were statistically significantly better stained by anti-NSE antibody than in CA1, 3, and 4. Cerebellar Purkinje cells were poorly stained by anti-NSE antibody, whereas neurons in cerebellar dentate nucleus and inferior olive in medulla oblongata were better stained. Anti-NSE immunostaining was lost in the injured areas of the cerebral neocortex while neurons in the intact areas were better stained in brain injury. These results indicate that anti-NSE immunostaining of neurons could reflect vital reaction and could be useful in evaluating neuronal damage in the hippocampal CA1 region or brain injury.

Sudden death of a patient with Crohn's disease

We describe a case of sudden death caused by a rare complication of Crohn's disease. A 29-year-old man with Crohn's disease who had not taken medications regularly complained of nausea, vomiting, and abdominal pain for 2 days, and then died suddenly. Autopsy revealed protruding intestinal loops filled with gas, internal fistulas between fused loops of the terminal ileum, and complete obstruction of the fistulous tract. The histologic findings of transmural inflammation consisting of lymphocytic infiltration, accumulation of partially hyalinized collagen, and fibrosis in the skip areas from the ileum to the cecum were compatible with Crohn's disease. Furthermore, marked emaciation, atrophic change of the heart muscle, and diffuse fatty change of the liver were found. Although the patient died of obstructive ileus caused by a stricture produced by progression of Crohn's disease, he was severely affected by malnutrition which may have been fatal. This case not only illustrates that Crohn's disease can cause obstructive ileus and sudden death, but also makes the forensic pathologist realize the importance of suspecting the presence of an active inflammatory bowel disease in a patient with internal fistulas or malnutrition.

Sensitive detection of trace aluminium in biological tissues by confocal laser scanning microscopy after staining with lumogallion

This paper describes a method for the sensitive detection of aluminium in biological tissues by real time confocal laser scanning microscopy after staining with lumogallion. The method enabled detection of aluminium > or = 9 micrograms g-1 in bone and is more sensitive than the conventional histochemical methods with aluminium and solochrome azurine, etc. Lumogallion reacts specifically with aluminium to form a fluorescent complex so that the proposed method is useful for detection and identification of aluminium in tissues.

Simulator for virtual surgery using deformable organ models and force feedback system

This paper describes a real-time surgery planning system using virtual reality techniques. This system allows us to simulate incision of skin and organs which respond as elastic objects with surgical tools in virtual space. Inner structures such as blood vessels and lesions can be seen and manipulated in the simulation. In addition to these functions we attempted to add a feedback function that responds to the operator's hands. We developed a force feedback device to manipulate the elastic organ model based on pressure from the operator's fingers.

3D and 4D atlas system of living human body structure

A reference system for accessing anatomical information from a complete 3D structure of the whole body "living human", including 4D cardiac dynamics, was reconstructed with 3D and 4D data sets obtained from normal volunteers. With this system, we were able to produce a human atlas in which sectional images can be accessed from any part of the human body interactively by real-time image generation.

[A case of dural sinus thrombosis during the medication of medroxyprogesterone acetate]

It is reported that medroxyprogesterone acetate (MPA) causes venous thrombosis as one of the side effects. A 49-year-old woman suffering from metastatic lung carcinoma from breast carcinoma was administered MPA 1200 mg/day for about four months. Thereafter she complained of dizziness about two weeks but the general practitioners could detect no abnormality on physical examinations and on brain CT X-ray findings. Six days later, she died suddenly at her home. Forensic autopsy findings revealed the marked superior sagital sinus thrombosis and the malignant lymphadenomatosis caused by metastatic lung carcinoma. As the patient had not disease or trauma causing dural sinus thrombosis except for the administration of MPA, we concluded that superior sagital sinus thrombosis was due to the medication of MPA. This case illustrates that forensic pathologist should consider the major side effect of some drugs like our case.

[Analysis of sudden death caused by intestinal obstruction]

Five autopsy cases of sudden death caused by intestinal obstruction are reported. The causes of death of the cases were duodenal obstruction of impacted food stuff, ileocaecal obstruction caused by Crohn's disease, incarceration of inguinal hernia, intestinal obstruction caused by heterotopic pancreas and paralytic ileus. In three cases, the patient was in cardiopulmonary arrest on arrival at hospital, and in the remaining cases the patient died within 12 hours from the beginning of treatment; therefore, a correct clinical diagnosis was not made before the death in all cases. All the patients had from one to three days history of nausea and abdominal pain, major complications of intestinal obstruction. Among all cases, the duration from the onset to death was the shortest in the case of a patient complicated with schizophrenia. It is characteristic that the patients of all cases died suddenly and resuscitation was not successful. Regarding the laboratory data of a hospitalized patient, marked hemoconcentration and an increased level of BUN/Cr ratio and blood sugar were shown. The patient who died from duodenal obstruction caused by impacted food-stuff had suffered from depression for six years, and the patient who died from paralytic ileus had suffered from schizophrenia for about 23 years. In both cases, it is characteristic that the complaints of the patient were poorer than what would be expected. Furthermore, these patients had been taking medication of psychotic, anti-depressant and anti-parkinsonism drugs; therefore the combination of these drugs was thought to be reflected in the bowel movement.

[Methamphetamine-like substance detected only in stomach contents from autopsied cadavers]

In this paper we show that a methamphetamine-like substance was detected in the stomach contents of deceased patients who had never taken methamphetamine (MA). MA was assayed by using gas chromatography/mass spectrometry. Blood, urine and stomach content samples were collected from 65 patients not suspected of taking MA. In seven victims, MA-like substance was detected in the stomach contents. Concentration of MA-like substance ranged from 0.03 to 0.38 microgram/ml. Though MA and amphetamine, a metabolite of MA, were detected in forensic samples of patients who had used MA, amphetamine could not be identified in the stomach contents of these seven cases. There was no correlation between MA concentration and interval of time from death to autopsy. The mechanism of the production of MA-like substance is not clear. This phenomenon should be paid attention to in the course of forensic drug analysis because of the possibility of misjudgement.

[Sudden unexpected natural death from a viewpoint of forensic pathology]

Sudden unexpected natural death (SUND) has several characteristics, such as unknown clinical history, very short course to death, evidence of trauma, interference of postmortem changes and social implications of diagnosis. From these points, SUND involves important challenges in forensic pathology. Presented here are the highlights of our SUND studies which allow scientific speculation into the antemortem pathophysiological course to death and a subsequent accurate diagnosis of the cause of death in SUND cases. 1. Forensic problems of SUND of unknown etiology 1) Do sudden infant death syndrome (SIDS) studies continue endlessly? In Japan there are many cases of sudden unexpected infant death (SUID) which were regarded as SIDS, often without postmortem examination. Pure SIDS should be a diagnosis of exclusion under thorough postmortem examination. Additionally, many SIDS studies have focused on pathogenesis of pure SIDS based on the analysis of so-called SIDS cases described above. In this sense, SIDS studies may continue forever. To clarify whether SIDS is an onion type, that is a heterogeneous disease entity, or bamboo shoot type, a single disease entity with a single cause, it is more vital to accurately search autopsy findings to exclude the cause of death, rather than to study pathogenesis of SIDS. Thereafter, pure SIDS will be carved in relief and we could study the pathogenesis, if it remains in the future. Present in 40% of our SUID cases examined was the existence of viral infection as a cause of death. 2) Pokkuri disease It has long been believed that the main branches of coronary arteries in Pokkuri-disease cases are macroscopically hypoplastic and cause sudden cardiac death. However, our two-dimensional morphometric analysis of the main branches, such as wall thickness, degree of stenosis, lumen area, area within internal elastic lamina, showed no significant differences between Pokkuri-disease cases and age and sex-matched control cases. 2. Information for grasping antemortem pathophysiological state in SUND cases 1) Standardization of the degree of cardiac hypertrophy based on heart weight. In the course of our preliminary examination, we found that heart weight correlates significantly with body length and weight. Therefore, we tried to standardize the range of normotrophy, hypertrophy and hypoplasia/atrophy of the heart based on the correlation between heart weight and body type index calculated by body length and weight (Broca's index). 2) Evaluation of the clinical laboratory data in cadaveric blood. We examined 32 clinical laboratory parameters in cadaveric blood samples obtained from 192 autopsy cases. Behaviour of the laboratory parameters in cadaveric blood in relation to postmortem interval was divided into four types: increased, decreased, no particular tendency and remaining between upper and lower normal value. Parameters included in the last type, which is a useful tool for speculation of antemortem pathophysiology were T-Bil, TTT, ZTT, BUN, Cre, UA, alpha 1- and beta 2-microglobin, T-Chol, GHA1c, TP, A/G, Hb and Hct. A case was demonstrated in which values of clinical laboratory parameters in agonar stage were the same as in cadaveric blood obtained at autopsy. This indicates that caution is necessary in evaluating clinical laboratory data in agonar patients in the emergency room. 3) Diagnostic evaluation of immunohistochemical myoglobin staining in the kidney In order to evaluate the diagnostic value of myoglobin (Mb) staining in the kidney in medicolegal autopsy cases, Mb staining was carried out on the kidney sections of 141 victims, including 59 natural and 82 unnatural deaths. At the same time, Serum and Urine GFR parameters were measured and systemic histological changes were observed on some sections of each kidney. The incidence of Mb positive cases was 74.6% in unnatural, and 25.4% in natural death, indicating the importance of nontraumatic rhabdomyolysis in natural death cases.

The quantitative analysis of inhalational anaesthetics in forensic samples by gas chromatography/mass spectrometry/selected ion monitoring

The quantitative analysis of volatile anaesthetics for biomedical applications by means of gas chromatograph/mass spectrometry/selected ion monitoring (GC/MS/SIM) was studied. Xenon gas was selected as an internal standard for the assay by adding to a closed system, because of its stability and inactivity. In the assay of inhalational anaesthetics, isoflurane and nitrous oxide (laughing gas), in forensic samples (serum and cerebrospinal fluid), the calibration of the anaesthetic was linear from 0.12 to 12 nmol/mL in isoflurane and from 30 to 300 nmol/mL in nitrous oxide. Our results suggest that this new method is suitable for the quantitative analysis of inhalational anaesthetics in the biomedical field.

Determination of serum creatinine by isotope dilution method using discharge-assisted thermospray liquid chromatography/mass spectrometry

A discharge-assisted thermospray (plasmaspray) liquid chromatography/mass spectrometric method for the determination of serum creatinine is described. The method incorporates stable isotope dilution using (D3)creatinine as an internal standard. Separation is performed in reversed-phase high-performance liquid chromatography using 0.01 M aqueous ammonium acetate as a flow solvent. Effluents are directly introduced to the mass spectrometer and [MH]+ ions are monitored during LC/MS using the selected ion monitoring method. Satisfactory agreement between the analytical result and the certified value of the serum sample of standard reference material and relative standard deviation ranging from 0.6% to 1.2% was obtained.

Supercritical fluid chromatographic determination of cholesterol and cholesteryl esters in serum on ODS-silica gel column

Cholesterol and cholesteryl esters in human serum were determined by supercritical fluid chromatography on an inert ODS-silica gel column using supercritical carbon dioxide as a mobile phase without a modifier. Chromatograms were obtained by monitoring the eluent simultaneously with an FID and UV detector at the wavelength of 190 nm. The retention behavior of cholesterol and cholesteryl esters was investigated in terms of the density of CO2 mobile phase. The separation mode was found to be reversed phase, as in liquid chromatography. The amounts of cholesterol and cholesteryl esters extracted from human serum reference material (NIST SRM 909) were determined individually using cholesteryl laurate as an internal standard to give good agreement of total cholesterol with the value certified by NIST.

Determination of serum cholesterol by stable isotope dilution method using discharge-assisted thermospray liquid chromatography/mass spectrometry

A discharge-assisted thermospray (plasmaspray) liquid chromatography/mass spectrometric method for the determination of total serum cholesterol is described. The method incorporates stable isotope dilution using (3,4-13C)cholesterol as an internal standard. Liquid chromatographic separation is performed using methanol as a flow solvent and effluents are directly introduced to the mass spectrometer. [MH-H2O]+ ions are monitored during liquid chromatography/mass spectrometry using the selected ion monitoring method. Satisfactory agreement between the analytical result and the certified value of the National Institute of Standards and Technology (formerly National Bureau of Standards) standard reference material serum is obtained with a relative standard deviation of 0.6%.

Unusual mechanism of lethal cervical spinal cord injury in a case of atlanto-axial diastasis

A case of traumatic cervical spinal cord injury due to congenital craniocervical abnormalities is described. The autopsy revealed evidence of hyperextension of the neck due to frontal impact, congenital occipitalization of the atlas accompanied by basilar invagination of the odontoid process and atlanto-axial diastasis. The subsequent narrowing of the spinal canal led to a predisposition for this unusual mechanism of spinal cord injury.

Stable isotope dilution method for the determination of serum glucose using discharge-assisted thermospray liquid chromatography/mass spectrometry

A discharge-assisted thermospray liquid chromatography/mass spectrometric method for the determination of serum glucose was studied. Isotope dilution technique was used with uniformly labelled (13C6) glucose as an internal standard. Successful liquid chromatography/mass spectrometry was achieved by post-column addition of aqueous ammonium acetate to the mobile phase. Quantification was performed by measuring the peak intensity ratios of the unlabelled and labelled [M + NH4]+ ions. Analytical results using the National Institute of Standards and Technology standard reference material serum showed satisfactory agreement with the certified value, and a relative standard deviation of about 1% was obtained.

[Scanning electron microscopic study of rat lungs in experimental chronic paraquat poisoning]

It is well known that Paraquat (1,1'-dimethyl-4,4'-bipyridylium dichloride), used widely as a herbicide, causes a primary toxic effect in the lungs of humans and laboratory animals. This paper describes the pulmonary changes of chronic paraquat poisoning in rats, comparing scanning electron microscopic findings. Twenty-four rats were given repeated injections of 10/kg body weight paraquat intraperitoneally for 6 consecutive months, and six control rats were given 0.9% NaCl solution. The animals exposed to paraquat showed thickening of alveolar septum, inflammatory cell infiltration, interstitial fibrosis, and marked proliferation of alveolar macrophages. Among them four rats (21%) showed the typical findings of diffuse pulmonary fibrosis. Lesions were more severe at the subpleural region of the lung. The desquamation of alveolar epithelial cells and subsequent exposure of the basement membranes were observed in places. Although alveolar epithelial cells both in the type I and the type II were prolific, the type II cells showed partial loss of microvilli and projections. These findings may indicate the lowering of the type II cell function and subsequent decrease of surfactant excretion which causes respiratory insufficiency. Furthermore, alveolar macrophages showed a tendency to increase in number with progressive development of fibrosis. This tendency may support the hypothesis by Schoenberger et al., in which alveolar macrophages release both fibronectin and a growth factor for fibroblast after paraquat exposure.

Species identification of blood stains using a biotin-labeled DNA probe

In an attempt to identify blood stains of human origin, DNA was extracted from human and animal dried blood stains and examined using recombinant DNA techniques. As a DNA probe, biotin-labeled or radioisotopically labeled human repetitive sequence 2.3 Kb Hind III fragment (pH 12) in pBR 322 was used. The probe clearly hybridized with human DNA, but not with DNA extracted from frog, fish, mouse, rat, rabbit, chicken, cat, dog, and sheep. DNA from a Japanese monkeies and from a chimpanzee also hybridized with comparable efficiency. The minimum amount of the blood for the species identification was estimated to 0.4 microliter of fresh blood, 2.1 microliters of 2 weeks old blood stain and 3.8 microliters of 3 months old blood stains, indicating that only one drop of human blood is sufficient for species identification. There was no difference of "signal" between isotopic and non-isotopic procedures for DNA analysis. The advantages of the non-isotopic method for species identification of blood stains in forensic science is briefly discussed.